Lakeview Specialty Hospital & Rehab Center

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 47413 Based on record review, observation and interview facility staff failed to respond to an abnormal cardiac (heart) rhythm outside of ordered parameters for 1 of 1 patient (Patient #4), and failed to perform continuous cardiac monitoring for 3 of 3 patients (Patients #1, 2, 3) requiring telemetry (continuous, wireless tracking of a patient’s heart rhythm and vital signs using small chest electrodes and a portable transmitter that sends data to a central nursing station) monitoring in a total of 19 medical records reviewed. Facility staff failed to respond to an abnormal cardiac rhythm outside of ordered parameters and failed to perform continuous cardiac monitoring. See Tag A-395.”

“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: 47413 Based on record review, observation and interview facility staff failed to respond to an abnormal cardiac (heart) rhythm outside of ordered parameters for 1 of 1 patient (Patient #4), and failed to perform continuous cardiac monitoring for 3 of 3 patients requiring telemetry (continuous, wireless tracking of a patient’s heart rhythm and vital signs using small chest electrodes and a portable transmitter that sends data to a central nursing station) monitoring (Patient #1, 2, 3) in a total of 19 medical records reviewed. Findings Include: A review of the hospital’s policy #7.810 titled, “Telemetry (cardiac monitoring), Cardiac, and Continuous SpO2 (oxygen) monitoring” last revised 12/2025 revealed, “... E. Alarm Management and Escalation... Bedside RN (Registered Nurse) will immediately assess the patient for crisis alarms... initiate appropriate interventions.... and notify the provider per clinical condition... G. Rhythm Strip... Documentation Requirements: Print/record and interpret a rhythm strip at a minimum once per shift and with any rhythm change or significantly clinical event...” Example of a failure to respond to an abnormal cardiac rhythm outside of ordered parameters: A review of Patient #4’s medical record revealed that she was admitted to the hospital for further rehabiliation and management on 05/04/2026 from an outside hospital for hypoglycemia (low blood sugar) and dense encephalopathy (severe, profound, or deep neurological impairment, or specific radiologic findings of severe brain injury), requiring continouous cardiac monitoring. Review of the record revealed the following note titled, “Chart Note” on 05/15/2026 at 3:25 AM by RN U” “... 0249 (2:49 AM)- Writer in hallway called to patients room. 0250 (2:50 AM) Patient unresponsive, turning blue, pulseless, not breathing. 911 called by staff...” A review of Patient #4’s medical record revealed heart rate parameters were set to alarm at “>120 BPM (beats per minute) and <60 BPM.” Review of the record revealed on 05/15/2026 at 2:18 AM: HR (heart rate) of 124 BPM, 2:29 AM: 57 BPM, 2:30 AM BPM: 48 BPM, 2:40 AM: 55 BPM, 2:46 AM: 39 BPM, 2:48 AM: 33 BPM, 2:49 AM: 34 BPM, 2:51 AM: 12 BPM and then asystole (no heart rate). There was no evidence of assessment, interventions, or any response to the alarms outside of ordered parameters performed on Patient #4 between 2:18 AM-2:51 AM (33 minutes prior to Patient #4 coding). Further review of the medical record revealed that Patient #4 was sent to a higher level of care on 05/15/2026 and then was readmitted to the facility on 5/16/2026 with a noted cognitive decline than previous admission. During an interview on 07/21/2026 at 10:38 AM CNA (Certified Nursing Assistant) L, she stated when the heart rate goes outside of the parameters, that the patient needs to be “checked on” and to notify the nurse right away. During an interview on 07/21/2026 at 10:39 AM RN (Registered Nurse) C stated that if a patient’s telemetry monitor is alarming that she goes in right away to assess the patient. During an interview on 07/22/2026 at 11:05 AM, Director of Quality K stated that it “could have been” time to hourly round on Patient #4 and that is why staff went into Patient #4’s room when they found her unresponsive. Examples of failure to perform continuous cardiac monitoring per physician order: A review of Patient #1’s medical record revealed an order was placed for “Telemetry Monitoring Twice Daily” on 06/06/2026 at 9:00 PM. During an observation on 07/21/2026 at 3:54 PM, Patient #1 did not have any evidence of telemetry electrodes connected or monitoring as per physician order. A review of Patient #2’s medical record revealed an order was placed for “Telemetry Monitoring Twice Daily” on 05/19/2026 at 4:04 PM. During an observation at 07/21/2026 at 3:57 PM, Patient #2 did not have any evidence of telemetry electrodes connected or monitoring as per physician order. A review of Patient #3’s medical record revealed an order was placed for “Telemetry Monitoring Twice Daily” on 06/10/2026 at 4:34 PM. Review of the record revealed facility staff only monitored his cardiac rhythm per physician order on 06/30/2026, 07/02/2026, 07/03/2026, 07/04/2026, 07/11/2026 and 07/16/2026 (35 days missing). During an interview on 07/21/2026 at 10:56 AM, RN C stated, “We should be reading and printing telemetry strips every shift.” During an interview on 07/22/2026 at 8:43 AM with Medical Director O, he stated that if the order is placed for telemetry monitoring (even if the order states twice daily), that the order is to be “continuous with no interruptions.””

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 47413 Based on observation, record review and interview, the facility staff failed to post isolation signage to prevent potential transmission of infections by failing to follow their isolation precautions in 2 of 2 patient observations on isolation (Patients #7, 8) in a hospital census of 24 patients. Findings Include: A review of the hospital’s policy #6.170 titled, “Standard Precautions/Transmission-Based Precautions” last revised 05/2026 revealed, “Upon admission... initiate precautions and signage ... Place the appropriate isolation sign outside of the patient’s room immediately... ensure it is visible and specific to the type of precautions...” A review of Patient #7’s medical record revealed he was placed on “Contact Isolation” for MRSA (Methicillin-resistant Staphylococcus aureus- a bacteria resistant to many antibiotics, requiring gown and glove use upon contact with the patient) on 07/13/2026 at 1:47 PM. A review of Patient #8’s medical record revealed she was placed on “Contact Isolation” for MRSA on 07/10/2026 at 5:10 PM. During an observation of the East Wing on 07/21/2026 from 10:25 AM-10:35 AM Patient #7’s and Patient #8’s rooms had yellow contact isolation gowns, gloves, and masks hanging on the door to enter the room but no isolation signage posted outside the door. During an interview on 07/21/2026 at 10:27 AM with Chief Executive Officer (CEO) S, he stated that the expectation is that there needs to “always” be a sign on the door or wall next to the door indicating what type of isolation precautions the patient requires.”

“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: 47413 Based on observation, record review and interview, facility staff failed to maintain a clean and sanitary environment free from potential sources of contamination in 2 of 4 areas observed (Main entrance of hospital and East wing of hospital) in a total of 4 areas observed. Findings Include: A review of the hospital’s policy #6.170 titled, “Standard Precautions/Transmission-Based Precautions” last revised 05/2026 revealed, “... For patient transport limit the movement and transport of the patient from the room... the patient should wear a clean hospital gown (preferred) or clean personal clothing... may a patient on isolation ambulate outside their rooms: the patient should wear a clean hospital gown...” An observation on 07/21/2026 at 2:35 PM revealed Patient #7 (a patient on the East wing of the hospital) (on contact isolation precautions for MRSA- Methicillin-resistant Staphylococcus aureus- a type of bacteria resistant to many antibiotics, requiring gown and gloves upon contact with the patient) walking into the main entrance of the hospital from outside with Therapy Staff T, and OT (Occupational Therapist) H, wearing gray sweatpants and blue shirt that he was observed wearing earlier in the day during interview (07/21/2026 at 11:15 AM). There was no evidence that Patient #1 was placed in fresh clothes or a hospital gown, per policy. During interview on 07/22/2026 at 9:51 AM with Infection Control Manager J, he stated that the recommendation if therapy staff are taking the patient out of the room, the expectation is that a new hospital gown is placed on the patient prior to exiting the patient’s room to keep dirty and clean separate.”

“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: 29963 Based on observation, record review and interview facility staff failed to wear proper Personal Protective Equipment (PPE) for 1 of 1 patient (Patient #14), in a total sample of 3 patient observations. Findings include: Review of facility’s policy titled, “Standard Precautions/Transmission Based Precautions,” #6.170 dated 06/2024 revealed, “ ... B.1. Contact Precautions: Use Contact Precautions: ... PPE- Wear gloves and isolation gown before entering the room for direct patient care or whenever clothing may contact surfaces in the room ... Perform hand hygiene after removal of PPE.” Review of Patient #14’s “History and Physical” dated 10/12/2024 revealed, admission to facility for multiple wounds with Multidrug-resistant organism of Enterobacteria requiring contact precautions. During observations of patient care on 10/22/2024 at 8:44 AM signage outside of Patient #14’s room revealed, “Contact Precautions (In addition to Standard Precautions) Everyone Must: Clean hands when entering and leaving room. Doctors and Staff Must: Gown and glove at door. Use patient dedicated or disposable equipment. Clean and disinfect shared equipment.” A rack containing Personal Protective Equipment including but not limited to isolation gowns and gloves was hanging on the outside of the door. Certified Nursing Assistant (CNA) N was observed entering room without cleaning hands or donning any PPE, retrieving a completed meal tray and bringing it to the opposite end of the hall to place in a metal meal tray cart. CNA N did not clean hands upon completion of this task. During an interview on 10/22/2024 at 9:32 AM with CNA I who when asked if PPE must be worn when entering a contact isolation room to pick up a meal tray responded “Yes, we have to wear PPE in contact isolation rooms even when only picking up a tray.” During an interview on 10/23/2024 at 10:16 AM, Chief Nursing Officer Z stated, “The staff are expected to put a gown and gloves on when entering a room for any reason.””

“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: 29963 50644 Based on interview and record review, the facility staff failed to administer medications within the time parameters per facility policy in 4 out of 10 patient (Patient #2, 3, 4, 7) medication administration logs reviewed in a total universe of 10 patient records reviewed. Findings Include: Review of facility policy #9.360 titled, “Standard Administration Times” last reviewed 03/2020 revealed, “Medications must be administered within 60 minutes of their scheduled administration time unless otherwise specified (60 minutes prior to or after the scheduled administration time) ...1. Standard medication administration times: a. Daily ...0900 b. Twice daily or every 12 hours ... 0900-2100 ...d. Three times daily ...0900-1500-2100 ...bedtime ...2100 ...L. Every 6 hours ...0600-1200-1800-2400 ...m. Every 8 hours ...0600-1400-2200 ...2. Per feeding tube administration differences ... b. Twice daily or every 12 hours 0900-2100 c. Three times daily 0600-1400-2000.” Review of Patient #2’s medical record revealed a 67-year-old who was admitted to the facility for respiratory failure on 06/14/2024 and is currently a patient at the facility. A review of Patient #2’s physician ordered scheduled medications included the following: -Hydrocodone/acetaminophen (pain medication) 10 mg-325 mg, Give 1 tablet by mouth Daily. Make sure to give at least 30 minutes prior to therapy. Therapy to start at 10:00 AM. Review of Patient #2’s “Administration History” for Hydrocodone/acetaminophen revealed: -9/22/2024 medication given at 10:30 AM, after therapy start time. -10/6/2024 medication charted as not given. There was no reason why the medication was not administered documented. -10/12/2024 medication given at 10:09 AM, after therapy start time. -10/19/2024 medication given at 10:02 AM, after therapy start time. Review of Patient #3’s medical record revealed a 47-year-old who was re-admitted to the facility for traumatic brain hemorrhage post craniotomy on 9/23/2024 and is currently a patient at the facility. A review of Patient #3’s physician ordered scheduled medication included the following: -Gabapentin (anticonvulsant; may also be used to treat chronic pain) 100 MG, Give 100 mg per tube Three times a day per tube. Review of Patient #3’s “Administration History” for Gabapentin revealed: -9/28/2024 missed dose at 2:00 PM. There was no reason why the medication was not administered documented. -10/19/2024 missed dose at 6:00 AM. There was no reason why the medication was not administered documented. Review of Patient #4’s medical record revealed, a 33-year-old who was admitted initially to the facility for ventilatory dependent respiratory failure on 9/4/2024 and continues to be a current patient at the facility. A review of Patient #4’s physician ordered scheduled medication included the following: -Cefazolin Sodium/Dextrose (antibiotic) 2 grams, Infuse 2 gm over 30 minutes Intravenously Every 8 hours. Review of Patient #4’s “Administration History” for medication Cefazolin revealed: -09/06/2024 afternoon dose given at 1:37 PM, night dose given at 11:56 PM (10 hours between doses). -09/09/2024 morning dose given at 5:05 AM, afternoon dose given at 3:19 PM (10 hours between doses). Patient #7 is a 55-year-old who was admitted to the facility for respiratory failure on 10/10/2024 and is currently a patient at the facility. A review of Patient #7’s physician ordered scheduled medication included the following: -Heparin Sodium (anticoagulant), Inject 5000 unit subcutaneously Every 8 hours -Pregabalin (nerve pain medication) 100 MG, Give 100 mg by mouth Three times a day Review of Patient #7’s Administration History of Heparin revealed: -10/11/2024 morning dose given at 5:13 AM, next dose given at 3:14 PM (10 hours between doses). -10/16/2024 missed dose at 6:00 AM. There was no reason why the medication was not administered documented. Review of Patient #7’s Administration History of Pregabalin revealed: -10/22/2024 morning dose given at 8:18 AM, missed dose at scheduled time of 3:00 PM, evening dose given at 10:19 PM (14 hours between doses). During an interview on 10/22/2024 at 9:53 AM, Patient #7 was asked if he receives his medications on time. Patient #7 stated that the medications are brought late a lot. Typically, 45 minutes to an hour late, and often more than hour late. Patient #7 said that the staff tell him that they are busy. During an interview on 10/22/2024 at 10:43 AM, Patient #2 was asked if he was provided his medication on time. Patient #2 stated, he is supposed to receive his pain medication before his therapy at 10:00 AM and almost every time it’s an hour late or longer which makes it difficult or impossible to go to therapy. Patient #2 said he has had to cancel therapy because of it multiple times which is very frustrating.”

“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: 43264 Based on record review and interview, the facility failed to ensure that individualized nursing care plans were developed based on patient’s needs assessments to determine patient care issues and diagnoses in 8 of 10 medical records (Patient (Pt.) #1, 2, 3, 5, 6, 8, 9, 10), in a total sample of 10 medical records reviewed. Findings Include: A review of facility policy, titled “Nursing Care Plan”, date reviewed 04/2023, revealed: “PURPOSE...ensuring that patient goals and care plans are...individualized...II. Nursing Diagnosis A. The nurse will analyze the assessment data to determine patient-focused care issues/Nursing Diagnoses. B. The nurse will prioritize and document diagnoses to be addressed in the Nursing Care Plan...” A review of Pt. #1’s medical record, revealed: A 16-year-old female admitted 10/23/2023 - 06/06/2024 status post motor vehicle accident with Traumatic Brain Injury (TBI) and Chronic Respiratory Failure. Past medical history included: Trach (tracheostomy) was placed on 08/21/2023, and a foley catheter on admission for bladder incontinence. Pt. #1’s Nursing Care Plan did not address the patient’s diagnoses related to Trach and foley catheter care. During an interview on 08/06/2024 at 1:33 PM with CNO D, when asked what the Nursing Care Plan expectation is for patients with a tracheostomy and foley catheter, CNO D stated “Ideally we’d expect to see those reflected on Care Plans.” A review of Pt. #2’s medical record, revealed: A 70-year-old female that is a current inpatient, was admitted on 05/17/2024 for Chronic Respiratory Failure with Chronic Pneumonia. Past medical history included: Trach and PEG (tube feeding) was in place on admission. Pt. #2’s Nursing Care Plan did not address the patient’s diagnoses related to Trach or PEG tube feedings. During an interview on 08/06/2024 at 3:40 PM with CNO D, when asked what the Nursing Care Plan expectation is for patients with a PEG, CNO D stated “I would like to see them in the Care Plans.” A review of Pt. #3’s medical record, revealed: A 67-year-old male that is a current inpatient, was admitted on 06/15/2024 for Acute on Chronic Hypoxic Respiratory Failure. Past medical history included: A chronic foley catheter in place for recurrent UTI (urinary tract infection) and urinary incontinence, Congestive Heart Failure (CHF) and Diabetes. Pt. #3’s Nursing Care Plan did not address the patient’s diagnoses related to foley catheter, CHF and Diabetes. Confirmed during interview with CNO D at the time of review on 08/06/2024 at 3:45 PM. A review of Patient #5’s medical record, revealed: A 58-year-old male admitted 03/19/2024 - 04/26/2024 for TBI with SHD (subdural hematoma) status post craniotomy (surgical opening into the skull). Past medical history included: Seizures (on anti-seizure medication) and a PEG was placed to provide nutritional support. Pt. #5’s Nursing Care Plan did not address the patient’s diagnoses related to Seizures and PEG tube feedings. Confirmed during interview with CNO D at the time of review on 08/06/2024 at 4:30 PM. A review of Patient #6’s medical record, revealed: A 18-year-old female admitted 06/21/2024 - 07/16/2024 for TBI due to motor vehicle accident. Past medical history included: Chronic Respiratory Failure with Tracheostomy tube and PEG tube for tube feedings, both placed on 06/10/2024. Pt. #6’s Nursing Care Plan did not address the patient’s diagnoses related to Tracheostomy and PEG tube feedings. Confirmed during interview with Quality Coordinator C at the time of review on 08/07/2024 at 9:42 AM. A review of Patient #8’s medical record, revealed: A 75-year-old male admitted 07/08/2024 - 07/24/2024 for TBI due to motor vehicle accident. Past medical history included: Bilateral hearing aides for hearing loss and Anorexia due to poor appetite but able to eat with encouragement. Pt. #8’s Nursing Care Plan did not address the patient’s diagnoses related to auditory impairment and eating disorder. Confirmed during interview with CNO D at the time of review on 08/07/2024 at 10:25 AM. A review of Patient #9’s medical record, revealed: A 34-year-old female admitted 05/10/2024 - 06/21/2024 for Deep Tissue Infection status post right thigh incision and debridement (removal of damaged tissue). Past medical history included: IV (intravenous) antibiotics to be continued via PICC (peripheral inserted central catheter) line, Malnutrition with high protein/calorie diet, and Alcoholism with vitamin deficiency. Pt. #9’s Nursing Care Plan did not address the patient’s diagnoses related to IV antibiotics, dietary needs and alcohol abuse. Confirmed during interview with CNO D at the time of review on 08/07/2024 at 10:40 AM. A review of Patient #10’s medical record, revealed: A 17-year-old female that is a current inpatient, was admitted on 05/30/2024 for Acute on Chronic Hypoxic Respiratory Failure. Past medical history included: Trach dependent, Seizures and PEG placed for tube feedings. Pt. #10’s Nursing Care Plan did not address the patient’s diagnoses related to Tracheostomy, Seizures and tube feedings. Confirmed during interview with CNO D at the time of review on 08/07/2024 at 11:05 AM.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 29972 Based on observation, record review, and interview the facility failed to ensure patients receive care in a safe environment in 1 of 1 patient units (South unit), in a total sample of 1 patient units observed; and failed to develop and implement a corrective action plan based on a comprehensive root cause analysis and monitor the action plan for compliance in 1 of 1 adverse events reviewed (Patient (Pt) #1), in a total sample of 1 adverse events reviewed. Facility staff failed to ensure patients receive care in a safe environment. See A-0144. Facility statff failed to develop and implement a corrective action plan based on a comprehensive root cause analysis and monitor the action plan for compliance. See A-0144.”

“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: 29972 Based on observation, record review, and interview the facility failed to ensure patients receive care in a safe environment in 1 of 1 patient units (South unit), in a total sample of 1 patient units observed; failed to ensure the safety of 1 of 1 patients (patient #1) who required intensive supervision and failed to develop and implement a corrective action plan based on a comprehensive root cause analysis and monitor the action plan for compliance in 1 of 1 adverse events reviewed (Patient (Pt) #1), in a total sample of 1 adverse events reviewed. Findings Include: Review of policy and procedure #21.010 titled, “Incident Report (IR)/Safety Events” last reviewed 01/2023 revealed the following: -A patient/resident safety event is an event, incident, or condition that could have resulted or did result in harm to a person. -To provide a comprehensive, responsive system to avoid further unusual occurrences. -To identify areas of concern where administrative intervention may be indicated. -Department Directors/Managers are responsible for reviewing reports and determine that listed follow-up actions occurred, and any further actions needed are documented. Review of policy and procedure #7.870 titled, “Intensive Supervision (IS)” last reviewed 04/23 revealed the following: - “Intensive Supervision: involves a patient being provided with extra monitoring and/or support to either ensure safety and/or facilitate progress on treatment goals.” - “Sitter: individual responsible for performing the intensive supervision of a patient under the supervision of the assigned nurse.” - “When intensive supervision is necessary, the nurse will initiate the service and then enters an Order for Supervision.” - Nurse is responsible for “Monitoring of the patient in intensive supervision...Providing the sitter with a report of the relevant clinical information regarding the patient’s needs and the sitter’s expected role, at the beginning of the shift... Supervising the sitter...Required shift documentation including safety plan of care...” - “The sitter will not leave the sitter role except to handoff the care of the patient to the care of a treating professional, when relieved for breaks/meals/end of shift by another sitter, as delegated by the nurse or physician responsible for the care of the patient.” Patient #1 Review of Pt #1’s medical record revealed Pt #1 was admitted to the sub-acute rehab facility on 09/27/2023 at 1:42 PM status post a Subarachnoid Hemorrhage (brain bleed) on 08/23/2023; Pt #1 was transferred to an acute care hospital on 12/26/2023 at 10:00 PM. Review of Pt #1’s Provider History and Physical dated 09/28/2023 at 12:10 PM revealed, “(Pt #1) is a 36 year old...with a history of left internal carotid artery aneurysm (enlargement of an artery) complicated by intracranial bleed, neurocognitive deficits, here for rehabilitation.” Review of Pt #1 Orders dated 12/26/2023 at 7:00 AM revealed, “Intensive supervision during waking hours...Indication: Impulsive.” Review of Pt #1’s Provider Progress Note dated 12/26/2023 at 12:48 PM revealed, “(Pt #1) Continues to need a one to one (sitter) due to impulsivity and attempting to put things in his mouth...” Per progress note Impression, “Patient is ambulatory.” Review of Registered Nurse (RN) D’s progress note dated 12/26/2023 at 10:00 PM revealed, “(Pt #1) alert and oriented to self, communicates needs with difficulty due to incomprehensible speech, inconsistently follows commands. (Pt #1) took his medication crushed in pudding. Just before 9:40 PM, (RN D) was called into the patient’s room by the CNA (certified nursing assistant) E. One of the nurses found a sealed pill container from a staff member in the hallway. (CNA E) immediately checked her purse in the nurses station and found another pill container containing Amlodipine and body lotion missing. (CNA E) found her body lotion and empty pill container in the patient’s room. The pill container was refilled a few days ago and had a 90 day supply of Amlodipine 10 mg (milligrams) tablets which was now empty. (Pt #1’s) room and bathroom searched and could not find any medication...Orders received to transfer the patient to the ER (emergency room). (RN D) called (Pt #1’s) POA (Power of Attorney)...at 9:46 PM and updated her. (RN D) informed (POA) of the incident, that staff were working and did not observe the patient in the nurses station but it was caught within approximately 10 minutes of the incident. (RN D) also informed (POA) that staff assigned to (Pt #1) were also assigned to other patients...” Per telephone interview with Family A on 01/08/2024 beginning at 4:00 PM, Family A stated that after taking the pills on 12/26/2023 Pt #1 was transferred to an acute care hospital where Pt #1 had “stomach pumped” and was in the ICU (Intensive Care Unit) for a few days. Per Family A, Pt #1 is out of the ICU but still in the hospital; Per Family A, Pt #1 continues to sleep a lot and does not communicate. Review of the staffing schedule/patient assignments dated 12/26/2023 revealed Patient Companion L (sitter) was assigned to Pt #1 and Pt #2. Review of Pt #1’s Incident Report revealed on 12/26/2023 at 9:40 PM, Pt #1 ingested personal staff supply (CNA E) of Amlodipine (blood pressure medication) 10 milligrams--approximately 84 pills. Per the description of the incident, “Patient was given his PM medications and was resting in bed. The person assigned to Intensive Supervision role went to use the bathroom as (Pt #1) appeared to be going to sleep...A sealed pill bottle was found on the isolation rack on the door across from (Pt #1’s) room. The employee (CNA E) who’s name was on the bottle was informed and (CNA E) looked into her bag and discovered a second bottle of pills was empty, missing the cap. They noticed (Pt #1) was no longer lying in bed but was sitting on the side of the bed drooling excessively. (Pt #1’s) room is one room away from the nurse station. They looked through (Pt #1’s) room and found the pill bottle cap in his bathroom.” Per review of Pt #1’s Incident Report, the “Immediate Corrective Action” that was implemented revealed, “Staff required to chart in nursing station. When PC (patient companion) (sitter) needs a break, there must be direct responsibility hand-off. Personal belongings to be stored out of sight or in lockers in lounge.” Review of Pt #1’s Incident Report, “Human Factors” contributing to the incident revealed, “Patient was able to enter nursing station, unnoticed, and get into employee bag. An RN was charting in the room next to nursing station-had she been in the nursing station, this would not have occurred. Also, employee assigned to supervise (Pt #1) should have given direct hand-off to someone to assume responsibility. On 01/10/2024 beginning at 10:20 AM, Observed the nurses station on the South unit (location of Pt #1’s incident), while touring with the Director of Quality/Chief Nursing Officer (CNO) B. Per observations, purses and bags were in the cubbies next to the table in the nurses station and there was no locked observed on the door handle. Per interview with CNA F, RN H, and RN G who were in the nurses station at the time of the observations, staff confirmed that there belongings were being stored in the nurses station. CNA F, RN H and RN G stated that the lockers were too far away so they preferred to keep their belongings in the nurses station. Per interview with CNO B on 01/10/2024 beginning at 10:20 AM, CNO B stated that there was no lock on the nurses station. Per CNO B, there is a unit secretary in the nurses station during the day shift, but not on the night shift; CNO B stated that on night shift there is not always a staff member present in the nurses station. Per CNO B, an email was sent to all nursing staff in regards to storing personal belongings in locked lockers and conducting Intensive Supervision handoffs when the sitter needs a break; CNO B stated that there was also education given to staff during daily huddles. CNO B stated that she/he was unable to provide evidence of who attended the huddles and a staff email acknowledgements. Per interview with Nurse Manager K on 01/11/2024 at 9:55 AM, Manager K stated that she/he was involved in investigating Pt #1’s incident. Manager K stated that Pt #1 was on Intensive Supervision and required a sitter while awake due to Pt #1 wandering, impulsive, and putting things in his/her mouth. Manager K stated that due to staffing shortage at the time, PC L was assigned to Pt #1 and Pt #2 on 12/26/2023 (date of incident); Manager K stated that a sitter should only be assigned to one patient. Manager K confirmed that Pt #1 was awake prior to the incident. Manager K stated that to address the staffing concerns, the facility is considering agency contract and being more “mindful” of patients being accepted to the facility to ensure staffing can accommodate patient needs. Manager K stated that staffs personal belongings should be locked in the break room and not kept in the nurses station. Manager K stated that staff was educated via email, huddle, and personally spoke with staff; Manager K stated she/he did not have documented evidence of this education. Per interview with CNA E on 01/10/2024 at 2:15 PM, CNA E confirmed that PC L was “sitting” with Pt #1 and Pt #2 on the night of Pt #1’s incident (12/26/2023). Per CNA E Pt #1 walked around all the time and would come into the nurses station, but when the incident occurred no staff were present in the hallway or in the nurses station to witness Pt #1 taking CNA E’s medications. When asked if CNA E received any emails containing follow up education to the incident, CNA E responded “No” and stated that she/he has not checked her work email. Per interview with RN D (Pt #1’s RN at the time of incident) on 01/10/2024 at 5:03 PM, RN D stated that PC L was assigned as the sitter for Pt #1 and Pt #2, Per RN D this is “not ideal.” Per interview, RN D was not aware that an order for Intensive Supervision meant the patient needed to have a sitter, RN D thought it was a “step down” from having a sitter. Per RN D, if there was “enough staff” then Intensive Supervision could be a one-to one. Per interview with Quality Coordinator C on 01/10/2024 at 2:00 PM, Coordinator C confirmed that the documented investigation did not include comprehensive root cause analysis which included analyzing the cause and implementing a plan to address Patient Companion (L) being assigned as a sitter for Pt #1 and Pt #2 on 12/26/2023. Coordinator C confirmed that there was no documented evidence that all staff were educated on the corrective action plan addressed in the incident report to ensure that all staff were aware of the expectations. Coordinator C stated that staff are not currently monitoring (auditing) compliance with the corrective action plan. Environmental Observations Review of policy and procedure #11.080 titled, “Crash Cart Checks” last reviewed 10/21 revealed, “The carts are to be locked at all times with breakaway locks or keyed lock if appropriate to assure the integrity of the contents.” Review of the Crash Cart medication list revealed the following medications: Amiodarone (heart rhythm), Narcan (narcotic overdose), Magnesium sulfate, Dopamine (increase blood pressure), Atropine (increase heart rate), Dextrose (increase blood sugar), Epinephrine (severe allergic reactions). Observations off the South unit (location of incident) while touring with Director of Quality/Chief Nursing Officer (CNO) B on 01/10/2024 beginning at 10:45 AM to 10:55 AM (10 minutes) revealed the following: -Observed a supply room (in the patient hallway) housing an emergency Crash Cart secured with a break away lock (pull off to gain access); the Crash Cart contained multiple medications (see list). Per observations, there was no lock on the supply door. Observations revealed there was no staff present in the hallway to ensure that patients did not have access to the supply room and crash cart. -Observed a housekeeping cart left unattended in the patient hallway; the cart contained bottles of bleach, isopropyl alcohol, toilet cleaner, and bathroom cleaner. -Observed a patient walking back and forth down the hallways during the observations, no staff were present in the hallway during the observations lasting approximately 10 minutes. Per interview with Housekeeper I on 01/10/2024 beginning at 10:56 AM, Housekeeper I stated that he/she normally will leave the housekeeping cart in the hallway (unattended), while Housekeeper I cleans the medication room and other rooms secured with a key lock. Housekeeper stated that he/she did not feel comfortable bringing the housekeeping cart in the medication room. Per interview with CNO B on 01/10/2024 beginning at 10:40 AM, CNO B confirmed there was no lock on the supply room door. CNO B stated that the facility provides care to a large number of patients with neurobehavioral issues and traumatic brain injuries who may suffer from confusion and/or disorientation. CNO B confirmed that medications in the crash cart were not secured from unauthorized access. CNO B confirmed that the housekeeping cart should not be left unattended in the hallway as confused patients could gain access to unsafe chemicals.”

“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: 29972 Based on record review and interview staff failed to ensure a Registered Nurse (RN) supervises and evaluates the care of all patients assigned to a Licensed Practical Nurse (LPN) in 8 of 10 medical records reviewed (Patient (Pt) #3, 4, 5, 6, 7, 8, 9, 10), and failed to ensure a RN performs a nursing shift assessment and progress note on all patients as per policy in 10 of 10 medical records reviewed (Pt #1, 2, 3, 4, 5, 6, 7, 8, 9, 10), in a total sample of 10 records reviewed. Findings Include: Review of policy and procedure #7.660 titled, “Nursing Daily Documentation” last reviewed 04/23 revealed the following: -“For each shift, nursing will generate a progress note that reflects medical status to communicate ongoing individualized treatment goals, levels of care, and the patient’s clinical condition.” -“All nursing personnel are required to complete daily documentation within Wellsky Electronic Medical Record (EMR) during each shift.” -“Nurses will be responsible for the accuracy of the information documented.” -“Nurses co-signing documentation for LPN, students, and persons in orientation must identify whom they are co-signing for...” Review of policy and procedure #07.020 titled, “Nursing Care Plan” last reviewed on 04/23 revealed the following: -“The Registered Nurse (RN) is responsible for all components of the nursing process, including assessment, care planning, education , and evaluation of care, including patient progress toward goals. Data collection and the implementation and documentation of specific medical and nursing interventions may be delegated to assistive staff, including LPN and Certified Nursing Assistants (CNA).” -“The RN will assess the patient’s physical, psychosocial, cultural, spiritual, nutritional, functional, educational., daily activity level, and medical and discharge expectations/needs.” -“Data collected and related to care and treatment will be documented in the electronic medical record.” -“The nurse is accountable for documenting all relevant patient information gathered independently or by delegation.” Review of Pt #1’s medical record revealed there was no documented evidence of a nursing assessment completed on 12/26/2023 for first shift (7:00 AM to 7:00 PM). Review of Pt #2’s medical record revealed there was no documented evidence of a nursing assessment completed on 12/26/2023 for first shift (7:00 AM to 7:00 PM) and on 12/25/2023 for night shift (7:00 PM to 7:00 AM). Review of Pt #3’s medical record revealed a LPN documented performing Pt #3’s nursing shift assessment on 12/29/2023 4:18 AM and 12/30/2023 at 2:10 AM, there was no documented evidence of a RN supervising and evaluating Pt #3’s care during this time. Review of Pt #4’s medical record revealed a LPN documented performing Pt #4’s nursing shift assessment on 12/26/2023 4:49 PM, 12/27/2023 at 3:48 AM, and 12/28/2023 at 6:18 PM, there was no documented evidence of a RN supervising and evaluating Pt #4’s care during this time. Review of Pt #5’s medical record revealed a LPN documented performing Pt #5’s nursing shift assessment on 1/04/2024 8:00 PM and 1/06/2024 at 4:41 AM, there was no documented evidence of a RN supervising and evaluating Pt #5’s care during this time. Review of Pt #5’s medical record revealed there was no RN day shift progress note completed on 1/04/2024, 1/05/2024, and 1/08/2024 as per policy. Review of Pt #6’s medical record revealed a LPN documented performing Pt #6’s nursing shift assessment on 12/26/2023 11:23 AM, 12/28/2023 at 3:01 PM, and 12/29/2023 at 12:28 AM, there was no documented evidence of a RN supervising and evaluating Pt #6’s care during this time. Review of Pt #6’s medical record revealed there was no RN night shift progress note completed on 12/26/2023 and no RN day shift progress note completed on 12/28/2023 and 12/31/2023 as per policy. Review of Pt #7’s medical record revealed a LPN documented performing Pt #7’s nursing shift assessment on 1/05/2024 2:08 AM and 1/09/2024 at 2:00 AM, there was no documented evidence of a RN supervising and evaluating Pt #7’s care during this time. Review of Pt #8’s medical record revealed a LPN documented performing Pt #8’s nursing shift assessment on 1/06/2024 4:27 PM, 1/07/2024 at 5:20 PM, 1/08/2024 at 4:08 PM , there was no documented evidence of a RN supervising and evaluating Pt #8’s care during this time. Review of Pt #8’s medical record revealed there was no RN day shift progress note completed on 1/08/2024 as per policy. Review of Pt #9’s medical record revealed a LPN documented performing Pt #9’s nursing shift assessment on 12/27/2023 11:59 PM and 1/01/2024 at 8:54 PM, there was no documented evidence of a RN supervising and evaluating Pt #9’s care during this time. Review of Pt #9’s medical record revealed there was no RN day shift progress note completed on 12/27/2023 and 12/31/2023 as per policy. Review of Pt #10 medical record revealed a LPN documented performing Pt #10’s nursing shift assessment on 12/26/2023 11:19 AM, there was no documented evidence of a RN supervising and evaluating Pt #9’s care during this time. Review of Pt #10’s medical record revealed there was no nursing day shift assessment completed on 12/22/2023 and 12/26/2023 and no night shift assessment completed on 12/23/2023, 12/24/2023, and 12/25/2023. Review of Pt 10’s medical record revealed there was no RN day shift progress note completed on 12/20/2023 and 12/26/2023, and no night shift progress note completed on 12/23/2023 and 12/24/2023 as per policy. Per interview with Quality Coordinator C while conducting medical records reviews on 01/10/2024 beginning at 2:45 PM, Coordinator C confirmed the above findings and stated that nursing assessments should be documented as completed on each shift and there should be a nursing progress note completed each shift. Per interview with Nurse Manager K on 01/11/2024 beginning at 9:55 AM, Manager K stated that the facility currently does not have a process in place reflecting RN supervision of LPNs and showing oversight of all patient care. Per Manager K this is an “area that needs improvement.” Per Manager K, LPNs will go to charge RN with question and concerns, but RNs do not sign off on LPNs documentation as evidence of supervising and evaluating patient care.”

“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: 29972 Based on record review and interview the facility failed to ensure an appropriate safety care plan was implemented for patients requiring Intensive Supervision/sitter as per policy in 3 of 10 medical records reviewed (Patient (Pt) #1, 2, 10), in a total sample of 10 medical records reviewed. Findings Include: Review of policy and procedure #07.020 titled, “Nursing Care Plan” last reviewed 04/23 revealed the following: -“An individualized Nursing Care Plan, which utilizes best practices and includes patient education, is developed for each patient within 24 hours of admission. The Nursing Care Plan is reviewed every shift and revised as appropriate based on changes in the patient’s condition and abilities. Any needs or goals identified by the patient should be reviewed and explored by the RN for incorporation into the plan of care.” -“The Nursing Care Plan includes individualized interventions, with realistic, measurable actions and goals directly relating to the nursing diagnosis.” Review of policy and procedure #7.870 titled, “Intensive Supervision (IS)” last reviewed 04/23 revealed that nursing responsibilities include: “Required shift documentation including safety plan of care.” Pt #1: Review of Pt #1 Orders dated 12/26/2023 at 7:00 AM revealed, “Intensive supervision during waking hours...Indication: Impulsive.” Review of Pt #1’s Provider Progress Note dated 12/26/2023 at 12:48 PM revealed, “(Pt #1) Continues to need a one to one (sitter) due to impulsivity and attempting to put things in his mouth...” Review of Pt #1’s Nursing Care Plans revealed there was no documented evidence of nursing staff implementing a “Safety” Nursing Care Plan as per policy. Pt #2: Review of Pt #2’s Provider Progress Note dated 12/26/2023 at 12:44 PM revealed Pt #2 “Remains on 1:1 (sitter) for impulsivity...” Review of Pt #2’s Orders dated 12/26/2023 at 7:00 AM revealed, “Intensive Supervision...Indication: Impulsive.” Review of Pt #2’s Nursing Care Plans revealed there was no documented evidence of nursing staff implementing a “Safety” Nursing Care Plan as per policy. Pt #10: Review of Pt #10’s Provider Progress Note dated 12/06/2023 at 08:23 AM revealed “TBI (traumatic brain injury) encephalopathy due to motorcycle accident...Patient is on one-to-one supervision due to impulsivity.” Review of Pt #10’s Orders dated 12/25/2023 at 7:00 AM revealed, “Intensive Supervision...Indication: Impulsive.” Review of Pt #10’s Nursing Care Plans revealed there was no documented evidence of nursing staff implementing a “Safety” Nursing Care Plan as per policy. Per interview with Nurse Manager K on 01/11/2024 beginning at 9:55 AM, Manager K stated that nursing staff should be implementing a Safety Nursing Care Plan to address each patient’s individual safety concerns related to needing Intensive Supervision/sitter.”