Oasis Point Rehabilitation Hospital

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure that all personnel were in compliance with the State’s Licensure regulations and standards. This deficient practice is evidenced by failing to maintain personnel files for 4 (S6CNA-S8CNA, S9LPN) of 8 requested files. Findings: On 01/22/2026 at 3:37 PM, surveyor requested personnel files for the following employees from the current list of employees provided: S3DON, S4RN, S7CNA, S8CNA, S9LPN, and S11RN. In an interview on 01/27/2026 at 9:44 AM, S1CO stated the facility did not have personnel files for S7CNA and S9LPN, further stating they were only employed for a month. S1CO stated at this time they were unable to locate the personnel file for S8CNA. S1CO stated they currently do not have a staff member for Human Resources due to the previous employee not returning after maternity leave. At this time surveyor requested additional personnel files for S5CNA and S6CNA who are currently on shift working. In an interview on 01/27/2026 at 12:18 PM, S1CO provided surveyor with an incomplete personnel file for S6CNA. Further review of S6CNA personnel file reviewed revealed an adverse action for S6CNA dated 01/27/2026. In an interview on 01/27/2026 at 12:30 PM, S1CO confirmed that the facility does not have personnel files on site readily available with all pertinent information. S1CO stated she was unable to provide evidence of completed background checks for S6CNA, S7CNA, S8CNA, and S9LPN prior to hire.”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 50453 Based on record reviews and interviews, the CEO failed to ensure the hospital met fiscal responsibilities. This deficient practice is evidenced by failure of the CEO to maintain updated insurance policies and provide documentation that the facility was current with payments. Findings: During entrance conference on 01/22/2026 at 9:48 AM, the surveyor requested documentation to verify the facility had current insurance policies in place. In an interview on 01/22/2026 at 1:56 PM, the surveyor made a second request for the current facility insurance policies. On 01/22/2026 at 2:08 PM, surveyor received facility insurance policies. Review of the provided policies revealed that the insurance documents (e.g., liability, property, malpractice, and other applicable policies) were either expired or contained the incorrect facility name/address. Further review of facility insurance policies failed to reveal in part the following: -Workers Compensation insurance policy expired 01/07/2026 and has the incorrect facility name and address; -Commercial/Property insurance policy, has the incorrect facility name; and -Professional/General Liability insurance policy has a partially correct facility name. In an interview on 01/22/2026 at 3:09 PM, S2ADM confirmed the above-mentioned findings. S2ADM confirmed that the address on the workers compensation insurance policy was for their previous location. S2ADM further confirmed that the previous location has been relocated to this current facility. S2ADM stated she would provide updated insurance policies for the facility. On 01/27/2026 at 8:34 AM, S2ADM provided updated insurance policies to surveyor. Review of the provided policies revealed in part the following: -Workers Compensation insurance policy, has the incorrect facility name; -Commercial/Property insurance policy, has the incorrect facility name; and -Professional/General Liability insurance policy has a partially correct facility name. The insurance policy reviewed did not include the facility’s name and property address, preventing verification that the policy provided coverage for the hospital’s operations and physical location. The facility could not demonstrate that it maintained continuous coverage, placing the hospital at risk for financial liability and potential interruption of services. These failures created the potential for significant operational and financial risk, which could negatively impact patient care, staff safety, and the hospital’s ability to maintain compliance with state and federal requirements. On 01/27/2026 at 11:40 AM, S2ADM confirmed that all insurance policies do not have the correct facility name listed as policy holder. S2ADM stated that past payments were paid through their LLC which is why the policy information and the facility name/address do not match. At time of exit on 01/28/2026 at 5:00 PM, the surveyor was not provided with evidence, verifying that insurance premiums and other required payments were current.”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 50453 Based on record reviews and interviews, the hospital failed to ensure that supplies and services provided or performed under contract were provided in a safe and effective manner. This deficient practice is evidenced by failure to pay contracted services resulting in accounts being placed on hold and delaying patient care. Findings: In an interview on 01/22/2026 at 11:23 AM, S13Staff confirmed that the hospital does have issues getting supplies in a timely manner to provide patient care. S13Staff stated at the time of the survey, the facility had all the patient care supplies needed to provide patient care. In an interview on 01/22/2026 at 1:35 PM, S12Staff confirmed there are issues with the facility obtaining supplies needed for patient care. S12Staff stated supplies are ordered weekly, but they often run low or are out of needed supplies due to accounts for contracted services being on hold. S12Staff stated that often staff will get what they need from another facility they work at to ensure they have what they need to provide patient care. Patient #1 Review of Patient #1’s medical record revealed Patient #1 was admitted on 01/16/2026 with a diagnosis of Non-traumatic Spinal Cord Injury. Review of Patient #1’s provider orders revealed the following: 01/20/2026 at 1:15 PM- Doppler Studies to Bilateral Lower Extremities (BLE) 01/20/2026 at 5:28 PM- Send out for Doppler BLE to rule out DVT (Deep Vein Thrombosis) Review of Patient #1’s provider notes revealed in part the following: Date of evaluation 01/20/2026:” We also ordered a doppler study now this is where there is some concern arises here, we received report that because of financial constraints on the hospital whereby there is payment not paid to the diagnostic team that we were not able to perform the designated Doppler study needed to rule out a DVT which is important. This patient at risk for pulmonary emboli and also pulmonary thrombosis she needs to have a Doppler performed, to make sure that she had this done so we sent her to acute care facility and transferred out to do so. “ In an interview on 01/28/2026 at 9:30 AM, S3DON confirmed the above-mentioned findings. S3DON stated that once the contracted company was paid, they couldn’t complete the order until the following day due to the schedule being full. S3DON stated this delay resulted in Patient #1 being sent out to the emergency department to have the ultrasound completed.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure each patient or patient representative consented to treatment. This deficient practice is evidenced by failing to obtain consent for the administration of blood/blood components. Findings: Review of hospital policy titled, “Blood Administration,” last revised 08/2024, revealed in part the following: “POLICY STATEMENT: All patients requiring administration of blood or blood products will be safely administered and documented by RN after informed consent. ADMINISTRATION PROCEDURE: 5. Obtain consent - Informed consent for administration of blood/blood components must be obtained from the recipient, or person authorized to sign for the recipient, and witnessed by the staff.” Review of Patient #2’s medical record revealed that Patient #2 was administered blood on 12/16/2025 and 01/10/2026. Review of Patient #2’s medical record failed to document evidence that Patient #2 signed a blood transfusion consent on 01/10/2026. In an interview on 01/28/2026 at 3:18 PM, S2ADM and S3DON confirmed the above-mentioned findings.”

“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 record reviews and interviews, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by: 1) failure to administer insulin per hospital policy on Patient #2; and 2) failure to ensure employees were BLS certified in 1 (S4RN) of 6 personnel files reviewed. Findings: Review of hospital policy titled “Medication Administration,” last revised 05/2024, revealed in part: “PURPOSE: To ensure safe, appropriate, and correct medication administration. ADMINISTRATION: Medications by Injection: Insulin multi-dose vials may be kept refrigerated or not refrigerated: High alert medications, require a double check by 2 clinicians prior to administration (See Policy High Alert Medications for a list of all high alert medications). A double-check will include each nurse, independently verifying the dose and drug prepared against the original prescriber order against the MAR (Medication Administration Record) and then performing associated cognitive checks with both parties signing the MAR. II. ADMINISTRATION OF MEDICATION: 1. All administered, refused, or omitted medication doses should be recorded in the patient’s medication administration record. 7. Use the Ten Rights Rule: Right Patient, Right Medication, Right Dose, Right Route, Right Time, Right Documentation, Right Education, Right of Refusal, Right Evaluation, Right Assessment. IV. MEDICATION ADMINISTRATION RECORD: 11. Document refusal of medications or inability to give medications on the MAR and in the nurse’s notes. 12. The nurse will notify the physician for any refusal or inability to give the medication so that the physician may select an alternative.” Review of hospital policy titled “High Alert Medications,” last revised 08/2024, revealed in part: “PURPOSE: To safeguard the use of high-alert medications by reducing or eliminating the potential for errors, and minimizing the consequences of errors. The policy applies to all employees and credentialed practitioners involved in prescribing, dispensing, handling, or administering high-risk medications. PROCEDURE: 2. All high-alert medication dosages will be checked by two nurses. HIGH RISK MEDICATIONS: High risk medications are those medications known to be error-prone or which pose a significant hazard to patients if not properly handled. They must be Double-Checked by 2 nurses prior to administration. They include, but are not limited to: 1. Insulin subcutaneous. INSULIN PRECAUTIONS: When drawing up insulin in a syringe always have another nurse double check before administering. Insulin pens are double-checked by 2 nurses.” 1) Failure to administer insulin per hospital policy on Patient #2. Review of Patient #2’s medical record revealed an admission date of 12/10/2025 with a diagnosis of Cervical Spinal Cord Injury and a stage 4 sacral wound. Further review of Patient #2’s medical record revealed Patient #2 was an insulin dependent diabetic. Review of Patient #2’s physician orders revealed in part the following: -Novolog, Inject 5 units, subcutaneously before meals, Start date: 12/10/2025. -Novolog, sliding scale, subcutaneously before meals and at bedtime, Start date 12/11/2025. -Lantus, 26 units, subcutaneously at bedtime, Start date: 12/10/2025. Review of Patient #2’s MAR revealed that Patient #2 was administered insulin on the following dates: 01/09/2026 01/10/2026 01/16/2025 01/21/2026 01/22/2026 01/24/2026 01/25/2026 01/26/2026 01/27/2026 01/28/2026 Further review of Patient #2’s MAR for the above-mentioned dates failed to reveal documented evidence that the administered insulin was double-checked by 2 clinicians/nurses, with both parties signing the MAR per hospital policy. In an interview on 01/28/2026 at 2:33 PM, S3DON confirmed the above-mentioned findings. 2) Failure to ensure employees were BLS certified in 1 (S4RN) of 6 personnel files reviewed. Review of the personnel record for S4RN revealed their BLS (Basic Life Support) certification expired on 11/30/2025. Further review failed to reveal a current certification in BLS. In an interview on 01/27/2026 at 12:30 PM, S1CO and S3DON confirmed the above-mentioned findings.”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 50453 Based on record reviews and interviews, the hospital’s governing body failed to ensure the Quality Assessment and Performance Improvement (QAPI) program included contracted services in the QAPI program. The deficient practice was evidenced by failing to include all contracted services in the QAPI program. Findings: Review of the hospital “Quality Strategic Plan Summary 2025,” revealed in part, no documentation related to contracted services as part of the hospitals QAPI Program to ensure these services are tracked and analyzed. Review of the provided QAPI minutes from April 2025 and the provided governing body and medical executive committee minutes from January 2025 - December 2025 failed to reveal a review of quality of the services provided by those contracted agents. In an interview on 01/27/2026 at 1:55 PM, S3DON stated that the hospital has issues with their contracted laboratory service. S3DON stated that the hospital receives lab results by fax, and at times it takes a few days to obtain the ordered laboratory results. In an interview on 01/28/2026 at 3:30 PM, S2ADM confirmed that the QAPI program documentation failed to reveal contracted services were reviewed.”

“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: 50453 Based on record review and interview, the hospital failed to ensure the nursing staff administered medications per physician order and hospital policy. This deficient practice was evidenced by: 1) failure to notify provider per policy of inability to administer scheduled medication for Patient #2; and 2) failure to notify the provider of abnormal blood glucose results for 1 (#1) of 3 medical records reviewed. Findings: Review of hospital policy titled “Medication Administration,” last revised 05/2024, revealed in part: “PURPOSE: To ensure safe, appropriate, and correct medication administration. MEDICATION ORDERS: 2. Nurse Responsibilities: Any action taken because of this intervention should be documented in the patient’s medical record. Information concerning changes shall be communicated to the appropriate health professionals caring for the patient. ADMINISTRATION: II. ADMINISTRATION OF MEDICATION: 1. All administered, refused, or omitted medication doses should be recorded in the patient’s medication administration record. 7. Use the Ten Rights Rule: Right Patient, Right Medication, Right Dose, Right Route, Right Time, Right Documentation, Right Education, Right of Refusal, Right Evaluation, Right Assessment. IV. MEDICATION ADMINISTRATION RECORD: 11. Document refusal of medications or inability to give medications on the MAR and in the nurse’s notes. 12. The nurse will notify the physician for any refusal or inability to give the medication so that the physician may select an alternative.” 1) Failure to notify provider per policy of inability to administer scheduled medication for Patient #2. Review of Patient #2’s medical record revealed an admission date of 12/10/2025 with a diagnosis of Cervical Spinal Cord Injury and a stage 4 sacral wound. Further review of Patient #2’s medical record revealed Patient #2 had a history of Hypertension and Benign Prostatic Hyperplasia (BPH). Review of Patient #2’s physician orders revealed in part the following: 01/06/2026 at 5:00 PM: Terazosin, 5mg capsule, by mouth at bedtime (start on 01/07/2026). Review of Patient #2’s Medication Administration Record (MAR) for Terazosin administration revealed in part the following: 01/07/2026: Held. 01/08/2026: Medication not available. 01/09/2026: Not available. 01/10/2026: Not available. 01/11/2026: Not given, pharmacy called. Patient #2’s medical record failed to reveal documented evidence that the provider was notified, per policy, that the nurse was unable to give the ordered/scheduled Terazosin from 01/07/2026-01/11/2026 (5 days). In an interview on 01/28/2026 at 2:47 PM, S3DON confirmed the above-mentioned findings and verified that the nursing staff did not follow hospital policy. 2) Failure to notify the provider of abnormal blood glucose results for 1 (#2) of 3 medical records reviewed. Review of Patient #2’s medical record revealed Patient #2’s medical history included insulin dependent diabetic. Review of Patient #2’s physician orders revealed in part the following: -Novolog, sliding scale, subcutaneously before meals and at bedtime, Start date 12/11/2025. Sliding scale coverage: Blood Glucose (BG) less than 200= 0 units; 201-250= 2 units; 251-300= 4 units; 301-350= 6 units; 351-400= 8 units; greater than 400= 10 units and notify MD. -01/25/2026 at 11:24 AM: if BG greater than 400 cover with sliding scale then recheck in 1 hour again and cover again. Notify MD for 2 consecutive BG greater than 400. Telephone Order. Review of Patient #2’s MAR revealed in part the following: 01/25/2026 at 7:30 AM: BG=480, 10 units. 01/25/2026 at 11:30 AM: BG=504, 10 units given; 01/25/2026 at 4:30 PM: BG=547, 10 units given; 01/25/2026 at 8:00 PM: BG=512, 10 units given; 01/25/2026 at 9:00 PM: BG=484, 10 units given; and 01/25/2026 at 10:00 PM: BG=374, no documented insulin administered. Further review of the MAR failed to reveal the documented site of insulin administration by the nursing staff. Review of Patient #2’s medical record failed to reveal documented evidence of provider notification per orders. Further review failed to reveal that the telephone order obtained on 01/25/2026 at 11:24 AM was implemented until 8:00 PM. In an interview on 01/28/2026 at 2:33 PM, S3DON confirmed the above-mentioned findings, and verified provider orders were not followed.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure blood transfusions were documented per policy in 1 (#2) of 1 patient record reviewed for blood administration. Findings: Review of hospital policy titled, “Blood Administration,” last revised 08/2024, revealed in part the following: “POLICY STATEMENT: All patients requiring administration of blood or blood products will be safely administered and documented by RN after informed consent. ADMINISTRATION PROCEDURE: 4. Conduct a two person verification process (the transfusionist who will transfuse the blood and one individual who conducts the verification). 8. b. Have 2 nurses (1 must be a RN) verify yellow slip on bag with lab Blood Bank Slip for the following: 1. Patient’s name. 2. Patient’s ID number (Patient’s Medical Record number). 3. Donor group. 4. Donor Rh type. 5. Bag number. 6. Expiration date. 7. Examine bag and segments of bag for any abnormal appearance of the blood/blood component; check for clotting or gross hemolysis. 21. Monitor vital signs 15 minutes after the start oof the infusion and then every hour until transfusion is complete. 28. Document procedure in the patient’s record.” Review of Patient #2’s medical record revealed that Patient #2 was administered blood on 12/16/2025. Review of the Blood Bank Slip revealed a section titled “Transfusion Information- Prior to starting this transfusion, we have checked this slip with the bag label and the patient’s wristband and all information agrees.” Further review of the Blood Bank Slip failed to reveal that the slip was signed by both nurses who conducted the verification process. Review of Patient #2’s transfusion documentation revealed the blood transfusion was started 12/16/2025 at 2:00 AM. Further review failed to reveal documented evidence that vital signs were documented every hour per policy at 4:00 AM or 5:00 AM. The blood transfusion was completed on 12/16/2025 at 5:55 AM. In an interview on 01/28/2026 at 2:03 PM, S3DON confirmed the above-mentioned findings and confirmed that the blood transfusion was not documented per hospital policy for Patient #2.”

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 50453 Based on record reviews and interviews, the hospital failed to ensure all orders were dated, timed, and authenticated by the ordering provider for 1 (#1) of 3 patient records reviewed. Findings: Review of hospital policy titled “Medication Administration,” last revised 05/2024, revealed in part: “PURPOSE: To ensure safe, appropriate, and correct medication administration. MEDICATION ORDERS: 1. Physician Responsibilities: Electronic or legibly written medication orders must include: f. Signature of physician. g. Date and Time. Telephone orders: b. Only accepted by staff authorized to do so and consistent with federal and state laws. c. Must include all elements of physician responsibility above.” Review of Patient #1’s medical record revealed an admission date/time of 01/16/2026 at 6:45 PM. Review of Patient #1’s admission orders revealed an order set obtained verbally by the nurse and signed by the provider. Further review failed to reveal that the admission orders contained a date or time. In an interview on 01/27/2026 at 1:51 PM, S3DON confirmed the admission orders for Patient #1 did not contain a date or time.”

“CONTENT OF RECORD: DISCHARGE SUMMARY CFR(s): 482.24(c)(4)(vii) [All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to include a discharge summary in the medical record for 1 (#3) of 1 reviewed record of a patient who was no longer at the facility. Findings: Review of Patient #3’s medical record revealed Patient #3 was admitted on 12/02/2025 with a diagnosis of a Stroke, Right Body Involvement. On 12/09/2025 Patient #3 was transferred to the emergency room for an evaluation of kidney function and never returned. Further review of Patient #3’s medical record failed to reveal documented evidence of a discharge summary or a discharge order. In an interview on 01/28/2026 at 4:12 PM, S3DON confirmed there was no discharge summary and no discharge order in Patient #3’s medical record.”

“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 remove outdated or otherwise unusable drugs and biologicals available for patient use. This deficient practice was evidenced by expired epinephrine being available for patient use. Findings: Observations during a tour on 01/22/2026 from 10:10 AM - 11:26 AM of the facility revealed in Room ‘b’ an Epinephrine Injection 0.3mg Auto Injector, expiration date of 11/30/2025 available for patient use. In an interview during the tour, S2ADM confirmed the above-mentioned findings.”

“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 were maintained to an acceptable level of safety and quality. This deficient practice was evidenced by failing to ensure expired supplies were removed from the patient care area. Findings: Review of hospital policy titled “Rotating Supplies and Maintaining Supply Closet/Storage Area,” last approved 01/2025, revealed in part: “PURPOSE: To maintain proper rotation of supplies as well as a clean, organized, and secure supply closet/storage area. POLICY: 1. All supplies are checked and rotated monthly and as needed by designated staff members. 2. When restocking supplies: a. Newer supplies will be placed in the back while older (non-expired) supplies will be brought forward to be utilized first. 3. Check expiration date on each package during rotation procedure and prior to use.” Observations during a facility tour on 01/22/2026 from 10:10 AM - 11:26 AM revealed the following: Crash cart: -Stat-Padz II Adult electrodes, Lot#4723A, quantity 1, expiration date of 11/25/2025. Room ‘a’: - Xeroform Petroleum Dressing 4in x 3yds, quantity 18, expiration date of 12/01/2025. Room ‘b’: -(1) bottle of Iodoform Packing Strips, expiration date of 08/19/2025. -(1) cleansing dressing with 20% sodium chloride, expiration date of 07/28/2025. -Xeroform Petroleum Dressing 4in x 3yds, quantity 1, expiration date of 12/01/2025. In an interview during the tour, S2ADM confirmed the above-mentioned findings were expired.”

“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: 50453 Based on observation and interview, the hospital failed to have an effective infection prevention and control program as evidenced by failing to have a clean and sanitary environment. Findings: Observations during a tour on 01/22/2026 from 10:10 AM - 11:26 AM revealed the following: Room ‘a’: -(1) opened single use bottle of Provodine Iodine Topical 10% solution in the supply cart with clean, unused supplies. Further inspection revealed dried brown/tan substance covering the side of the bottle. In an interview during the tour, S2ADM confirmed the above-mentioned findings. S2ADM also confirmed that the open bottle was stored in the cart with clean supplies.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48051 Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by: 1) failure to promptly resolve 2 (#1, #2) of 2 (#1, #2) patient grievances reviewed (See Findings Tag A0118); 2) failure to review and resolve 2 (#1, #2) of 2 (#1, #2) patient grievances reviewed (See Findings Tag A0119); 3) failure to provide written notice to 2 (#1, #2) of 2 (#1, #2) patient grievances reviewed (See Findings Tag A0123); 4) failure to reveal documentation of the patient or the patient’s representative participating in the development and implementation of his or her plan of care in 3 (#1 - #3) of 3 (#1 - #3) patient medical records reviewed (See Findings Tag A0130); 5) failure to include discharge planning in 1 (#2) of 3 (#1-#3) patient plan of cares reviewed for informed decisions (See Findings Tag A0131); 6) failure of the nurse call system to be functioning from the available nurse call button on the side railing of the patient beds in 3 (“a”, “h”, “l”) of 17 (“a” - “q”) rooms observed (See Findings Tag A0144); and 7) failure to provide the services necessary to avoid physical harm, mental anguish or mental illness to 2 (#1, #2) of 2 (#1, #2) patient grievance reports reviewed (See Findings Tag A0145).”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 48051 Based on observation, policy review, record review and interview, the hospital failed to establish a process for prompt resolution of patient grievance. This deficient practice was evidenced by the failure to promptly resolve 2 (#1, #2) of 2 (#1, #2) patient grievances reviewed. Findings: A review of facility policy, “Patient Rights,” Policy ID 16427107, last revised 10/2006 with GB approval 08/2024, revealed in part, Purpose: 2. Respect and Dignity: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition to his personal dignity. 4. Personal Safety: The patient has the right to expect reasonable safety in so far as the hospital practices and environment are concerned. A Patient’s Bill of Rights: 24. The patient has the right to be cared for in a safe environment. 27. The patient has a right to voice a complaint/grievance to the hospital and/or the Department of Health and Hospitals and have that complaint/grievance investigate within a reasonable amount of time, usually five (5) days. This is to be followed by a letter to the patient or their representative identifying the results of the investigation and the corrective action that has been taken. A review of facility policy, “Patient/Family Grievance” Policy ID 16427105, last revised 05/2024 and Governing Gody (GB) approval 08/2024, revealed in part, Procedure Grievances: 4. In cases of a grievance the Social Services/ case manager or the Director of Nursing will investigate the substance of the grievance, if resolution of the grievance cannot be achieved within 7 business days , the Director of Social Services or case manager will alert the Director of Nursing or Hospital Administrator to assist with resolution. 5. If by the 7th day the grievance still cannot be resolved, the patient and /or their representative will be sent a written letter informing them that the investigation is still underway and that a letter of resolution will be sent to them within 21 days by the Director of Social Services. 7. All Grievance will be entered into the grievance tracking database and the investigation documented on the Grievance Complaint Form. 8. A copy of all letters sent to patients will be maintained in Social Services/case manager’s office. A review of the hospital’s Complaint Log revealed a complaint on 08/04/2024 at 7:00 a.m. by Patient #1 with a statement of complaint: “gnats biting forehead.” Further review revealed a complaint on 08/07/2024 at 8:00 a.m. by Patient #2 with a statement of complaint: “gnats in food/room.” A review of a Patient Grievance Investigation Form from 08/04/2024 at 7:00 a.m. revealed Patient #1 filing a grievance on 08/04/2024. The form revealed, “Patient c/o gnats keep biting my forehead. Patient crying and states I can’t move to get them off of me.” The form also revealed the patient is a “Quad” and the patient suggested the facility obtain “gnat traps”. A review of a Patient Grievance Investigation Form from 08/07/2024 at 8:00 a.m. revealed Patient #2 filing a grievance on 08/07/2024. The form revealed, “Patient c/o excessive amount of gnats in his room. Patient state gnats are always flying in his food trays and on his face and body. Patient states it is disgusting.” Further the form revealed in part, nursing staff observed the flying gnats around the patients diaper and seen inside the diaper during diaper change and sacrum wound care. Documentation related to a resolution, an investigation or the results of an investigation to these grievances was requested and was not provided. There was no documentation related to a follow-up letter being sent to the patients or the patient’s representative communicating an investigation was still underway and a resolution letter would be sent to them within 21 days. Of note, it has been approximately 37 days since the initial grievance had been reported. An observation on 09/09/2024 at 11:45 a.m. revealed a black, tiny insect flying around Patient #1’s room. In an interview on 09/09/2024 at 11:45 a.m. Patient #1 confirmed the presence of black, tiny insects flying in his room. He indicated the insects were “gnats.” He confirmed they fly around his face and he was defenseless against these insects because he cannot move. In an interview on 09/09/2024 and present during the interview with Patient #1, S1RNHM confirmed the presence of the gnat in Patient #1’s room. In an interview on 09/09/2024 at 1:30 p.m. S1RNHM confirmed the the above mentioned findings. In an interview on 09/10/2024 at 9:00 a.m. S2LPN confirmed she was the case manager and received the grievances, however there had not been a follow up to the grievances and she was unaware the hospital was still having issues with these flying insects.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 48051 Based on policy review, record review and interview, the hospital’s Governing Body (GB) failed to establish a grievance process that effectively reviews and resolves grievances. This deficient process was evidence by the failure to review and resolve 2 (#1, #2) of 2 (#1, #2) patient grievances reviewed. Findings: A review of facility policy, “Patient Rights,” Policy ID 16427107, last revised 10/2006 with GB approval 08/2024, revealed in part, Purpose: 2. Respect and Dignity: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition to his personal dignity. A Patient’s Bill of Rights: 27. The patient has a right to voice a complaint/grievance to the hospital and/or the Department of Health and Hospitals and have that complaint/grievance investigate within a reasonable amount of time, usually five (5) days. This is to be followed by a letter to the patient or their representative identifying the results of the investigation and the corrective action that has been taken. A review of facility policy, “Patient/Family Grievance” Policy ID 16427105, last revised 05/2024 and GB approval 08/2024, revealed in part, Policy: The GB has delegated the responsibility for review, investigation, and resolution of the grievances to the Patient Safety Committee. Patient Safety Committee: The Committee consist of Quality/Risk Management, Hospital Administrator, Director of Nursing (DON), and Social Worker/Case Manager. A review of a Patient Grievance Investigation Form from 08/04/2024 at 7:00 a.m. revealed Patient #1 filing a grievance on 08/04/2024. The form revealed, “Patient c/o gnats keep biting my forehead. Patient crying and states I can’t move to get them off of me.” The form also revealed the patient is a “Quad” and the patient suggested the facility obtain “gnat traps”. A review of a Patient Grievance Investigation Form from 08/07/2024 at 8:00 a.m. revealed Patient #2 filing a grievance on 08/07/2024. The form revealed, “Patient c/o excessive amount of gnats in his room. Patient state gnats are always flying in his food trays and on his face and body. Patient states it is disgusting.” Further the form revealed in part, nursing staff observed the flying gnats around the patients diaper and seen inside the diaper during diaper change and sacrum wound care. Documentation related to a resolution, an investigation or the results of an investigation to these grievances was requested and was not provided. There was no documentation related to a follow-up letter being sent to the patients or the patient’s representative communicating an investigation was still underway and a resolution letter would be sent to them within 21 days. Of note, it has been approximately 37 days since the initial grievance had been reported. A review of the hospital’s Quality Assurance Performance Improvement (QAPI) Dashboard for 2024 year to date did not reveal the above mentioned grievances on the provided report. In an interview on 09/09/2024 at 1:30 p.m. S1RNHM confirmed the above mentioned findings and further confirmed the facility had recently changed DONs and was unaware if this DON had knowledge of these grievances. In an interview on 09/09/2024 at 4:00 pm, S3Adm confirmed the facility had been having problems with the flying insects (gnats), she was unaware of the continued problem. In an interview on 09/10/2024 at 9:00 a.m. S2LPN confirmed she was the case manager and received the grievances, however there had been no follow up to the grievances and she was unaware the hospital was still having issues with these flying insects (gnats). She further confirmed the hospitals QAPI Dashboard was not up to date.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 48051 Based on policy review, record review and interview, the hospital failed to provide the patient with a written notice of its decision regarding the resolution of a grievance that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. This deficient practice was evidenced by the failure to provide written notice to 2 (#1, #2) of 2 (#1, #2) patient grievances reviewed. Findings: A review of facility policy, “Patient Rights,” Policy ID 16427107, last revised 10/2006 with GB approval 08/2024, revealed in part, Purpose: 2. Respect and Dignity: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition to his personal dignity. 27. The patient has a right to voice a complaint/grievance to the hospital and/or the Department of Health and Hospitals and have that complaint/grievance investigate within a reasonable amount of time, usually five (5) days. This is to be followed by a letter to the patient or their representative identifying the results of the investigation and the corrective action that has been taken. A review of facility policy, “Patient/Family Grievance” Policy ID 16427105, last revised 05/2024 and GB approval 08/2024, revealed in part, Procedure Grievances: 4. In cases of a grievance the Social Services/ case manager or the Director of Nursing will investigate the substance of the grievance, if resolution of the grievance cannot be achieved within 7 business days , the Director of Social Services or case manager will alert the Director of Nursing or Hospital Administrator to assist with resolution. 5. If by the 7th day the grievance still cannot be resolved, the patient and /or their representative will be sent a written letter informing them that the investigation is still underway and that a letter of resolution will be sent to them within 21 days by the Director of Social Services. 7. All Grievance will be entered into the grievance tracking database and the investigation documented on the Grievance Complaint Form. 8. A copy of all letters sent to patients will be maintained in Social Services/case manager’s office. A review of a Patient Grievance Investigation Form from 08/04/2024 at 7:00 a.m. revealed Patient #1 filing a grievance on 08/04/2024. The form revealed, “Patient c/o gnats keep biting my forehead. Patient crying and states I can’t move to get them off of me.” The form also revealed the patient is a “Quad” and the patient suggested the facility obtain “gnat traps”. A review of a Patient Grievance Investigation Form from 08/07/2024 at 8:00 a.m. revealed Patient #2 filing a grievance on 08/07/2024. The form revealed, “Patient c/o excessive amount of gnats in his room. Patient state gnats are always flying in his food trays and on his face and body. Patient states it is disgusting.” Further the form revealed in part, nursing staff observed the flying gnats around the patients diaper and seen inside the diaper during diaper change and sacrum wound care. Documentation related to a resolution, an investigation or the results of an investigation to these grievances was requested and was not provided. There was no documentation related to a follow-up letter being sent to the patients or the patient’s representative communicating an investigation was still underway and a resolution letter would be sent to them within 21 days. Of note, it has been approximately 37 days since the initial grievance had been reported. In an interview on 09/09/2024 at 1:30 p.m. S1RNHM confirmed the above mentioned findings. In an interview on 09/10/2024 at 9:00 a.m. S2LPN confirmed she was the case manager and received the grievance, however there had been no follow up to the grievances and she was unaware the hospital was still having issues with the flying insects (gnats).”

“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: 48051 Based on policy review, record review and interview, the hospital failed to include the right of the patient to participate in the development and implementation of his or her plan of care. This deficient practice was evidenced by the failure to reveal documentation of the patient or the patient’s representative participating in the development and implementation of his or her plan of care in 3 (#1 - #3) of 3 (#1 - #3) patient medical records reviewed. Findings: A review of facility policy, “Patient Rights,” Policy ID 16427107, last revised 10/2006 with GB approval 08/2024, revealed in part, Purpose: 6. Information: The patient has a right to obtain, from the practitioner responsible for coordinating his care, complete and current information concerning his diagnosis, treatment, and any known prognosis. A Patient’s Bill of Rights: 20. The patient has the right to assist in the development and implementation of their plan of care. A review of facility policy, “Individual Plan of Care,” Policy ID 15957970, last revised with GB Approval 08/2024, revealed in part, Policy: All patients will have an individualized plan of care that is individually tailored, integrated and coordinated by competent professional through licensure, training and experience. Procedure: 1. Each patient has a care plan developed based on the initial assessment. 2. The individual care plan includes the following information: b. The patient’s stated goals and nursing goals are included in the care plan. A review of facility policy, “Plan of Care” Policy ID 15674247, last revised with GB Approval 05/2024, revealed in part, Policy: B. All disciplines involved in the care of a patient collaborate to develop a patient’s plan. C. The patient/family/caregiver is included in the development, implementation, maintenance and evaluation of the care provided. A review of Patients #1 - #3’s medical record failed to reveal documentation of the patient or the patient’s representative participating in the development and implementation of his or her plan of care. In an interview on 09/09/2024 at 2:30 p.m. S2LPN confirmed the above mentioned findings. In an interview on 09/10/2024 at 11:00 a.m. S1RNHM confirmed the above mentioned findings.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 48051 Based on policy review, record review and interview, the hospital failed the patient’s right to make informed decisions regarding his or her care which included being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This deficient practice was evidenced by the failure to include discharge planning in 1 (#2) of 3 (#1-#3) patient plan of cares reviewed for informed decisions. Findings: A review of facility policy, “Patient Discharge Planning,” Policy ID 1566777, last revised and GB approval 05/2024, revealed in part, 1. Discharge planning will begin at the time that the initial psychosocial assessment is completed ... 2. Discharge planning decisions shall be assessed on an ongoing basis during each patient’s stay ... 3. Discharge planning options are to be provided to the patient/family during the initial assessment and at any other time that the discharge plan is being re-assessed. A review of facility policy, “Patient Rights,” Policy ID 16427107, last revised 10/2006 with GB approval 08/2024, revealed in part, Purpose: 2. Respect and Dignity: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition to his personal dignity. 8. Consent: The patient has the right to reasonable informed participation in decisions involving his health care. A Patient’s Bill of Rights: 3. The patient has the right to received form his physician information necessary to give informed consent prior to the stat of any procedure and/or treatment. A review of Patient #2 revealed an admission date of 07/19/2024 and discharge on 08/13/2024. A review of the Finalized Plan of Care failed to reveal documentation related to discharge planning problems, interventions, and goals. Further, the Finalized Plan of Care failed to reveal documentation related to Case Management or Discharge Planning involvement. In an interview on 09/10/2024 at 11:00 a.m. S1RNHM confirmed the above mentioned findings.”

“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, policy review and interview, the hospital failed the patient’s right to receive care in a safe setting. This deficient practice was evidenced by the failure of the nurse call system to be functioning from the available nurse call button on the side railing of the patient beds in 3 (“a”, “h”, “l”) of 17 (“a” - “q”) rooms observed. Findings: A review of facility policy, “Patient Rights,” Policy ID 16427107, last revised 10/2006 with GB approval 08/2024, revealed in part, Purpose: 2. Respect and Dignity: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition to his personal dignity. 4. Personal Safety: The patient has the right to expect reasonable safety in so far as the hospital practices and environment are concerned. A Patient’s Bill of Rights: 24. The patient has the right to be cared for in a safe environment. A tour of the facility on 09/09/2024 from 10:30 am to 11:45 am revealed the presence of the nurse call system to be non-functioning from the available nurse call button on the side railing of the patient beds located in Rooms “a”, “h” and “l”. In an interview and present during the tour on 09/09/2024, S1RNHM confirmed the above mentioned findings.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48051 Based on observation, policy review, record review, and interview, the hospital failed the patient’s right to be free from all forms of abuse or harassment. This deficient practice was evidenced by the failure to provide the services necessary to avoid physical harm, mental anguish or mental illness to 2 (#1, #2) of 2 (#1, #2) patient grievance reports reviewed. Findings: A review of facility policy, “Patient Rights,” Policy ID 16427107, last revised 10/2006 with GB approval 08/2024, revealed in part, Purpose: 2. Respect and Dignity: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition to his personal dignity. 4. Personal Safety: The patient has the right to expect reasonable safety in so far as the hospital practices and environment are concerned. A Patient’s Bill of Rights: 1. The patient has a right to considerate and respectful care. 23. The patient has a right to be free from all forms of abuse and/or harassment during their hospital stay. 24. The patient has the right to be cared for in a safe environment. 27. The patient has a right to voice a complaint/grievance to the hospital and/or the Department of Health and Hospitals and have that complaint/grievance investigate within a reasonable amount of time, usually five (5) days. This is to be followed by a letter to the patient or their representative identifying the results of the investigation and the corrective action that has been taken. A review of facility policy, “Abuse and Neglect: Identification, Assessment, Response, and Reporting,” Policy ID 16427103, last revise with GB approval 08/2024, revealed in part, Purpose: To provide guidance on identifying and addressing circumstances in which a patient is suspected of having been subject to physical or emotional abuse and/or neglect ... Definitions: Neglect: for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Policy: The hospital will ensure patients are free from all forms of abuse, neglect or harassment. III. Identify: a. Staff shall be informed of what constitutes abuse and how to identify events for reporting suspected abuse. i. Neglect: Failure of the facility, its employees or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. v. Protect: a. The facility will make efforts to ensure patients are protected from abuse during the investigation of any allegations of abuse, neglect, or harassment. v. Investigate: a. An immediate investigation is warranted when suspicion of abuse, neglect, or harassment, or reports of abuse, neglect or harassment occurs. vii. Report/Respond: a. The hospital will report and respond to any incidents of abuse, neglect or harassment and analyze, and the appropriate corrective, remedial or disciplinary action occurs ... g. Defining how care provision will be changed and/or improved to protect patients receiving services. A review of a Patient Grievance Investigation Form from 08/04/2024 at 7:00 a.m. revealed Patient #1 filing a grievance on 08/04/2024. The form revealed, “Patient c/o gnats keep biting my forehead. Patient crying and states I can’t move to get them off of me.” The form also revealed the patient is a “Quad” and the patient suggested the facility obtain “gnat traps”. A review of a Patient Grievance Investigation Form from 08/07/2024 at 8:00 a.m. revealed Patient #2 filing a grievance on 08/07/2024. The form revealed, “Patient c/o excessive amount of gnats in his room. Patient state gnats are always flying in his food trays and on his face and body. Patient states it is disgusting.” Further the form revealed in part, nursing staff observed the flying gnats around the patients diaper and seen inside the diaper during diaper change and sacrum wound care. Documentation related to a resolution, an investigation or the results of an investigation to these grievances was requested and was not provided. Of note, it has been approximately 37 days since the initial grievance had been reported. An observation on 09/09/2024 at 11:45 a.m. revealed a black, tiny insect flying around Patient #1’s room. In an interview on 09/09/2024 at 11:45 a.m. Patient #1 confirmed the presence of black, tiny insects flying in his room. He indicated the insects were “gnats.” He confirmed they fly around his face and he was defenseless against these insects because he cannot move. In an interview on 09/09/2024 and present during the interview with Patient #1, S1RNHM confirmed the presence of the flying insect (“gnat”) in Patient #1’s room. In an interview 09/09/2024 at 3:54 p.m., S4Maint confirmed she has been treating the hospital for these flying insects. She further confirmed the hospital does not have a pest control contract with a professional control company and a professional pest control company has not been contacted to assist with the remediation of these flying insects. In an interview on 09/09/2024 at 4:00 p.m. S3Adm confirmed it has been approximately 37 days since the initial grievance was filed, the hospital does not have a pest control contract with a professional pest control company and the hospital has not sought professional assistance with this remediation. She further confirmed she was unaware the flying insects remained a nuisance in the hospital.”

“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: 48051 Based on policy review, record review and interview the hospital failed to measure, analyze and track all adverse patient events and the hospital’s administrative officials failed to ensure there were clear expectations for safety. This deficient practice was evidenced by: 1) failure to analyze and track identified grievances; and 2) failure of the administrative officials to be responsible and accountable to ensure clear expectations for patient safety were established. Findings: A review of facility policy, “Performance Improvement Plan,” Policy ID 14968871, last revised with GB approval 03/2024, revealed in part, Purpose: The Performance Improvement Plan of the hospital is designed to provide a systematic and organized program for the promotion of safe and quality patient care and services ... patient care and processes that affect patient care outcomes shall be continuously monitored and evaluated to promote optional achievements ... Policy: The mission of the hospital will be based upon a comprehensive system that allows for the implementation of continuous quality improvement through the following: ... assessment of the effectiveness of action taken by initiation and ongoing monitoring ... A. Goals: The goals of the program are as follows: 1. To improve patient care safety, quality and services by measuring, assessing and improving ... support processes that most affect patient outcomes. 2. To improve patient care processes and outcomes, and to promote patient safety. F. Administration: The leadership of the hospital through the CEO with his/her Senior Management Staff and QAPI Committee, assumes the responsibility for the quality and safety of care and performance of non-physician professional and technical staff. I. Quality and risk Management Integration: It is essential and part of the Performance Improvement Plan that the Performance Improvement and Risk Management programs are integrated to assure the flow of information to the appropriate areas and up to the department and committee level for review, action, and/or follow-up. 1) Failure to analyze and track identified grievances A review of the hospital’s Complaint Log revealed a complaint on 08/04/2024 at 7:00 a.m. by Patient #1 with a statement of complaint: “gnats biting forehead.” Further review revealed a complaint on 08/07/2024 at 8:00 a.m. by Patient #2 with a statement of complaint: “gnats in food/room.” A review of Patient Grievance Investigation Forms revealed the above two patient’s complaints being reported as grievances. Documentation related to a resolution, an investigation or the results of an investigation to these grievances was requested and was not provided. Of note, it had been approximately 37 days since the initial grievance had been reported. A review of the hospital’s Quality Assurance Performance Improvement Dashboard for 2024 year to date did not reveal the above mentioned grievances on the provided report. In an interview on 09/09/2024 at 1:30 p.m. S1RNHM confirmed the above mentioned information. In an interview on 09/10/2024 at 9:00 a.m. S2LPN confirmed the above mentioned information. 2) Failure of the administrative officials to be responsible and accountable to ensure clear expectations for patient safety are established A review of the hospital’s Complaint Log revealed a complaint on 08/04/2024 at 7:00 a.m. by Patient #1 with a statement of complaint: “gnats biting forehead.” Further review revealed a complaint on 08/07/2024 at 8:00 a.m. by Patient #2 with a statement of complaint: “gnats in food/room.” A review of Patient Grievance Investigation Forms revealed the above two patient’s complaints being reported as grievances. Documentation related to a resolution, an investigation or the results of an investigation to these grievances was requested and was not provided. Of note, it had been approximately 37 days since the initial grievance had been reported. A review of the hospital’s Quality Assurance Performance Improvement Dashboard for 2024 year to date did not reveal the above mentioned grievances on the provided report. In an interview on 09/09/2024 at 4:00 p.m. S3Adm confirmed the above mentioned information and further confirmed she was unaware the “gnats” were still a problem in the hospital.”

“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, record review and interview, the hospital failed to develop and maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients were assured. The deficient practice was evidenced by failure to remediate flying insects within the hospital in a timely manner. Findings: An observation on 09/09/2024 at 11:45 a.m. revealed a black, tiny insect flying around Patient #1’s room. In an interview on 09/09/2024 at 11:45 a.m. Patient #1 confirmed the presence of black, tiny insects flying in his room. He indicated the insects were “gnats.” He confirmed they fly around his face and he was defenseless against these insects because he cannot move. In an interview on 09/09/2024 and present during the interview with Patient #1, S1RNHM confirmed the presence of the gnat in Patient #1’s room. An observation on 09/09/2024 at 1:30 p.m. revealed a black, tiny insect flying around the surveyor’s face while reviewing documents in the hospital’s conference room. In an interview on 09/09/2024 at 1:30 p.m. S1RNHM confirmed the presence of flying insect. A review of a Patient Grievance Investigation Form from 08/04/2024 at 7:00 a.m. revealed Patient #1 filing a grievance on 08/04/2024. The form revealed, “Patient c/o gnats keep biting my forehead. Patient crying and states I can’t move to get them off of me.” The form also revealed the patient is a “Quad” and the patient suggested the facility obtain “gnat traps”. A review of a Patient Grievance Investigation Form from 08/07/2024 at 8:00 a.m. revealed Patient #2 filing a grievance on 08/07/2024. The form revealed, “Patient c/o excessive amount of gnats in his room. Patient state gnats are always flying in his food trays and on his face and body. Patient states it is disgusting.” Further the form revealed in part, nursing staff observed the flying gnats around the patients diaper and seen inside the diaper during diaper change and sacrum wound care. It has been approximately 37 days since the initial grievance had been reported and these flying insect remain in the facility. In an interview 09/09/2024 at 3:54 p.m., S4Maint confirmed she has been treating the hospital for these flying insects. She further confirmed the hospital does not have a pest control contract with a professional control company and a professional pest control company has not been contacted to assist with the remediation of these flying insects. In an interview on 09/09/2024 at 4:00 p.m. S3Adm confirmed the above mentioned findings and further confirmed she was unaware the flying insects remained a nuisance in the hospital.”

“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 record review and interview, the facility failed to ensure infection control standards were maintained. The deficient practice is evidenced by failure of the facility to maintain separate storage for clean and dirty items. Findings: A review of facility policy, “Infection Control Program and Plan,” Policy ID 14966839, last revised and GB approval 03/2024, revealed in part, Program Goals: 8. Provide the policies, tools and education necessary for staff and physicians to limit the transmission of infections associated with the use of medical equipment, devices and supplies. Observation and Evaluation: Environmental Considerations: Inspect the environment on rounds and observe personnel activities for the purpose of detecting infection hazards. Surveillance: Standard Precautions: Environmental cleaning and disinfection shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility, and are to report problems outside of their scope to the appropriate department. Equipment Protocol: All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. An observation during a facility tour on 09/09/2024 from 10:30 a.m. to 11:45 a.m. revealed an equipment closet containing 10 wheelchairs, 3 walkers, 3 sets of crutches, an electric floor buffer containing a buffing pad that appeared to be used, an electric floor scrubber, a 5 gallon container of High Gloss Floor Finisher, a gallon container of Pioneer Products Floor Cleaner and an empty mop bucket stored atop a wheelchair. None of the patient care equipment was covered or had any indication that it had been sanitized prior to storage. The contents of this equipment closet should not be comingled due to the risk of the transmission of HAIs from floor cleaning equipment to patient equipment. In an interview and present on the facility tour on 09/09/2024, S1RNHM confirmed the above mentioned findings and indicated the equipment should have been covered once it was sanitized and prior to storing.”

“MEDICAL STAFF - APPOINTMENTS CFR(s): 482.12(a)(2) [The governing body must] appoint members of the medical staff after considering the recommendations of the existing members of the medical staff. This Standard is not met as evidenced by: 48050 Based on record review and interview the governing body failed to appoint members of the medical staff after considering the recommendations of the existing members of the medical staff. This deficient practice is evidence by the governing body failing to appoint a director of rehabilitation services and a director of respiratory services. Findings: Review of the organizational chart on 07/31/2024 at 3:00 p.m. failed to reveal a director of rehabilitation services or director of respiratory services employed by the hospital. In an interview on 07/31/2024 at 3:10 p.m., S2ADM verified that there is no director of rehabilitation services or director of respiratory services.”

“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: 48050 Based on observation, record review and interview the hospital failed to ensure each patient received care in a safe setting. This deficient practice is evidenced by the hospital’s failure to ensure 2 (S6Driver, S7Driver) of the 2(S6Driver, S7Driver) transport drivers were CPR certified and a first aid kit available in the transport van. Findings: Review of the provided job description for Transportation Driver revealed in part: ESSENTIAL FUNCTIONS INCLUDE BUT ARE NOT LIMITED TO: Transportation Driver: 11. Maintains CPR and First Aid equipment in the vehicle. 15. Follows all city and state laws with regards to driving the company vehicle. An observation on 07/31/2024 at 11:20 a.m. of the transport van revealed no first aid kit available in the transport van. Further observation revealed inspection sticker with an expiration date of 04/2024. In an interview on 07/31/2024 at 11:25 a.m. S6Driver verified there was no first aid kit in the transport van and the inspection sticker expired 04/2024. In an interview on 07/31/2024 at 12:20 p.m., S3NM verified that S6Driver and S7Driver are not certified CPR as required by the facility job description.”

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d)(1) The patient has the right to the confidentiality of his or her clinical records. This Standard is not met as evidenced by: 48050 Based on policy review, observation, and interviews, the hospital failed to ensure patients had the right to confidentiality of his/her clinical records. This deficient practice is evidenced by: 1) Failure to ensure an unattended computer screen accessible to visitors, patients and staff did not contain private patient information; and 2) Failure to ensure patients’ medical records were not left unattended. Findings: 1)Failure of the hospital to ensure an unattended computer screen accessible to visitors, patients and staff did not contain private patient information. Direct observation on 07/29/2024 at 1:00 p.m. revealed an unattended computer at the nursing station accessible to visitors, patients, and staff with visible patient information on the screen. In an interview on 07/29/2024 at 1:05 p.m., S3NM verified the unattended computer with confidential information on the screen at the nursing station was visible to visitors, patients, and staff with patient information. 2)Failure of the hospital to ensure patients’ medical records were left unattended. An observation on 07/29/2024 at 1:08 p.m. medical records department door open with no one attending the area. Further observation revealed open access to a shred box with the ability to access patient information. In an interview on 07/29/2024 at 1:10 p.m. S3NM verified that the medical records were not secured.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48050 Based on record review and interview, the director of nursing failed to ensure all nursing staff adhered to the policies and procedures of the hospital. The deficient practice is evidenced by failure of the nursing staff to adhere to the service animal policy. Findings: Review of the policy titled, “Pet visits and/or Assisted Therapy” last approved 03/2024 revealed in part: PROCEDURE: The Infection Control Professional or designee must be notified prior to any Pet visits/therapy in an attempt to control infectious diseases or eliminate harm to patients, visitors, and/or staff. A copy of this policy must be given to anyone requesting a pet visit. A current health certificate form a licensed veterinarian is required for any pet visits to take place. The pet must be free from external parasites, specifically fleas, ticks, lice, and mites. The pet is free from internal parasites, specifically hookworms, heartworms, roundworms, tapeworms, whipworms, and strongyloides. All necessary immunizations and licenses by the jurisdiction of residence are current. The Pets are allowed to visit in owner/patient rooms only or outside the facility. Pets are not allowed in other rooms or areas of the hospital. In an interview on 07/29/2024 at 11:15 a.m. S3NM reports that Patient #2 had a pet dog while hospitalized. She verified the Infection Control Professional or designee was not notified, and dog’s current health certificate from a licensed veterinarian was not obtained and the dog’s vaccination and parasite status was unknown. In an interview on 07/31/2024 at 9:30 a.m. S8ST verified that Patient #2’s pet dog was allowed to come into the therapy room. S8ST verified the dog was not restricted to Patient #2’s room or areas outside the facility.”

“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 07/29/2024 at 12:20 p.m. the medication room door was unlocked and propped open leaving medications unsecure. Observation in the medication room included an unlocked medication cart with patients’ prescription medications and the unit’s OTC medications. In an interview on 07/29/2024 at 12:30 p.m., S3NM 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.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 48050 Based on record review and interview the hospital failed to employ a full time director of food and dietetic services. Findings: Review of the personnel files revealed the dietician was contracted for consultations as needed and was not a full time employee. Further review revealed there was no one trained to perform the duties of dietary manager or food director. In interview on 07/30/2024 at 3:10 p.m., S2ADM verified there was no full time employee trained to manage the dietary services.”

“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: 48050 Based on observation and interview the facility failed to maintain the condition of the physical plant and overall hospital environment in such a manner that the safety and well-being of patients are assured. The deficient practice is evidence by failing to label all chemicals used with MDS information maintain on all chemicals used. Findings: During a tour of the housekeeping closet on 07/30/2024 at 2:15 p.m., two unlabeled spray bottles with liquid were identified on the housekeeper cart. In an interview on 07/30/2024 at 2:20 p.m., S5Main verified that all products on the housekeeping cart are used in the facility for cleaning including the 2 unlabeled spray bottles with unidentified liquid. Furthermore S5Main verified there is no MSDS information regarding the unidentified liquid.”

“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: 48050 Based on observation, record review and interview, the facility failed to maintain an infection prevention and control program which includes surveillance, prevention, and control of HAIs, and maintains 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 failing to maintain patients’ shower room in a sanitary condition. Findings: During a tour of the facility on 07/29/2024 at 12:33 p.m., direct observation revealed dirty towels, dirty washcloths, used gloves, and trash left in Room a. In an interview on 07/29/2024 at 12:34 p.m., S3NM verified that Room a should be cleaned after use by each patient and dirty towels/washcloths or trash should not be left in Room a. During a tour of the facility on 07/29/2024 at 12:35 p.m., direct observation in Room b revealed a torn “crash” mat with exposed foam filling which was used in patient care. In an interview on 07/29/2024 at 12:36 p.m. verified that the torn “crash” mat should not be used due to unable to effectively clean the foam.”

“DIRECTOR OF REHABILITATION SERVICES CFR(s): 482.56(a)(1) The director of the services must have the necessary knowledge, experience, and capabilities to properly supervise and administer the services. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to designate a director of rehabilitation services who had the knowledge, experience, and capabilities to properly supervise and administer the services. The deficient practice is evidenced by failure of the facility to designate a qualified employee as Director of Rehabilitation services. Findings: Review of the provided organizational chart failed to reveal a Director of Rehabilitation services In an interview on 07/31/2024 at 3:00 a.m., S2ADM verified the hospital did not have anyone designated as the Director of Rehabilitation Services.”

“DIRECTOR OF RESPIRATORY SERVICES CFR(s): 482.57(a)(1) There must be a director of respiratory care services who is a doctor of medicine or osteopathy with the knowledge, experience and capabilities to supervise and administer the service properly. The director may serve on either a full-time or part-time basis. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure compliance with all requirements for Respiratory Services. The deficient practice is evidenced by failure of the facility to appoint a doctor to supervise the service. Findings: Review of the hospital’s organizational chart revealed no documented evidence that a doctor of medicine or osteopathy was appointed to supervise the respiratory services. In interview on 07/31/24 at 3:15 p.m., S2ADM confirmed there was no doctor appointed to provide medical direction for respiratory services.”

“RESPIRATORY CARE PERSONNEL POLICIES CFR(s): 482.57(b)(1) Personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures must be designated in writing. This Standard is not met as evidenced by: 48050 Based on record review and interview the hospital failed to ensure personnel were qualified to perform specific respiratory care procedures. This deficient practice was evidenced by failure to provide policies and procedures that included the qualifications, including job title, education, training and experience of personnel authorized to perform each type of respiratory care service and whether they may perform it without respiratory supervision. Findings: Review of S9RT’s orientation skills assessment/competency checklist revealed only a self-evaluation with no evaluation done to show competencies. In an interview on 07/31/2024 at 12:40 p.m. S3NM verified S9RT’s Orientation Skills Assessment/Competency Checklist was only has a self-evaluation with no evaluation of S9RT’s Skills Assessment/Competencies.”

“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: 14442 Based on record review and interview, the hospital failed to ensure each patient was informed of his/her patient care rights in a manner that he/she could understand. This deficient practice was evidenced by failing to ensure the services of a translator or interpreter were available to facilitate communication between the patient and hospital staff for 3 (#1, #2, #3) of 3 non-English speaking patients sampled. Findings: Review of the hospital policy titled Patient’s Rights and Responsibilities effective 01/2022 revealed, in part: Procedure: B. For patients with language barriers or those that are unable to read, the contents of the statement should be interpreted and/or explained to the extent possible in a language the patient can understand. Review of the hospital Patient Bill of Rights and Responsibilities revealed, in part: You have the right to ...12. Have access to interpreter services at no cost to you or your companion when you do not speak or understand the language. Review of the hospital policy titled Communication, Non-English Speaking effective 05/2017 revealed, in part: Policy: If language or communication barriers exist between staff and patients, arrangements shall be made for interpreters or for the use of other mechanisms to ensure adequate communication between patients. Procedure: 1. When confronted with a situation which requires an interpreter, the Social Worker has the phone numbers of the contracted agencies who can provide assistance with interpretation. 2. The Social Worker will make contact with the appropriate interpreter service that can meet the need of the patient. 3. The Social Worker will arrange for the interpreter to come into the hospital to provide services for the patient. 4. The Social Worker will communicate to the patient/significant other that interpretation services will be provided. Review of Patient #1, Patient #2, and Patient #3’s medical records revealed all three patients non-English speaking patients. Further reviewed revealed documented evidence of communication issues between patients and staff. In an interview on 04/22/2024 at 11:34 a.m., S4LPN confirmed Patient #1 and Patient #2 were non-English speaking patients. S4LPN confirmed hospital staff tried to communicate with Patient #1 and Patient #2 with a communication board and cell phone translate app without success. S4LPN indicated the communication barrier made it difficult to provide routine nursing care for Patient #1 and Patient #2. S4LPN indicated the hospital did not have translator or interpreter services to provide assistance with communication between non-English speaking patients and hospital staff. In an interview on 04/22/2024 at 11:47 a.m., S3RN confirmed Patient #1 did not speak or understand English. S3RN indicated Patient #1 would often get agitated and frustrated when trying to communicate with the patient using a communication board and cell phone translate app. S3RN indicated hospital staff had to call Patient #1’s son to come to the hospital to help with communication between Patient #1 and hospital staff. S3RN indicated the hospital did not have translator or interpreter services to provide assistance with communication between non-English speaking patients and hospital staff. In an interview on 04/22/2024 at 12:39 p.m., S2Nurse Manager confirmed Patient #1, Patient #2, and Patient #3 were non-English speaking patients. S2Nurse Manager indicated the communication barrier between Patient #1, Patient #2, and Patient #3 made it difficult for staff to provide routine nursing care. S2Nurse Manager indicated the hospital did not have translator or interpreter services to provide assistance with communication between non-English speaking patients and hospital staff. In an interview on 04/22/2024 at 1:16 p.m., S5Case Manager indicated she was not aware of hospital contracted agencies or other arrangements to provide assistance with interpretation between non-English speaking patients and hospital staff. In an interview on 04/24/2024 at 11:09 a.m., S1Administrator indicated the hospital did have interpreter services. S1Administrator indicated hospital staff not aware of this service and needed education on this subject.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 14442 Based on observation, record review, and interview, the hospital failed to protect the patient’s right to personal privacy. This deficient practice was evidenced by allowing a patient’s (#1) family member to attend therapy sessions with other hospital patients present in the therapy room without obtaining his/her prior consent. Findings: Observation on 04/22/2024 at 1:19 p.m. revealed a sign posted on the wall outside of the hospital therapy room in all capitalized letters that read: Stop. No visitors or family members allowed beyond this point! Review of the hospital policy titled Patient Visitation effective 01/2018 revealed, in part: Procedure: D. Visitor access is limited to public areas of the hospital. In an interview on 04/22/2024 at 1:22 p.m., S6PT confirmed no visitors or family members were allowed in the hospital therapy room. In an interview on 04/22/2024 at 1:24 p.m., S7OT confirmed no visitors or family members were allowed in the hospital therapy room. S7OT confirmed Patient #1 did not speak English and Patient #1’s son needed to be present during therapy sessions for him to communicate with the patient. S7OT confirmed other hospital patients received therapy in the presence of Patient #1’s son. In an interview on 04/22/2024 at 12:39 p.m., S2Nurse Manager confirmed Patient #1’s son was present during therapy sessions while other patients received therapy. S2Nurse Manager confirmed only hospital patients should be in the therapy room during sessions to protect the privacy of other patients. S2Nurse Manager indicated prior consent or approval was not obtained from the other patients that were present when Patient #1’s son was in the therapy room.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 44495 Based on record review and interview, the facility failed to review and resolve a grievance. The deficient practice is evidenced by failure to document an investigation for 1(#2) of 1 reviewed patient records with an associated grievance. Findings: Review of Policy #14231748,”Patient /Family Grievance,” last approved 07/2021, revealed in part, “G. In cases of a grievance the Director of Social Services/ case manager or the Director of Nursing will investigate the substance of the grievance, if resolution of the grievance cannot be achieved within 5 business days , the Director of Social Services or case manager will alert the Director of Nursing or Hospital Administrator to assist with resolution. H. If by the 7th day the grievance still cannot be resolved, the patient and /or their representative will be sent a written letter informing them that the investigation is still underway and that a letter of resolution will be sent to them within 21 days by the Director of Social Services.” Review of the requested grievances revealed a “Patient Complaint Form” filled out by the case manager dated 12/19/2023 at 2:59 p.m. The complaint was initiated by the son of Patient #2. The document revealed the son had called the police because he found another patient’s medication in his father’s medication and he believed it was causing the patient to act abnormally. The bottle of medication was requested back by the case manager and she was informed by the son that emergency medical services had taken the bottle. Nursing staff, the administrator and the physician had been notified. There was no investigation associated with the grievance and no attempt at resolution documented. In interview on 04/23/2024 at 3:11 p.m., S4RN verified there was no additional documentation to indicate the facility attempted to investigate and/or resolve the grievance.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 44495 Based on record review and interview, the facility failed to resolve a grievance with written notice of the hospital decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. The deficient practice is evidenced by failure to send the requisite letter to 1 (#2) of 1 reviewed patient records with an associated grievance. Findings: Review of Policy #14231748,”Patient /Family Grievance,” last approved 07/2021, revealed in part, “G. In cases of a grievance the Director of Social Services/ case manager or the Director of Nursing will investigate the substance of the grievance, if resolution of the grievance cannot be achieved within 5 business days , the Director of Social Services or case manager will alert the Director of Nursing or Hospital Administrator to assist with resolution. H. If by the 7th day the grievance still cannot be resolved, the patient and /or their representative will be sent a written letter informing them that the investigation is still underway and that a letter of resolution will be sent to them within 21 days by the Director of Social Services.” Review of the requested grievances revealed a “Patient Complaint Form” filled out by the case manager dated 12/19/2023 at 2:59 p.m. The complaint was initiated by the son of Patient #2. The document revealed the son had called the police because he found another patient’s medication in his father’s medication and he believed it was causing his father to act abnormally. The bottle of medication was requested back by the case manager and she was informed by the son that emergency medical services had taken the bottle. Nursing staff, the administrator and the physician had been notified. There was no investigation associated with the grievance and no attempt at resolution documented. In interview on 04/23/2024 at 3:11 p.m., S4RN verified a letter was not sent to the patient of his family.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to ensure proper documentation of informed consent. The deficient practice is evidenced by failure of the person obtaining the consent to sign the document in 2 (#1, #5) of 5 (#1-#5) reviewed patient records. Findings: Review of Policy#14224978, “Consent/Legal Documents, Witnessing of,” last approved 06/2017, revealed in part, “It is the policy of this facility that the witnessing of legal documents while a patient is in the care of the facility be approved by the registered nurse or social worker.” Review of the admission consents for Patient #1 revealed a six page document which included the consent to medical procedures, nursing care, the legal relationship between the hospital and the physician, release of information, consent to photograph, assignment of benefits, notification of emergency services when a physician is not present at the facility, visitation, and financial responsibility. The sixth page was signed by the patient’s representative. The form was not dated, did not indicate the relationship of the person who signed to the patient, and did not have the signature of the person obtaining the consent. In interview on 04/23/2024 at 5:30 p.m., S4RN verified the person obtaining the consent did not sign the document and the document was not dated. Review of the admission consents for Patient #5 revealed the Consent to Photograph/Videotape was signed and dated by the patient but there was no signature by hospital staff to indicate who was responsible for obtaining the consent and the form was not witnessed. In interview on 04/23/2024 at 3:46 p.m., S4RN verified the consents were not witness and were not signed by the person who obtained the consent from the patient. S4RN also verified that Patient #5 had wounds and pictures were taken.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 44495 The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. Findings: Based on record review and interview the hospital failed to employ adequate numbers of nurses. The deficient practice is evidenced by documentation of two nurses working 2 consecutive 12-hour shifts. Findings: Review of Policy #14224630, “Staffing Plan,” last approved 08/2020, revealed in part, “Procedure: A. Work Schedule: 1. It is the facility’s prerogative to specify any employee’s work hours according to operational requirements. 2. Patient care staff should not work more than 16 consecutive hours or 60 hours per week without approval of the Administrator. . . .3. Master schedules comprising a minimum of 4 weeks, should be prepared for the facility by the DON or designee. A definite work schedule for full-time and part-time employees will be established and be prepared at least fourteen (14) days in advance. . . . B. Schedules: 1. Unit schedules will be saved for a period of five (5) years, two (2) years of nursing unit staffing will be filed in the DON’s office. 2. Daily staffing schedules should include documentation of: a Date; b. Shift hours; c. Employee’s name, skill level; d. Illness or absence reason.” Review of the “Daily Staffing Assignment Sheet” for 03/08/2024 revealed S5RN and S7LPN worked the day shift. Further review revealed S5RN, S7LPN along with S6LPN and S8LPN worked the night shift. There was no documentation on the assignment sheet that any of the nurses worked a partial shift. In interview on 04/23/2024 at 11:46 a.m., S7LPN verified there was no documentation that either worked only part of the night shift.”

“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: 44495 Based on record review and interview, the hospital failed to ensure a registered nurse supervised the care of each patient. The deficient practice is evidenced by: 1) one daily staffing assignment sheet with no documented registered nurse at the facility; 2) failure of nursing staff to document vital signs twice a day as ordered in 1 (#5) of 5 (#1- #5) reviewed medical records; and 3) failure of nursing staff to document rounds every 2 hours in 1 (#5) of 5 (#1- #5) reviewed medical records. Findings: 1) One daily staffing assignment sheet with no documented registered nurse at the facility. Review of the “Daily Staffing Assignment Sheet” for the night shift on 03/10/2024 revealed only 2 licensed practical nurses were providing care with 9 patients in the facility. In interview on 04/23/2024 at 11:40 a.m., S4RN verified the assignment sheet did not document a registered nurse was on site to supervise the care of the patients. 2)Failure of nursing staff to document vital signs twice a day as ordered. Review of the medical record for Patient #5 revealed admission on 04/10/2024 with a diagnosis of cardiac disorder and heart failure. Review of the admission orders for Patient #5 revealed vital signs were to be performed two times a day. Review of the vital signs revealed they were performed only once on 04/11/2024 and 04/12/2024. In interview on 04/23/2024 at 4:17 p.m., S4RN verified the vital signs were not documented twice a day as ordered. 3) Failure of nursing staff to document rounds every 2 hours. Review of the medical record for Patient #5 revealed admission on 04/10/2024 with a diagnosis of cardiac disorder and heart failure. Review of the “Daily Nursing Flowsheet” for Patient #5 for 04/20/2024 revealed no rounds were documented between 7:00 p.m. on 04/20/2024 and 5:00 a.m. on 04/21/2024. In interview on 04/23/2024 at 4:15 p.m., S6LPN verified the rounds were not documented. S6LPN verified the rounds should have been documented every 2 hours.”

“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: 44495 Based on record review and interview, the hospital failed to ensure the Nursing Care Plan was completed per hospital policy. The deficient practice is evidenced by 1) failure to complete the Nursing Care Plan within the first 24 hours of admission for 1 (#4) of 5 (#1-#5) reviewed patient records; and 2) failure to modify the care plan after a significant event for 1 (#3) of 5 (#1-#5) reviewed patient records. Findings: 1)Failure to complete the Nursing Care Plan within the first 24 hours of admission. Review of Policy #14224971, “Patient Care Standards,” last approved 02/2125, revealed in part, “II. PLANNING: A. An individual care plan will be developed within eight hours of admission.” Review of the medical record for Patient #4 revealed admission on 12/08/2023 at 3:04 p.m. Further review revealed the Nursing Care Plan was not completed until 12/11/2023. In interview on 04/23/2024 at 2:11 p.m., S6LPN verified the Nursing Care Plan was not completed in the timeframe required by the facility’s policy. 2) Failure to modify the care plan after a significant event. Review of the medical record for Patient # revealed admission on 11/29/2023. Review of the Wound Care Sheet and photographs for Patient #4 on admit revealed the patient had a 5 -6 centimeter intact pressure sore on the left hip and preventive measures were initiated. Review of the Wound Care Sheet for Patient #4 on 12/06/2024 revealed the skin was no longer intact. Further review of the orders, nursing notes, and care plan failed to reveal the nurse initiated any additional care and there was no documentation that the physician was notified. Photographs were not taken. Further review of the record revealed on 12/11/2023 a photograph of the lesion on the left hip was taken. The photograph revealed an 8 centimeter crusted open lesion. Additional measures for treatment were initiated at that time. In interview on 04/23/2024 at 4:53 p.m., S4RN and S6LPN verified the above findings. The Policy #14231906,”Wound Care: Pressure Ulcer Prevention & Management of Pressure Ulcers,” last approved 06/2020, was reviewed. The policy did not address when photographs should be taken or notification of the physician. S6LPN verified the hospital policy is to take photographs when a change in the pressure ulcer is noted. S6LPN verified the care plan should have been modified, pictures should have been taken and the physician should have been notified on 12/06/2024 when it was first discovered to have non-intact skin.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to ensure patient care assignments were performed according to hospital policy and use of the Patient Acuity Tool. The deficient practice is evidenced by failure to assign patient acuities for 10 of 14 shifts in the week prior to the survey. Findings: Review of the provided document, “Patient Acuity Scoring Process,” which was provided as the current policy for patient assignments which was not dated and not associated with an approved policy, revealed in part, “1. Educate all nursing staff on the use of patient acuity tool Monday 8/21. 2. Nurses will complete a patient acuity tool on each of their assigned patients.” Review of the document, “United Medical Rehabilitation Hospital Patient Acuity Tool,” which was provided as current but did not have a date of review or approval, revealed in part, “Each shift the RN will review the acuity tables and will make assignments according to acuity and competency of the licensed nurse up to 20 points per nurse.” Review of the assignment sheets from 04/15/2024 through 04/21/2024 revealed patient acuity was not documented on the day shift or night shift for each patient on the assignment sheet for 04/15/2024, 04/16/2024, 04/17/2024, 04/18/2024, and 04/19/2024. In interview on 04/23/2024 at 11:26 p.m., S4RN verified the patients were not assigned by acuity.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 44495 Based on record review and interview, the facility failed to ensure contract staff were properly supervised. The deficient practice is evidenced by the use of contracted registered nurses as a charge nurse on 5 shifts between 03/16/2024 and 04/10/2024. Findings: Review of the provided list of recently used agency nurses included S8ARN, S9ARN, and S11ALPN. Review of the “Daily Staffing Assignment Sheet” from 03/16/2024 through 04/10/2024 revealed the following: -On 03/16/2024 on the day shift, S8ARN was the only registered nurse on the schedule. -On 03/31/2024 on the day shift, S8ARN was the only registered nurse on the schedule. S8ARN was identified as a contracted nurse by the placement of “RN-A” on the schedule. -On 03/31/2024 on the night shift, S10ARN was the only registered nurse on the schedule. S10ARN was identified as a contracted nurse by the placement of “RN-A” on the schedule. -On 04/21/2024 on the night shift, S8ARN was the only registered nurse on the schedule. Further review revealed there was only one licensed practical nurse working that shift, S11ALPN, who was also a contracted nurse. -On 04/10/2024 on the night shift, S8ARN was the only registered nurse on the schedule. S8ARN was identified as a contracted nurse by the placement of “RN-A” on the schedule. In interview on 04/23/2024 at 11:50 a.m., S6LPN verified the use of agency nurses as the nurse in charge of the shifts.”

“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: 44495 Based on record review and interview, the hospital failed to ensure each admitted patient had a history and physical performed no more than 30 days before or 24 hours after admission. The deficient practice is evidenced by a history and physical documented more than 24 hours after admission in1 (#4) of 5(#1- #5) reviewed medical records. Findings: Review of Policy #14224590, “Time Frames,” last approved 02/2015, revealed in part, “Document- History and Physical-Completion time: 24 hours.” Review of the medical record for Patient #4 revealed admission on 12/08/2023 at 3:04 p.m. Review of the documented history and physical revealed it was performed on 12/10/1013 at 9:20 a.m. In interview on 04/23/2024 at 2:10 p.m., S6LPN verified the history and physical was not completed within 24 hours of admission.”

“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, record review, and interview, the hospital failed to ensure the infection prevention program included surveillance of the facility to identify and mitigate identified sources with potential for transmission of infection. The deficient practice is evidenced by: 1) expired items in the emergency cart; 2) tape covering a hole in the therapy mat; 3) failure to ensure food was kept free of spoilage. Findings: 1) Presence of expired items in the emergency cart. Direct observation during tour of the facility on 04/23/2024 at 8:40 a.m. revealed 2 boxes of nitrile gloves with an expiration date of 09/2022 and 3 non-rebreather masks with an expiration of 02/2016. At the time of discovery, S4RN verified the items were expired. 2) Presence of tape covering a hole in the therapy mat. Direct observation during tour of the facility on 04/23/2024 at 8:55 a.m. revealed the therapy mat had two pieces of tape covering palpable holes in the covering. In interview at the time of discovery, S4RN verified the tape was an infection control issue. 3) Failure of the hospital to ensure food was kept free for spoilage. Review of the temperature logs for the patient refrigerator and the patient freezer for March of 2024 revealed the temperatures were not checked on 03/30/2024 and 03/31/2024. In interview on 04/23/2024 at 8:35 a.m., S4RN verified the refrigerator and freezer temperatures were not checked.”

“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: 38777 Based on observations and interviews the hospital failed to provide care in a safe setting as evidence by utilizing portable space heaters in 2 (104, 106) of 8(103, 104, 106, 107, 108, 109, 201, 205) patient rooms observed, which pose a fire safety hazard. Findings: On 01/19/2024 at 3:29 p.m. a tour of the facility with S1Adm revealed a portable heater running with an oxygen concentrator running in patient room 104 and a portable heater in patient room 106, not currently in use. In an interview on 01/19/2024 at 3:29 p.m. Patient #2 stated the hospital provided the heater as her room got cool at times. In an interview on 01/19/2024 at 3:50 p.m. S1Adm verified the use of portable heater in patient rooms, lobby and the therapy room.”

“General Requirements - Other CFR(s): NFPA 101 General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 35367 Based on visual observation the facility failed to maintain a patient comfortable environment via a properly functioning central heating system as per the manufactures specifications. The central heating system proper maintenance is essential to assure the patients are protected as best as possible from a mechanical failure that could possibly result in a fire or smoke emergency. The deficient practice had the potential to affect nine of nine patients. Findings: During the facility tour on January 19, 2024 between the hours of 3:45 p.m. to 7:00 p.m. The HVAC did not appear to be operating at a adequate level to supply heat to the patient care areas/ rooms. The Administration had contacted a HVAC company and was awaiting their call back for service. Shall provide all HVAC equipment with proper operating capability to achieve a set thermostat heat temperature level at any given time regardless of the outside temperature. The interview with the Administrator and the Facility Director revealed the facility was aware the central heating system was not heating up to the proper standards and at time of survey the Administrator had contacted a licensed HVAC company and was awaiting a service technician to schedule a prompt visit to inspect and improve the performance of the six central heaters to allow the patients a more comfortable environment.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 35367 Based on visual observation the facility failed to assure that portable heating devices were not restricted from use. Since the devices are portable, they can be placed to closely to a combustible ignition source which would result in a fire/smoke emergency. This deficient practice has the potential to affect nine of nine residents. Findings: During the facility tour on January 19, 2024 between the hours of 3:45 p.m. to 7:00 p.m. the facility was using space heaters to supplement the central heating of the rehab hospital in the wake of this weekend temperatures possibly achieving a low of twenty six degrees Fahrenheit. The following locations had space heaters provided: patient room 104, patient room 106, lobby and the physical therapy room. The physical therapy room and patient room 104 had active space heaters in operation at time of survey. The other locations had space heaters that were not being used but stored for use if needed. The six HVAC units were functioning; however, they did not appear to be performing at the proper standard to provide enough heat throughout the Hospital to reach the set thermostat temperature. For example, the approximate temperature outside the facility was fifty one degrees Fahrenheit at time of survey and all six thermostats were set at temperatures a minimum of five degrees higher than the indoor temperature could achieve. The concern is the central heat may not be able to provide enough comfortable heat this upcoming weekend for the facility during the predicted below freezing temperature drop. The facility is required to perform a fire watch every thirty minutes and using a infrared temperature device provide a hourly temperature check by monitoring the patient sleeping rooms and six thermostats indoor temperature display. Please refer to Louisiana Department of Health and Hospitals guidance if the temperature does not meet the acceptable comfortable conditions. Note: The patients appeared to be comfortable with the temperature at the time of inspection. L.R.S. 40:1578.6 (C) This inspector deems that a serious life hazard exists due to the lack of adequate comfortable patient temperature. This facility shall implement a fire watch in accordance with State Fire Marshal Guidelines, a copy of said guidelines was given to the Administrator and said fire watch shall remain in effect until the HVAC equipment is functioning properly and an inspection has been conducted by this office. The interview with the Administrator and the Facility Director revealed the facility was not aware the space heaters are not allowed to be used to supplement heat in the patient sleeping rooms at time of survey. The Administrator had contacted a licensed HVAC company and was awaiting a service technician to schedule a prompt visit to inspect and improve the performance of the six central heaters to allow the patients a more comfortable environment.”