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Based on observation and interview, the facility failed to ensure supplies stored in 1 of 2 emergency crash carts for patients care and services were not expired (Broselow Pediatric Cart 1)

Findings:

An bservation in trauma room 2, on 08/27/25 at 9:30 a.m. in the presence of acting director of nursing showed the following supplies stored in the pediatric emergency crash cart were expired:

Pink drawer; 1 Broselow/ Henkle Pediatric Emergency system intubation module; lot # 0004248507 expired on 2/28/25.

Pink drawer; 1 Broselow/ Henkle Pediatric Emergency system intravenous module; lot # 0004241778 expired on 2/28/25.

Orange drawer; 1 Broselow/ Henkle Pediatric Emergency system oxygen airway module; lot # 00041246993 expired on 5/31/25.

Green drawer; 1 Broselow/ Henkle Pediatric Emergency system oxygen delivery module; lot # 0004246983 expired on 5/31/25.

Yellow drawer; 1 Broselow/ Henkle Pediatric Emergency system oxygen airway module; lot # 0004140099 expired on 3/31/25.

During an interview on 08/27/25 at 9:30 am, the acting Director of Nursing stated that the carts were checked regularly by staff assigned.

Based on observation, record review and interview, the facility failed to ensure 2 of 2 physicians (Physician D and E) who provided care and services to patients at the facility participated in emergency management training.
Findings:

Physician (D)
On 08/25/25 at 2.40 p.m. Physician (D) was observed providing care and services to patients in the emergency room.

A review of credentialing files showed the physician was reappointed on 2/21/25 - 2/21/27 to provide care and service to patients at the facility.

Review of credentialing and training files showed no evidence that the physician participated in emergency management training for the facility.

Physician (E)
Review of credentialing files showed the physician was reappointed on 11/20/23 - 11/20/25 to provide care and service to patients at the facility.

Review of credentialing and training files showed no evidence that the physician participated in emergency management training for the facility.

During an interview on 08/27/25 at 9:30 a.m, the CEO stated physicians (D and E) were contract staff and did not participate in emergency management training for the facility.

Based on observation, record review and interview, the facility failed to address nutritional needs for 2 (Patients # 1 and 2) of 7 sampled patients.

Findings:

Patient #1
On 08/25/25 at 1:32 p.m. Patient #1 was observed in his room lying in bed with foley catheter in place, heplock to his right arm and oxygen 4l/ minute via nasal cannula. The patient was alert to person, place, time and situation.

During an interview on 08/25/25 at 1:32 pm, the Chief Nursing Officer stated the patient was admitted with a stage three wound to his coccygeal area and deep tissue damage to his heal.

Observiation on 08/26/25 at 9:07 a.m. with Registered Nurse (I) showed Patient #1 had a stage three wound to coccyx, excoriation of the buttock, groin and scrotum and a blackened area to his left heel. Registered Nurse (I) provided wound care to the patient.

Review of the clinical record showed the patient was readmitted to the facility on 08/25/25, post discharge from the hospital on 08/23/25 with admitting diagnosis of pneumonia.

Review of the nurse progress notes dated 08/25/25 showed the following measurement of the wounds:

Sacrum unstageable and redness 2 cm x1.5 cm x 0.5 cm. Left heal unstageable and redness 3 cm x 3.5 cm, right foot lateral plantar unstageable deep tissue injury 1.5 cm x0.5 ccm.

Review of the attending physician's history and physical, dated and signed by the attending physician 08/25/2025, showed no documentation of the patient having a sacral wound or any skin impairment. Documentation and assessment in the physician's history and physical was as follows: "integumentary; warm pink and dry."

Review on 08/26/2025 of the clinical record (Laboratory values) showed the following findings: 08/23/2025; albumin 2.2 g/dl, 08/25/25 albumin 1,7 g/ dl and 08/26/25 albumin 1.7 g/dl. Reference range 3 - 5 g/dl.

Review of the clinical record showed a physician's order for regular diet.

A review of nursing notes, dated 08/26/25 showed the following documentation: " Meals other, patient refused."

During an interview on 08/26/25, Registered Nurse (I) stated, "The patient is not evaluated by the nutritionist, the nurse just gives him ensure."

Review of the patient's record showed no documentation of a nutritional assessment, no documentation of nutritional supplement intake, and no documentation as to the amount of ensure the patient consumed.

During an interview on 08/26/25 at 11.45, the dietary manager stated they had no documentation of the patient receiving nutritional supplement.


Patient #2
Review of the clinical record showed the patient was admitted to the facility on 08/18/25 with admitting diagnosis of pyelonephritis, sepsis, weakness and disability. The record showed the patient was discharged to swing bed on 08/21/2025.

Review of the Patient ' s laboratory values showed the following findings:
08/18/25: albumin 3.1 g/dl
08/19/25: albumin 2.6 g/dl
08/22/25: albumin 2.6 g/dl
Reference range 3 - 5 g/dl

Continued review of the record showed a nutritional assessment dated 8/21/25 with the following documentation. "FND will provide appropriate nutritional supplement/ snack."

Review of the nurses progress notes showed no documentation of the patient receiving nutritional supplement or the amount consumed.

Patient #4
Review of the clinical record showed the patient was admitted to the facility on 08/11/25 with admitting diagnosis of status post femur fracture repair and presented with a stage 2 ulcer to his sacral area.

A review of a nurse progress note (SuperBill Details) dated 08/13/25 for wound assessment showed the following "pressure ulcer of sacral region, stage 3"

Review of wound measurement dated 08/20/2 showed stage 3, 3.7 x 1.5 cm.

Review of the patient ' s laboratory values showed the following findings:

08/18/25: albumin 2.4 g/dl

Reference range 3 - 5 g/dl

A physician's order dated 08/11/25 showed: "diet order, regular, consistency 5 - minced and moist, liquids midley thick."

A dietary assessment dated 8/20/25 showed: "Recommendation, offers house supplement with meals for extra K cal."

A progress note dated 0 8/11/2025 - 8/26/2025 showed no documentation if house supplements were served with meals and the amount consumed by the patient.

On 08/26/25 at 3:45 pm, the Chief Nursing Officer stated there were no additional supplement consumption documents available for patients #2 and #4.

Based on observation, record review, and interview,direct care staff failed to practice infection control practices of cleaning contaminated supplies and washing hands after direct contact with contaminated supplies in two of three (Pharmacy Manager A and Licensed Vocational Nurse B) staff observed

Findings

Review of the facility's current policy and procedure on handwashing hygiene updated March 31, 2020, directed staff as follows: " Hospital personnel shall wash their hands, to prevent the spread of infection:

(1) When coming on duty

(2) before applying and after removing gloves

(3) When hands are obviously soiled

(4) Before and after contact with individual patient

(5) Before and after personal use of the toilet

(6) After Sneezing, coughing, blowing or wiping the nose or mouth

(7) On leaving isolation area or after handling articles from an isolation area

(8) After handling used sputum containers, soiled urinal, catheters and bedpan

(9) Before eating

(10) On completion of duty."

Observation on 08/26/2025 at 7;30 a.m. Pharmacy Manager (A) was observed pulling intravenous ciprofloxacin from the Omnicell machine for administration to Patient #2. showed during the process of removing the medication, the bag with the medication fell to the floor. The pharmacy manager picked up the medication in the contaminated packet and gave it to Licensed Vocational Nurse (B) who took it, went to the clean counter which stored patient care supplies for medication administration, placed the contaminated packet containing the medication on the clean counter, and picked up clean supplies of intravenous lines and to administer medication to patient #2.

Continued observation showed Licensed vocational (B) proceeded to the patient's room, holding supplies for administration of the patient's intravenous antibiotic (with the contaminated package) holding the ciprofloxacin intravenous medication. Licensed vocational (B) placed the contaminated package and the supplies on the computer station, then picked up a clean pair of gloves from the box of gloves stored in the patient's room. The nurse did not wash or sanitize her contaminated hands prior to applying clean gloves. Licensed vocational (B) then proceeded to the patient's bedside and rearranged the patient's bed linen.

Review of patient #2's clinical record showed the patient was admitted to the facility with a diagnosis of sepsis currently on antibiotic therapy.

Licensed vocational nurse (B)
Observation on 08/26/25 at 8:10 a.m. showed, Licensed Vocational Nurse (B) was observed pulling oral medication from the Omnicell machine located adjacent to the pharmacy.

Continued observation showed while removing the medication from the Omnicell machine, the patient's oral medication fell to the floor. Licensed Vocational Nurse (B) retrieved the medication from the floor, handed it to the Director of Nursing and continued removing medication with her contaminated hands to be administered to a patient. Licensed Vocational Nurse (B) did not wash or sanitize her contaminated hands used to retrieve the medication from the floor.

The Surveyor notified the Facility ' s Chief Nursing Officer of her observation.

During an nterview on 08/26/25 at 8:09 a.m., regarding the procedure for supplies that falls to the floor, the Pharmacy Manager stated, "I should have wiped it off."