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Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Governing Body was met, as evidenced by:

1. The facility's governing body (GB, the group of individuals legally responsible for overseeing the hospital's operations and ensuring compliance with health and safety regulations) failed to provide oversight of the Engineering Department (the team responsible for maintaining the hospital's physical infrastructure, including plumbing, electrical systems, and structural repairs) and the Infection Prevention Department (the team responsible for identifying, monitoring, and preventing the spread of infections within the facility) to ensure that repair services were delivered in a manner that protected the health and safety of 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) daily, including staff in the Emergency Department (ED, the hospital area for treating urgent and serious conditions). The facility's GB failed to ensure the Engineer Department and Infection Prevention Department implemented required environmental safety measures, such as:

-Environmental assessment by Infection Prevention Services (a team responsible for identifying and preventing the spread of infections in healthcare settings),
-Containment (physical barriers to isolate the work area and prevent the spread of contaminants),
-Ventilation (airflow systems to reduce airborne particles and maintain air quality), and
-Environmental testing (checking air and surfaces for harmful substances such as mold, dust, or bacteria), prior to and during plumbing repairs (starting 9/09/2025 through 10/15/2025) involving wet drywall (a construction material used for interior walls) that had visible brown and dark discoloration, which may have indicated the presence of mold (a type of fungus that grows in damp areas and can cause respiratory problems).

This deficient practice resulted in staff (staff working in the ED Admitting/phlebotomy area) and 57 of the 83 sampled patients (Patients 27 through 83) daily (from 9/9/2025 through 10/15/2025), being exposed to hazardous environmental conditions such as sewer-like odors, smoke from cutting of piping during repair in the ED admitting area. Staff reported symptoms including headaches, nausea, cough, and in one case (Admitting Representative [AR 7]), required medical evaluation and treatment. Additionally, the second ongoing repair process (of a leak piping) in the ED Nursing Station posed a potential risk for further staff and patient exposure, increasing the likelihood of serious adverse health outcomes. (Refer to A-0083)

This deficient practice resulted in the facility's inability to provide quality health care in a safe environment.

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient Rights was met, as evidenced by:

1. The facility failed to ensure that 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83), and staff members, who were present daily in the affected areas (Emergency Department's Admitting/Phlebotomy area, the section where patients are registered and blood samples are collected) and the Nursing Station (a central hub in a hospital where nurses coordinate patient care), were informed of safety risks and the measures implemented to mitigate risks during repair construction (activities aimed at restoring or fixing defects, damage, or failures in a building's structure). The facility did not post the required Infection Prevention Construction Permit signage (a sign posted at a construction or renovation site that provides a clear, documented summary of the required safety and infection control measures based on a formal Infection Control Risk Assessment [ICRA, process used to evaluate and mitigate the risk of infection transmission during construction]) during plumbing repairs conducted from 09/09/2025 through 10/15/2025, in accordance with the facility's policies titled, "Environment of Care Safety Management Plan" and "Infection Prevention Measures During Construction and Renovation Projects."

This deficient practice violated patients' rights of 57 patients (Patients 27 to 83) to be informed of safety risks while hospitalized and to receive care in a safe and sanitary environment. (Refer to A-0116)

2. The facility failed to ensure Admitting Department (a hospital section responsible for processing patient admissions) staff provided a copy of the facility's condition of services (a contract that outlines a patient's responsibilities and consent for hospital services. Key elements typically include informed consent for medical treatment, financial responsibilities, and patient rights [the fundamental legal and ethical protections that guarantee individuals receive respectful, dignified, and high-quality healthcare]) and patient rights information copy to one of 83 sampled patients (Patient 5), in accordance with the facility's admitting and registering procedure, when Patient 5 was admitted to the facility on 11/1/2025.

This deficient practice resulted in Patient 5 not knowing and not being able to exercise his (Patient 5's) patient rights during the hospitalization. Patient 5 expressed concerns about being discharged without a clear care plan or understanding of what to expect upon returning home. (Refer to A-0117)

3. The facility failed to ensure one of 83 sampled patients (Patient 9) spouse and designated primary representative (RP 1) was able to exercise their rights on behalf of Patient 9, when RP 1 was not contacted by the facility regarding Patient 9's mortuary's (funeral home) "Authorization for Release of Remains" form. In accordance with the facility's policy regarding "Decedent Affairs (the administrative process of handling matters related to a deceased person)." Instead, Patient 9's next of kin and second representative (RP 2) was contacted and thus RP 2 signed Patient 9's mortuary's (funeral home) "Authorization for Release of Remains" form without the knowledge of RP 1. The nursing office also failed to ensure that the primary representative (RP 1) was contacted first.

This deficient practice led to Patient 9's RP 1 not being able to exercise their right and legal authority to make decisions on behalf of Patient 9. (Refer to A-0131)

4. The facility failed to ensure a safe patient-care environment for 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) when it conducted plumbing repairs in an active Emergency Department (ED) patient-care areas without implementing required containment measures (physical barriers designed to prevent the spread of dust, debris, and contaminants during construction), without completing an Infection Control Risk Assessment (ICRA, a structured, multidisciplinary process used to determine infection-control precautions required during construction or maintenance), and without providing ventilation or air-filtration controls, including High-Efficiency Particulate Air (HEPA filtration, a mechanical filtering system that captures small airborne particles) or negative air pressure (a ventilation technique that keeps air flowing into, but not out of, a contaminated area).

This deficient practice exposed patients and staff to hazardous environmental conditions, including airborne particles (microscopic solid or liquid substances suspended in air), sewer-like odors (strong odors produced by leaking wastewater piping), wet drywall with brown/black discoloration suggestive of mold (fungal growth capable of releasing spores), smoke, and water diverted from ceiling leaks into a clinical hand-washing sink, increasing the risk of exposure to waterborne pathogens (disease-causing microorganisms transmitted through contaminated water) and environmental contaminants (harmful biological or chemical substances present in the environment). (Refer to A-0144)

5. The facility failed to fully implement the methods and mechanisms required to ensure that patients are free from all forms of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse), in accordance with the facility's policy and procedure regarding abuse, for two of 83 sampled patients (Patients 1 and 8) when:

5.a. The facility did not conduct a thorough investigation, when Patient 1 alleged that a male registered nurse (RN 1) pushed her (Patient 1) onto the bed and held her down, then locked her (Patient 1) in the room all night long.

This deficient practice resulted in a lack of thorough investigation by the facility and the inability to determine whether or not abuse occurred, which placed other patients at risk of potential abuse or harm. (Refer to A-0145)

5.b. The facility did not interview or assess Patient 8 (Patient 1's roommate) to verify if Patient 8 witnessed any type of abuse or if Patient 8 sustained abuse or injury by RN 1.

This deficient practice resulted in a lack of thorough investigation by the facility and the inability to determine whether or not abuse occurred, which placed other patients at risk of potential abuse or harm. (Refer to A-0145)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by:

1. The facility failed to ensure nursing staff performed head-to-toe assessments (a comprehensive physical examination that systematically evaluates a patient's body from head to feet to establish a baseline, monitor changes, and identify health issues. This includes checking vital signs [temperature, heart rate, blood pressure], assessing the skin, and examining all body systems like the respiratory, cardiovascular, neurological, and gastrointestinal systems. The assessment helps providers understand the patient's current health status and needs) for two of 83 sampled patients (Patients 1 and 8), in accordance with the facility's policy and procedure regarding nursing assessments and reassessments.

This deficient practice had the potential for the inability of nursing staff to identify changes in patients' condition. (Refer to A-0395)

2. The facility failed to provide one of seven sampled staff members (Registered Nurse [RN] 1) orientation (A structured, unit-specific orientation helps nurses understand and adhere to the specific policies, procedures, and safety protocols of that unit, which reduces errors and improves patient outcomes) to the medical surgical unit (M/S, department for patients who need close attention but are not critically ill) and to evaluate RN 1's competency (a process to evaluate their knowledge, skills, and abilities in order to ensure they can provide high-quality, safe patient care. This evaluation goes beyond basic education and includes assessing their proficiency in specific clinical tasks, using hospital equipment, and adhering to the organization's standards and protocols), when RN 1 started working in the M/S unit on 7/12/2025, in accordance with the facility's policies regarding orientation and competency assessment.

This deficient practice had the potential for RN 1's inability to perform unit specific duties and placed patients' health and safety at risk. (Refer to A-0397)

3. The facility failed to ensure that the nursing office confirmed one of 83 sampled patient's (Patient 9's) spouse and primary representative (RP 1) information was documented on Patient 9's mortuary's "Authorization for Release of Remains," in accordance with the facility's policy and procedure (P&P) titled, "Decedent Affairs."

This deficient practice led to Patient 9's next of kin and secondary representative (RP 2) to sign the form instead of RP 1, who had the legal authority to do so. (Refer to A-0398)

4. The facility failed to ensure one of 83 sampled patient's (Patient 9) physician was notified of Patient 9's changes in mental status and blood pressure (BP, amount of force needed to move blood throughout the body and organs, with normal range of 120/90 millimeters of Mercury [mmHg, a unit of measurement]), in accordance with the facility's policy and procedure (P&P) titled, "Provider Notification."

This deficient practice resulted in a delay of Patient 9's care, when Patient 9 remained in the medical surgical unit for more than 24 hours before being transferred to the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries) for closer monitoring and blood pressure support. (Refer to A-0398)

5. The facility failed to ensure its nursing staff assessed a patient's ability to void (urinate) after foley catheter (Foley catheter [brand name] for urinary indwelling catheter - a flexible tube inserted into the bladder that remains there to provide continuous urinary drainage) removal for one of 83 sampled patients (Patient 5), in accordance with the facility's policy and procedure regarding foley catheter removal.

This deficient practice had the potential to put Patient 5 at risk for urinary retention (inability to completely empty the bladder) and urinary tract infection (UTI, an infection in any part of the urinary system). (Refer to A-0398)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Physical Environment was met, as evidenced by:

1. The facility failed to ensure a safe and sanitary environment in the Emergency Department (ED, the hospital area for treating urgent and serious conditions) for 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) and staff. The facility failed to implement required infection control and environmental safety measures during plumbing repairs in the ED Admitting and Phlebotomy areas (the section of the ED where patients are registered and blood samples are collected) as required by facility's policy titled, "Infection Prevention Measures During Construction and Renovation Projects," and failed to notify the Department of Health Care Access and Information (HCAI, the state agency responsible for reviewing and approving construction plans and safety protocols in healthcare facilities) as required by the FREER Manual- Revised August 2025 (a regulatory guide published by the California Department of Health Care Access and Information [HCAI], It provides instructions for healthcare facilities on how to manage construction, maintenance projects, and helps outlines the necessary steps to obtain clearances, permits, and approvals) , published by HCAI.

This deficient practice resulted in approximately 60 patients per day and multiple staff members being exposed to hazardous environmental conditions during the repair period from 09/09/2025 through 10/15/2025. These conditions included sewer-like odors, airborne particles (microscopic solid or liquid substances suspended in the air that may pose respiratory risks), and visible mold-like substances (fungal growths that can release spores and cause health issues). Staff reported experiencing symptoms such as headaches, nausea, coughing, and respiratory distress (difficulty breathing or shortness of breath). One staff member required medical evaluation and treatment (clinical assessment and care provided by a licensed healthcare professional). (Refer to A-0701)

This deficient practice resulted in the facility's inability to provide quality health care in a safe environment.

Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Infection Prevention/Control/Antibiotic Stewardship Program was met, as evidenced by:

1. The facility failed to implement its infection prevention and control program in a manner that protected 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) from potential infection risks while these patients were treated in the Emergency Department (ED). The facility did not have a policy or procedure to address cross-contamination risks associated with leaking piping in patient care areas and failed to conduct an Infection Control Risk Assessment (ICRA) when a leak was identified in the ED. Clinical staff continued to use a handwashing sink where water from a ceiling leak was actively diverted into the basin. There was no signage indicating restricted use of the sink, and the Infection Prevention Department was not notified.

This deficient practice placed 57 of the 83 sampled patients (Patients 27 - 83) at risk of exposure to waterborne pathogens (disease-causing microorganisms that are transmitted through contaminated water) and environmental contaminants (harmful substances present in the surrounding environment), increasing the potential for transmission of infectious agents (organisms such as bacteria, viruses, or fungi that can cause disease). (Refer to A-0749)

2. The facility failed to ensure one of seven (7) sampled staff members (Admitting Supervisor [Sup 1]) had annual tuberculosis (TB, an infectious disease that affects the lungs) testing, in accordance with the facility's policy and procedure regarding tuberculosis screening for employees.

This deficient practice had the potential to spread tuberculosis if TB status of an employee was unknown, which may infect patients, staff, and visitors in the hospital. (Refer to A-0749)

3. The facility failed to maintain a clean and sanitary environment (a clean, safe, and healthy space that minimizes the risk of disease by managing and controlling factors like preventing human contact with harmful substances to break the cycle of disease transmission) and prevent potential sources of infection for 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83), and staff members who were present in the affected area (Emergency Department's Admitting/phlebotomy, which involves the initial administrative processing and the critical first step of diagnostic testing for patients presenting to the emergency room) daily, when:

3.a. The facility did not consult the Infection Preventionist (IP, a healthcare professional responsible for overseeing infection prevention and control activities) for an assessment prior to initiating construction repairs (the process of fixing or restoring an existing structure to its original or functional condition by replacing or renewing its components) following water damage.

This deficient practice resulted in no assessment or safety recommendations from the Infection Prevention Department (IPD) prior to the Engineering Department starting the repair project, potentially placing patients and staff at risk of exposure to contaminants released during construction. (Refer to A-0750)

3.b. The facility did not implement appropriate environmental controls, such as providing ventilation (the intentional movement of air to dilute or remove airborne contaminants) to the affected area during the repair of drywall (a construction material used for interior walls, which can harbor mold [a type of fungus that can pose health risks] when wet) and tile with visible dark brown staining. These actions were not performed in accordance with the facility's "Environment of Care Safety Management Plan" and "Infection Prevention Measures During Construction and Renovation Projects" policy and procedures.

This deficient practice had the potential to expose patients, staff, and visitors to airborne contaminants (microscopic particles or biological agents suspended in the air that may cause illness) and HAIs (Healthcare-Associated Infections, conditions acquired by patients while receiving treatment in a healthcare setting), increasing the overall infection risk (the likelihood of exposure to and transmission of infectious agents). (Refer to A-0750)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on observation, staff interviews, and record review, the facility's governing body (GB, the group of individuals legally responsible for overseeing the hospital's operations and ensuring compliance with health and safety regulations) failed to provide oversight of the Engineering Department (the team responsible for maintaining the hospital's physical infrastructure, including plumbing, electrical systems, and structural repairs) and the Infection Prevention Department (the team responsible for identifying, monitoring, and preventing the spread of infections within the facility) to ensure that repair services were delivered in a manner that protected the health and safety of 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) daily, including staff in the Emergency Department (ED, the hospital area for treating urgent and serious conditions). The facility's GB failed to ensure the Engineer Department and Infection Prevention Department implemented required environmental safety measures, such as:

-Environmental assessment by Infection Prevention Services (a team responsible for identifying and preventing the spread of infections in healthcare settings),
-Containment (physical barriers to isolate the work area and prevent the spread of contaminants),
-Ventilation (airflow systems to reduce airborne particles and maintain air quality), and
-Environmental testing (checking air and surfaces for harmful substances such as mold, dust, or bacteria)
prior to and during plumbing repairs (starting 9/09/2025 through 10/15/2025) involving wet drywall (a construction material used for interior walls) that had visible brown and dark discoloration, which may have indicated the presence of mold (a type of fungus that grows in damp areas and can cause respiratory problems).

This deficient practice resulted in staff (staff working in the ED Admitting/phlebotomy area) and 57 of the 83 sampled patients (Patients 27 through 83) daily (from 9/9/2025 through 10/15/2025), being exposed to hazardous environmental conditions such as sewer-like odors, smoke from cutting of piping during repair in the ED admitting area. Staff reported symptoms including headaches, nausea, cough, and in one case (Admitting Representative [AR 7]), required medical evaluation and treatment. Additionally, the second ongoing repair process (of a leak piping) in the ED Nursing Station posed a potential risk for further staff and patient exposure, increasing the likelihood of serious adverse health outcomes.

On 11/6/2025 at 4:13 p.m., the survey team called a second Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Executive Officer (CEO), Vice President of Quality (VPQ), and Risk Management Accreditation, Regulatory & Licensing. The facility's Governing Body failed to have oversight of the Engineering Department and Infection Prevention (IP) processes to ensure that services were provided in a safe and effective manner.

This failure had potentially exposed 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) to harmful substances released during construction or repair activities. These substances included tiny airborne particles (tiny solid particles or little liquid drops that float around in the air), such as disease-causing bacteria (tiny organisms that can multiply in the body, release poisons, or damage tissues, causing illness), viruses (infective agents), and fungi (organisms capable of causing disease), which could be inhaled and cause infections. Despite repeated staff complaints, no action was taken to relocate staff or patients, and the unsafe conditions persisted from 9/9/2025 through 10/15/2025.

The facility permitted construction activities in patient care areas without completing an Infection Control Risk Assessment (ICRA, a formal, structured process used to evaluate and mitigate the risk of infection transmission during construction, renovation, maintenance, or repair activities when these occur in or near patient care areas), notifying the infection prevention team (a group of healthcare professionals who work to stop the spread of germs and infections in a medical facility. They make sure the environment is clean and safe for patients, staff, and visitors.) or conducting environmental testing (checking the air and surfaces in a hospital area for things that could be dangerous to health, such as mold [a type of fungus that grows in damp places and can cause breathing problems], dust [tiny particles that can carry germs or irritate the lungs], or bacteria [tiny organisms that can cause infections]). As a result, 57 of the 83 sampled patients (Patients 27 through 83), and staff per day were exposed to hazardous environmental conditions. Staff and patients reported persistent sewer-like odors, visible mold-like substances, and symptoms including headaches, nausea (a feeling of sickness with an inclination to vomit), and respiratory distress (difficulty in breathing). At least one staff member required medical evaluation and treatment.

On 11/7/2025 at 5:29 p.m., the Second Immediate Jeopardy (IJ) was removed in the presence of the Chief Executive Officer (CEO), Chief Operating Officer (COO), Chief Medical Officer (CMO), Chief Financial Officer (CFO), Chief Nursing Officer (CNO), and Vice President of Quality (VPQ). The survey team verified and confirmed the elements of the IJ Removal Plan (interventions to correct the deficient practice) through observation, interview, and record review while onsite. The IJ Removal Plan indicated that the Governing Board is responsible for ensuring the safety of patients and employees. This includes ensuring all Environment of Care and Safety issues involving the Engineering Department and Infection Prevention Departments are carried out timely and appropriately. Environment of Care (EOC) Safety Log: This log was created to track issues, hazards, and mitigation actions. The Safety Officer is responsible for updating the log after completing Environment of Care Safety Rounds. The log will be included in the Governing Board Packet for review. The Safety Officer ensured that the leak above the ED Nurses' Station, classified as a utility failure from an air handling unit, was entered into the log. Containment was placed, and a swab test was completed on November 7, 2025.

Environment of Care Safety Dashboard (EOCSD): This dashboard was created to report all repair and construction projects to the EOC Committee, the Infection Control Committee, and the Governing Board Committee. It ensures compliance with risk assessments before initiating projects. The Director of Engineering updates the dashboard monthly with metrics such as the number of open/pre-construction projects, closed projects, compliance with ICRAs and PCRAs, environmental testing compliance, and the percentage of projects completed within the timeline.

Monthly Review: The dashboard will be reviewed monthly with the Chief Operating Officer to ensure compliance with risk assessments and validate that repairs, construction projects, and safety issues are appropriately accounted for and reported.
Construction/Repair Tracking Dashboard: This dashboard includes all projects moving forward, including the ED Leak at the Nursing Station. The Director of Engineering logs projects onto the dashboard, which is reviewed bi-weekly with representatives from Infection Prevention, Engineering, and the Chief Operating Officer. The information is cross-referenced with the total number of work orders in the database to ensure accuracy.

Education on Tools: Education on the use and interpretation of the Environment of Care Safety Tool, Dashboard, and Construction/Repair Tracking tool was provided to the Governing Board on November 7, 2025, by the Chief Operating Officer. The Chief Operating Officer ensures the accuracy of these tools before presenting them to the Governing Board for monthly review.

Findings:

During an interview on 10/23/2025 at 2:10 p.m. with Engineering staff (ENG 2), ENG 2 stated that a strong sewer odor was reported in late August. The engineering department inspected the area and suspected it was coming from the sink drain, so a plumbing engineer poured chemicals into the drain. However, ENG 2 stated that the odor was not resolved. On 9/9/2025, they opened the wall by the sink and discovered a leaking pipe. ENG 2 stated that the drywall was wet and had dark brown and black spots, which had to be cut out. Despite the repair to the sink area, the odor persisted. Later, they discovered another pipe leaking above the ceiling, which was the source of the odor. They had to remove the ceiling tile and cut through the piping to remove the damaged pipe. ENG 2 confirmed that the repair started 9/9/2025 and was completed on 10/31/2025 without construction barriers (temporary, physical partitions that separate construction zones from patient care areas to control the spread of dust, debris, and disease-causing agents ensuring patient safety and maintaining a sterile environment).

During a concurrent observation and interview on 11/04/2025 at 11:55 a.m. with the Nurse Manager of the Emergency Department (EDM) in the ED Nursing Station (the central area in the Emergency Department where nurses coordinate patient care and documentation), a plastic covering was observed above the ceiling, positioned over a sink. A piece of tubing extended from the ceiling, through the plastic covering, and into the sink. The EDM confirmed that this setup was related to a second active leak (in addition to two previously identified leaks in the admitting/phlebotomy area). The EDM confirmed the leak occurred in early July this year. The EDM described the leak as forming a paint bubble "the size of a dinner plate" on the ceiling. There was no signage posted to indicate that the sink should not be used. The EDM stated that no instructions had been provided by the Infection Preventionist (a healthcare professional responsible for preventing the spread of infections in the facility) or the Engineering Department (the team responsible for maintaining the hospital's physical infrastructure, including plumbing and repairs) regarding the use of the sink. EDM confirmed the facility was currently using the space for patient care, and that they never closed off this area. There was no signage displayed indicating that an Infection Control Risk Assessment (ICRA, a structured, multidisciplinary process used to evaluate and reduce the risk of infection transmission during any construction, renovation, or maintenance work that occurs in or near patient care areas) completed by Infection Control Department.

During an interview on 11/04/2025 at 10:50 a.m. with Admitting Representative (AR 1), AR 1 stated that there had been a persistent sewer-like odor (a smell similar to raw sewage) in the Emergency Department (ED) Admitting/Phlebotomy area (the section of the ED where patients are registered and blood samples are collected) for approximately two and a half months. AR 1 reported that the odor caused symptoms among staff, including headaches and nausea, and that patients also expressed discomfort due to the strong smell. AR 1 stated that during the repair process, the Engineering Department (the team responsible for maintaining the hospital's physical infrastructure, including plumbing and repairs) only covered the computers in the area. AR 1 confirmed that no physical barriers or containment (structures used to isolate the work area and prevent the spread of contaminants) were set up. AR 1 further stated that one staff member required hospital evaluation due to symptoms. AR 1 reported that this concern was communicated to the former Admitting Manager (MA). However, AR 1 stated that the MA did not provide any directions to staff, as she was no longer employed at the facility after the report was made.

During an interview on 11/04/2025 at 11:49 a.m. with Phlebotomist (Phleb 1), Phleb 1 stated that patients continued to be seen in the affected area during the repair period and that patients complained of a strong odor during blood draws. Phleb 1 confirmed that no physical barriers or containment (structures used to isolate the work area and prevent the spread of contaminants) were set up during the repair work. Phleb 1 further stated that no directives were issued to stop using the area during the construction activities.

During an interview on 11/05/2025 at 11:05 a.m. with AR 7, AR 7 stated that during the repair work on 09/09/2025, there was a significant amount of smoke in the room while work was being performed in the ceiling. AR 7 confirmed that no containment (physical barriers used to isolate the work area and prevent the spread of contaminants) or air filtration (equipment used to remove airborne particles and maintain air quality) was set up during the repair. AR 7 reported experiencing symptoms including coughing and difficulty breathing and stated that they had to miss work due to illness resulting from the exposure.

During a record review of the facility's "Organizational Chart (a diagram that shows the structure of an organization, including departments and reporting relationships)," which was undated, the organizational chart indicated that the Director of Engineering (the individual responsible for overseeing the hospital's physical infrastructure and maintenance operations) reported to the Chief Operating Officer (COO, the executive responsible for managing the hospital's daily operations). The chart further indicated that the COO reported directly to the Chief Executive Officer (CEO, the highest-ranking executive responsible for overall hospital administration), and the CEO reported directly to the Governing Body (the group legally responsible for overseeing the hospital's operations and ensuring compliance with health and safety regulations).

During an interview on 11/4/2025 at 2:17 p.m. with the Chief Operating Officer (COO, the executive responsible for managing the hospital's daily operations), the COO stated that due to the fact they were concentrating on getting the repair done, the COO confirmed that the required environmental safety measures, such as containment (physical barriers to isolate the work area), ventilation (airflow systems to reduce airborne particles), and environmental testing (checking air and surfaces for harmful substances such as mold, dust, or bacteria), were not verified prior to or during plumbing repairs conducted from 09/09/2025 through 10/31/2025. These repairs involved cutting into wet drywall (a construction material used for interior walls) that had visible brown and dark discoloration, which may have indicated the presence of mold (a type of fungus that grows in damp areas and can cause respiratory problems).

During the same interview on 11/4/2025 with the COO, the COO also stated that, initially, they (facility administrative team) were not aware that staff had reported symptoms. The COO later became aware of the reports but was unsure of the exact date this information was received. The COO confirmed that they did not report to the Chief Executive Officer (CEO, the highest-ranking executive responsible for overall hospital administration) that staff had reported symptoms including headaches, nausea, and coughing. The COO also confirmed that one staff member, identified as Admitting Representative (AR 7), required medical evaluation and treatment due to these symptoms.

During a concurrent interview and record review on 11/04/2025 at 2:04 p.m. with the Director of the Engineering Department (DED, the individual responsible for overseeing the hospital's physical infrastructure and maintenance operations), the work order submitted by the Director of Phlebotomy/Laboratory Services on 09/09/2025, was reviewed. The work order indicated that there was an unusual odor coming from the sink inside the Emergency Room (ER) draw station (a designated area where blood samples are collected), describing it as a "sewage smell" and requesting that engineering staff investigate. The DED stated that after engineering staff opened the wall near the sink in the Admitting/Phlebotomy Station (the area where patients are registered and blood is drawn), they identified a leaking pipe and repaired it. However, the odor persisted.

During the same interview on 11/04/2025 at 2:04 p.m. with the DED, the DED further stated that on 08/19/2025, they sent an engineering plumber to the Emergency Department (ED) admitting area (the section of the ED where patients are initially processed), where a second leaking pipe was identified above the ceiling. The DED confirmed that he (DED) instructed the engineer to repair the leaking pipe above the ceiling, and that the final repair was completed by 10/31/2025, as documented in the work order. DED also confirmed that there was another active leak above the ED Nursing Station (the central area in the ED where nurses coordinate patient care and documentation), which had been ongoing since 7/07/2025. He (DED) stated that this repair was on hold, pending fabrication of replacement piping, which would need to be soldered or welded into the existing system above the ceiling.

During an interview on 11/4/2025 at 2:17 p.m., with the Director of Engineering (DED) and the Chief Operations Officer (COO), the COO confirmed that repairs began on 9/9/2025 without notifying Department of Health Care Access and Information (HCAI, department oversees a wide range of programs and regulatory functions, including responsible for reviewing and approving construction plans, permits, and safety clearances for health care facilities. This includes ensuring compliance with seismic safety standards and infection control protocols during construction or renovation projects).

During an interview on 11/4/2025 at 2:30 p.m. with the Chief Operating Officer (COO), the COO confirmed there was no environmental testing for mold or air quality testing conducted before, during, or after the repairs.

During an interview on 11/05/2025 at 2:10 p.m. with the Engineering Supervisor (ES), the ES confirmed that no Infection Control Risk Assessment (ICRA, a structured, multidisciplinary process used to evaluate and reduce the risk of infection transmission during any construction, renovation, or maintenance work that occurs in or near patient care areas.) was completed. The ES also confirmed that the Infection Prevention Department (the team responsible for identifying, monitoring, and preventing the spread of infections within the facility) was not involved in either the admitting area or nursing station repair projects. The ES stated that environmental testing, when conducted, would check for:

-Spores (tiny, invisible fungal particles that float in the air and can cause respiratory issues),
-Asbestos (a group of minerals that are not visible to the eye; when disturbed, asbestos fibers can become airborne and, if inhaled at high levels, may cause lung damage and potentially lead to cancer), and
-Other airborne particles (substances suspended in the air that may pose health risks).
The ES stated that the ICRA form must be completed whenever construction or repair work occurs in a patient care area. The ES further stated that the proper process should involve relocating patients from the affected area before beginning any repair work.

During a concurrent interview and record review on 11/4/2025 at 3:15 p.m. with the Chief Operating Officer (COO) and the Director of Engineering and Design (DED), the FREER Manual (Revised August 2025), published by the California Department of Health Care Access and Information (HCAI), was reviewed. The manual indicated that plumbing repairs involving the replacement or rearrangement of valves, pipes, or fixtures are not considered Excluded Work (routine maintenance that does not require regulatory reporting). These types of repairs were classified as New Work (construction or repair activities that alter the original configuration of building systems) and therefore required submission of the OSHPD-102 form (a regulatory form used to notify HCAI of construction or repair work in healthcare facilities) and formal review by HCAI (California Department of Health Care Access and Information) prior to the start of work. The COO stated they were not aware that piping exchange (replacement of plumbing pipes) requires reporting to HCAI.

During an interview on 11/4/2025 at 3:30 p.m. with the Vice President of Revenue Cycle Management (VP), VP stated that they were not aware of the issue and did not receive a report from admitting leaders regarding the odor.

During an interview on 11/4/2025 at 4:08 p.m. with the Infection Prevention Manager (IPM), IPM confirmed that the department was not informed about the project, nor were they aware of the presence of a strong sewer-like odor or wet drywall with brown and dark spots, which the IPM indicated would have suggested the presence of mold and required further testing.

During an interview on 11/05/2025 at 3:22 p.m. with the CEO, the CEO stated that during Daily Safety Meetings (routine meetings involving department leaders to discuss safety-related issues), major repair work performed by the Engineering Department was typically discussed. The CEO recalled hearing about the repair project but was unsure of the specific date. The CEO stated that the COO reported a leak that required calling in a vendor for the Nursing Station repair (the central area in the Emergency Department where nurses coordinate patient care and documentation). However, regarding the Admitting Area's sink and ceiling repair (the section of the Emergency Department where patients are first registered and processed), the CEO was unsure when the report was received but was aware that the area had been repaired.

During the same interview on 11/5/2025 at 3:22 p.m. with the CEO, the CEO confirmed that major repairs should be reported to both the CEO and the Governing Body. The CEO stated that if they had been made aware of issues such as staff complaints of strong odors, headaches, or nausea, the appropriate departments would have been notified to consider closing the affected area and rerouting patients before initiating repairs.

During the same interview on 11/5/2025 at 3:22 p.m. with the CEO, the CEO also confirmed that while they received general reports indicating when repairs would take place, they did not receive detailed information about the nature or scope of the repairs. The CEO stated that the GB relied on the COO and the Director of Engineering to ensure compliance with safety protocols during demolition, construction, or general maintenance projects, and to ensure the involvement of the Infection Prevention Department to protect patient and staff safety.

During a review of the Facility's Governing Board Bylaws, dated 2025, the Bylaws indicated the following: "General Functions and Responsibilities of the Governing Board: Specific Powers. The Hospital Governing Board shall be delegated the following rights and responsibilities...Oversee and have ultimate accountability for the safety and quality of patient care, treatment, and services at the Hospital; Participate in the strategic planning initiatives for the Hospital ... Enforce policy relating to the general conduct of the Hospital to ensure compliance with the requirements of all applicable federal and state laws and accrediting bodies; Periodically review the Hospital's activities to ensure that it is operating in a manner consistent with the accomplishment of its stated purposes ..."

During a review of the facility's policy and procedure (P&P) titled, "Environment of Care Safety Management Plan," dated 10/23/2024, the P&P indicated the following: The EOC Safety Management Plan provides a framework for managing the environment of care and addresses six areas of the environment of care: safety, security, hazardous materials and waste, fire safety, medical equipment and utility systems. Separate management plans are available for the Emergency Management and Life Safety programs. The objective of the EOC Safety Management Plan is to provide a guideline for the development of a safety management program that will enable the hospital:

-To comply with all relevant safety standards and regulations
-To develop or maintain effective program elements that contribute to an overall reduction in workplace injuries and improved patient safety
-To improve employee performance through effective safety education and training
-To develop standards to monitor, assess, measure and improve EOC performance
-To monitor the effectiveness of the safety program
The CEO is responsible for assuring the existence and effectiveness of a comprehensive safety program by providing the vision, leadership, financial and administrative support to facilitate the ongoing activities of the EOC committee ... The Governing Board receives regular reports of the activities of the hospital safety management program from the Environment of Care (EOC) Committee. The members of the Governing Board review reports and, as appropriate, communicate concerns about identified issues and regulatory compliance to the Chief Executive Officer (CEO) or administrative liaison.

During a review of the facility's policy and procedure (P&P) titled, "Infection Prevention Measures During Construction and Renovation projects," dated 10/24/2018, the P&P indicated, "Engineers, Infection Prevention personnel, Nursing staff, EVS staff and contractors will establish and observe Infection Prevention protocols during demolition, construction, renovation or general maintenance projects. Risk assessments will be conducted and permits signed before construction begins. Responsibilities: Engineering Department will: Notify the Infection Prevention department and review all projects with the Infection Prevention Manager prior to beginning the project. Notify Environmental Services prior to beginning project regarding requirements for personnel and supplies to ensure project and adjacent areas are cleaned/disinfected/pest controlled. Notify all affected departments/services when there is planned/unplanned disruption in water supply and assist in providing alternate sources ... Ensure that barrier materials as required are constructed and maintained properly, HEPA filtered vacuum and portable HEPA filter units for control of airborne contamination are provided unless otherwise contracted ... Obtain Infection Prevention Construction Permit from Infection Prevention before construction/renovation begins. Infection Prevention Permit must be obtained whether work is performed by external contractor or by hospital employees. Obtain signatures of responsible party from general contractor and any prime contractor or hospital project manager, as appropriate."

Based on observation, interview, and record review, the facility failed to ensure that 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83), and staff members, who were present daily in the affected areas (Emergency Department's Admitting/Phlebotomy area, the section where patients are registered and blood samples are collected) and the Nursing Station (a central hub in a hospital where nurses coordinate patient care), were informed of safety risks and the measures implemented to mitigate risks during repair construction (activities aimed at restoring or fixing defects, damage, or failures in a building's structure).

The facility did not post the required Infection Prevention Construction Permit signage (a sign posted at a construction or renovation site that provides a clear, documented summary of the required safety and infection control measures based on a formal Infection Control Risk Assessment [ICRA, process used to evaluate and mitigate the risk of infection transmission during construction]) during plumbing repairs conducted from 09/09/2025 through 10/15/2025, in accordance with the facility's policies titled, "Environment of Care Safety Management Plan" and "Infection Prevention Measures During Construction and Renovation Projects."

This deficient practice violated patients' rights of 57 patients (Patients 27 to 83) to be informed of safety risks while hospitalized and to receive care in a safe and sanitary environment.

Findings:

During a review of the work order (a formal request for maintenance or repair services) for the Emergency Department's Admitting/Phlebotomy area (patient registration and blood collection), dated 9/9/2025, the work order indicated, "An unusual odor is emitting from the sink located inside the Emergency Room draw station."

During a review of a follow-up work order entered by the Engineer Plumbing (ENG) 1, dated 9/11/2025, the work order indicated, "Searched in the ceiling and found some cast iron pipe and fittings completely corroded (a pipe that has deteriorated due to chemical reactions, leading to a breakdown of its material) and cracked causing major sewer gas odors. Replaced several sections of the cast iron pipe and fittings."

During an interview on 10/23/2025 at 2:10 p.m. with Engineering Staff (ENG 2), ENG 2 stated, on 09/09/2025, engineering staff opened the wall near the sink in the Emergency Department (ED) and discovered a leaking pipe. ENG 2 stated that the drywall (a construction material used for interior walls that can harbor mold when wet) was saturated and exhibited dark brown and black discoloration, which had to be cut out. Despite the initial repair to the sink area, ENG 2 stated that the odor persisted. A subsequent inspection revealed a second leaking pipe located above the ceiling, which was identified as the source of the odor. ENG 2 stated that ceiling tiles were removed, and the damaged pipe was cut out and replaced.

During an interview on 11/04/2025 at 10:50 a.m. with Admitting Representative (AR 1), AR 1 stated that there had been a persistent sewer-like odor (a smell similar to raw sewage) in the Emergency Department (ED) Admitting/Phlebotomy area (the section of the ED where patients are registered and blood samples are collected) for approximately two and a half months. AR 1 confirmed that during the repair process there was no signage posted regarding infection control risk assessment.

During an interview on 11/05/2025 at 11:05 a.m. with AR 7, AR 7 stated that during the repair work on 09/09/2025, there was a significant amount of smoke in the room while work was being performed in the ceiling. AR 7 confirmed that there was no signage posted regarding the safety assessment completed to the construction site. AR 7 confirmed there was no air filtrations system (equipment used to remove airborne particles and maintain air quality) set up during the repair. AR 7 reported experiencing symptoms including coughing and difficulty breathing and stated that they had to miss work due to illness resulting from the exposure.

During an interview on 11/4/2025 at 2:17 p.m. with the Chief Operating Officer (COO, the executive responsible for managing the hospital's daily operations), the COO stated the process was the engineering department would reach out to the Infection Prevention Department (IPD) prior to initiating a repair construction in a patient care area, so the IPD could perform an Infection Control Risk Assessment (ICRA, a risk assessment tool used to determine the class of infection control precautions required for a construction or renovation project. It evaluates factors such as the type of work, proximity to patient care areas, and patient risk groups. The ICRA process results in a classification such as Class I-IV). The COO stated due to the fact that they were concentrating on getting the repair done, the COO confirmed that required environmental safety measures, such as containment (physical barriers to isolate the work area), ventilation (airflow systems to reduce airborne particles), and environmental testing (checking air and surfaces for harmful substances such as mold, dust, or bacteria), were not verified prior to or during plumbing repairs conducted from 09/09/2025 through 10/31/2025. These repairs involved cutting into wet drywall (a construction material used for interior walls) that had visible brown and dark discoloration, which may have indicated the presence of mold (a type of fungus that grows in damp areas and can cause respiratory problems).

During an interview on 11/04/25 at 4:08 p.m. with the Infection Prevention Manager (IPM), the IPM confirmed that the Infection Prevention Department (IPD) had not been informed of either project and had not been made aware of the issue regarding the black and brown spots, which were suggestive of mold. The IPM stated, "Both would have been classified as Class III ICRA (Infection Control Risk Assessment, a specific level of stringent precautions for healthcare construction/renovation, requiring active dust control like HEPA vacuums [uses a specialized vacuum with a High-Efficiency Particulate Air- {HEPA} filter to capture at least 99.97% of tiny particles {down to 0.3 microns} like dust, pollen, mold], sealing vents, negative air pressure, sealed waste containers, and thorough post-work cleaning before barriers are removed, used for moderate-to-high dust activities or higher-risk patient areas, ensuring dust/pathogens don't spread to vulnerable patients) projects." IPM stated prior to initiating repair construction in a patient care area, an Infection Control Risk Assessment (ICRA) which was a risk assessment tool used to determine the class of infection control precautions required for a construction, should be completed by IPD. It evaluates factors such as the type of work, proximity to patient care areas, and patient risk groups.

The IPM stated the ICRA process results in a classification such as Class I - IV. The IPM further stated that after the ICRA has been assessed and determined the Class, the Infection Prevention Construction Permit was required for projects classified as Class III or IV. IPM further stated there should have been an Infection Prevention Construction Permit posted at the site for both repair projects (ED Nursing station and Admitting/Phlebotomy area). IPM stated the permit confirms that: The ICRA has been reviewed and approved. Required controls such as HEPA filtration, containment barriers, and signage were in place. IPM stated that the Infection Prevention Department must sign off on the project before work begins. The IPM stated that the IPD should have been informed of both repair projects, because there must be an ICRA assessment completed prior to initiating the repair in the patient care area. The IPM stated that staff could have been exposed to bacteria.

During a review of the facility's policy titled, "Infection Prevention Measures During Construction and Renovation Projects," dated 10/24/2018, the P&P indicated the following: To prevent the acquisition of healthcare associated infections related to environmental contamination in patients/visitors/healthcare workers during hospital demolition, construction and renovation ...Infection Prevention Department will: Review all construction/renovation plans. An Infection Control Risk Assessment (ICRA) must be completed for all projects (Appendix A). Infection Prevention will determine class with Engineering input. Provide written recommendations, as appropriate ... Infection Prevention Permits: Construction/renovation activities require consultation with the Infection Prevention Practitioner ...An Infection Prevention Construction Permit (Appendix A) is required when the construction activity and risk level indicate that Class 111 and Class IV control procedures are required. When an Infection Prevention Construction Permit is required, it must be obtained from the Infection Prevention department before beginning any demolition or construction work. Decisions regarding classification of construction activities rest with the Infection Prevention department. The Infection Prevention Construction Permit must be displayed at the entrance to the work area during the entire construction period. Review and sign Infection Prevention Construction Permit, prior to beginning work.

During a review of the facility's policy and procedure (P&P) titled, "Environment of Care Safety Management Plan," dated 10/23/2024, the P&P indicated, "The Director of Facilities, in concert with Administration and Infection Prevention, will ensure planning for remodels, renovations, alterations, modifications and new facilities takes into consideration patient safety, diagnosis and treatment facilities and special services appropriate to the needs of the community ... Areas used by the patient are safe, clean, functional, and comfortable. This includes lighting, ventilation and cleanliness. Areas are free from offensive odors ...Engineers, Infection Prevention personnel, Nursing staff, EVS staff and contractors will establish and observe Infection Prevention protocols during demolition, construction, renovation and general maintenance projects ...When planning for demolition, construction, renovation or general maintenance, the hospital will conduct a pre-construction risk assessment for air quality requirements, infection control and sanitation, utility requirements, noise, vibration, dust and other hazards that affect care, treatment and services. The hospital takes action based on the risk assessment to minimize risks during construction, such as: Ensure that barrier materials as required are constructed and maintained properly, HEPA filtered vacuum and portable HEPA filter units for control of airborne contamination are provided otherwise contracted. Inspect project during the course of construction, at completion and prior to occupancy of area."

Based on interview and record review, the facility failed to ensure Admitting Department (a hospital section responsible for processing patient admissions) staff provided a copy of the facility's condition of services (a contract that outlines a patient's responsibilities and consent for hospital services. Key elements typically include informed consent for medical treatment, financial responsibilities, and patient rights [the fundamental legal and ethical protections that guarantee individuals receive respectful, dignified, and high-quality healthcare]) and patient rights information copy to one of 83 sampled patients (Patient 5), in accordance with the facility's admitting and registering procedure, when Patient 5 was admitted to the facility on 11/1/2025.

This deficient practice resulted in Patient 5 not knowing and not being able to exercise his (Patient 5's) patient rights during the hospitalization. Patient 5 expressed concerns about being discharged without a clear care plan or understanding of what to expect upon returning home.

Findings:

During a review of Patient 5's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 11/2/2025, the H&P indicated Patient 5 was admitted to the facility from an outside hospital with left sided flank (the side of the body between the ribs and hips) pain on 11/1/2025. The H&P also indicated Patient 5 was pending surgery to treat nephrolithiasis (kidney stones).

During a review of the complaint received by the Department of Public Health (DPH, the state agency responsible for protecting public health and ensuring patient safety in healthcare facilities), dated 11/6/2025, the complaint indicated the following: Patient 5 had a procedure of ureteroscopy (a medical procedure to break up or remove kidney stones) with ureteral-stent (a small, flexible tube placed inside the ureter [the duct connecting from the kidney to the bladder] to allow urine to flow) placement on 11/3/2025 around 5 p.m. Patient 5 was told by on duty night shift nurse same evening (11/3/2025) that he (Patient 5) was discharged (to go home) and would become financially responsible for any additional stay leaving him (Patient 5) no option to refuse discharge. The complaint also indicated Patient 5 did not speak with any physician prior to discharge and was not involved in discharge plan of care (a comprehensive guide created by a healthcare team to ensure a patient has a smooth and safe transition from hospital to home or other lower level of care), and not aware of what to expect after being discharged home.

During a concurrent interview and record review on 11/7/2025 at 9:08 a.m. with the Nurse Manager (NM 1) of Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery) Unit, Patient 5's electronic medical record (EMR) from 11/1/2025 to 11/3/2025, was reviewed. Patient 5's EMR indicated there was no "Condition of Services (a contract that outlines a patient's responsibilities and consent for hospital services. Key elements typically include informed consent for medical treatment, financial responsibilities, and patient rights)" on file. NM 1 stated that admitting department should upload a scanned copy of "Condition of Services" to EMR but there was no "Condition of Services" found in Patient 5's EMR.

During an interview on 11/7/2025 at 4:15 p.m. with the Director (DIR 2) of Admitting, DIR 2 stated the admitting department was responsible for giving the "Condition of Service" and patient's rights and responsibilities notices and obtaining patient's signature for direct admits (patient directly transferred from an outside hospital). DIR 2 stated the signed copy would be scanned and uploaded to a patient's EMR.

During an interview on 11/7/2025 at 5:05 p.m. with the Manager of Accreditation, Regulatory & Licensing (MARL), MARL stated there was no "Condition of Services" found in Patient 5's EMR and MARL was unsure if Patient 5 was informed and aware of his (Patient 5's) rights as a patient.

During a review of the facility's policy and procedure (P&P) titled, "Registration Process, Patient," dated 6/2022, the P&P indicated, "At the time of registration and/or admission, the patient or the patient's legal representative shall acknowledge receipt by signing the following consent forms: a. conditions of services ... f. Patient Rights ... 4. Patients also receive a copy of all the forms upon completion of registration 5. Upon admission to the hospital, patients receive a Patient Folder and Visitors Guide to help orient them to the hospital."

During a review of the facility's policy and procedure (P&P) titled, "Patients Rights and Responsibilities," dated 8/2025, the P&P indicated, "Patient Rights ... The patient has the right to ... 1. Considerate and respectful care, and to be made comfortable ... 20. Be informed by the physician, or a delegate of the physician, of continuing health care requirements and option following discharge from the hospital. They have the right to be involved in the development and implement of their discharge plan ... Procedure: 1. Upon admission to [the facility], either through the Admitting Department or the Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care), the admitting person shall provide written information of an individual's rights under state law to make decisions regarding medical care including the right to accept or refuse treatment and the right to formulate advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor).

Based on interview and record review, the facility failed to ensure one of 83 sampled patients' (Patient 9's) spouse and designated primary representative (RP 1) was able to exercise their rights on behalf of Patient 9, when RP 1 was not contacted by the facility regarding Patient 9's mortuary's (funeral home) "Authorization for Release of Remains" form. In accordance with the facility's policy regarding "Decedent Affairs (the administrative process of handling matters related to a deceased person)." Instead, Patient 9's next of kin and second representative (RP 2) was contacted and thus RP 2 signed Patient 9's mortuary's (funeral home) "Authorization for Release of Remains" form without the knowledge of RP 1. The nursing office also failed to ensure that the primary representative (RP 1) was contacted first.

This deficient practice led to Patient 9's RP 1 not being able to exercise their right and legal authority to make decisions on behalf of Patient 9.

Findings:

During a record review of Patient 9's "History and Physical (H&P)," dated 10/29/2024, the H&P indicated Patient 9 was admitted to the facility for weakness and pain. Patient 9's medical history included stroke (loss of blood flow to a part of the brain) and hypertension (HTN, high blood pressure). The record did not indicate Patient 9 had a durable power of attorney (DPOA, legal document where a patient designates someone to make decisions for them if unable to).

During a record review Patient 9's "Face sheet (front page of the chart that contains a summary of basic information about the patient)," dated 11/1/2024, the Face sheet indicated Patient 9 had a spouse (RP 1) and next of kin (RP 2) listed as emergency contacts.

During a record review of Patient 9's "Progress Note SOAP (subjective, observation, assessment, plan)," dated 10/31/2024, the Progress Note indicated Patient 9's RP 1 was recognized as the spouse and was involved in Patient 9's plan of care.

During a record review of Patient 9's "Notice of Death," dated 11/2/2024, the record indicated Patient 9's RP 1 was made aware of Patient 9's death.

During an interview on 11/3/2025 at 2:30 p.m. with Registered Nurse (RN) 2, RN 2 stated an emergency contact would be the spouse or the designated decision maker, children, and blood relatives. RN 2 stated she would contact the spouse or designated decision maker first if there was no DPOA and acknowledged patients' rights applied to them.

During a concurrent interview and record review on 11/6/2025 at 10:42 a.m. with House Supervisor (HS), Patient 9's "Mortuary Release Form," dated 11/4/2024, was reviewed. The record indicated the release was signed by the mortuary, and on the mortuary's form for "Authorization for Release of Remains," Patient 9's RP 2 was listed as the "Representative," the relationship was marked as "Next-of-Kin (Closest Living Relative)," and RP 2 signed the form. Patient 9's RP 1 was not listed on this form, and the facility did not contact RP 1 to sign the form.

During a continued interview and record review on 11/6/2025 at 10:42 a.m. with HS, HS stated the next of kin was considered the emergency contact. HS stated the next of kin was usually the spouse, parent, or other living relative. HS stated she would have gone with RP 1 and RP 1 should have signed the document. HS also stated nursing office was responsible for making sure the form received from the mortuary was correct, and they would check for discrepancies such as name or to update information.

During a review of the facility's policy and procedure (P&P) titled, "Decedent Affairs," dated 7/27/2022, the P&P indicated, "Prior to releasing remains to mortuary transporter, the Nursing Office shall ensure that the "Release Authorization" form is completed in full by the mortuary and is properly signed. The following relatives may sign a "Release Authorization" (listed in order of who may consent).
a. An agent named in the Advanced Directive
b. Surviving spouse/domestic partner
c. Adult child (in the case of multiple adult children, one child may sign if they represent the wishes of the majority of the adult children)
d. Surviving parent
e. Adult sibling (in the case of multiple adult siblings, one sibling may sign if they represent the wishes of the majority of the adult siblings)
f. Surviving adults in degree of kinship."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 8/27/2025, the P&P indicated, "The patient has the right to: 11. Formulate advance directives. This includes designating a decision maker if they become incapable of understanding a proposed treatment or become unable to communicate their wishes regarding care. The decision maker may be any adult over the age of 18, including but is not limited to a spouse, unmarried partner of the same or opposite sex, parent, sibling, child or friend. Hospital staff and practitioners who provide care in the hospital shall comply with these directives. All patients' rights apply to the person who has legal responsibility to make decisions regarding medical care on their behalf."

Based on observation, interview, and record review, the facility failed to ensure a safe patient-care environment for 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) when it conducted plumbing repairs in an active Emergency Department (ED) patient-care areas without implementing required containment measures (physical barriers designed to prevent the spread of dust, debris, and contaminants during construction), without completing an Infection Control Risk Assessment (ICRA, a structured, multidisciplinary process used to determine infection-control precautions required during construction or maintenance), and without providing ventilation or air-filtration controls, including High-Efficiency Particulate Air (HEPA filtration, a mechanical filtering system that captures small airborne particles) or negative air pressure (a ventilation technique that keeps air flowing into, but not out of, a contaminated area).

This deficient practice exposed patients and staff to hazardous environmental conditions, including airborne particles (microscopic solid or liquid substances suspended in air), sewer-like odors (strong odors produced by leaking wastewater piping), wet drywall with brown/black discoloration suggestive of mold (fungal growth capable of releasing spores), smoke, and water diverted from ceiling leaks into a clinical hand-washing sink, increasing the risk of exposure to waterborne pathogens (disease-causing microorganisms transmitted through contaminated water) and environmental contaminants (harmful biological or chemical substances present in the environment).

Findings:

During a concurrent observation and interview on 11/04/2025 at 11:55 a.m. with the Emergency Department Manager (EDM), in the Emergency Department Nursing Station, a transparent plastic sheet was observed taped across the ceiling with a drainage tube discharging water into a hand-washing sink used by clinical staff. Water was visible inside the plastic.
The EDM stated the leak had been present since early July 2025, that there was no signage to indicate restricted use of the sink, and that no Infection Control Risk Assessment (ICRA) had been completed.

During a review of the work order for the Emergency Department Admitting/Phlebotomy area, dated 09/09/2025, the work order indicated "An unusual odor is emitting from the sink located inside the Emergency Room draw station."

During a review of a follow-up work order entered by Engineering (Plumbing) on 09/11/2025, the work order indicated "Searched in the ceiling and found some cast iron pipe and fittings completely corroded (deterioration of metal due to chemical reaction) and cracked, causing major sewer gas odors. Replaced several sections of the cast iron pipe and fittings."

During an interview on 10/23/2025 at 2:10 p.m. with Engineering Staff (ENG 2), ENG 2 stated a strong sewer-like odor had been reported in late August 2025. ENG 2 stated that on 09/09/2025 the wall near the sink was opened and wet drywall with dark brown and black spots suggestive of mold (fungal growth capable of producing spores) was found and removed. ENG 2 stated the odor persisted until a second leaking pipe above the ceiling was discovered. ENG 2 stated the ceiling tiles were removed, and pipe sections were cut and replaced without construction containment barriers. ENG 2 stated repairs occurred from 09/09/2025 through 10/31/2025 without ventilation or filtration systems in place.

During an interview on 11/04/2025 at 10:50 a.m. with the Admitting Representative (AR 1), AR 1 stated a sewer-like odor persisted for approximately two and a half months in the ED Admitting/Phlebotomy area and caused staff headaches and nausea. AR 1 stated that patients also complained of the odor. AR 1 stated no containment barriers, air-filtration systems, or infection-control oversight were in place during the repairs, and that one staff member required hospital evaluation.

During an interview on 11/04/2025 at 11:49 a.m. with Phlebotomist (Phleb 1), Phleb 1 stated patients continued to be seen in the area during repairs and complained of the odor. Phleb 1 stated no containment barriers or ventilation systems were used.

During an interview on 11/05/2025 at 11:05 a.m. with the Admitting Representative (AR 7), AR 7 stated the ED Admitting area had a strong sewer odor from 09/09/2025 until 10/15/2025. AR 7 stated the repair work produced significant smoke in the room, that only a 10-inch by 10-inch window was available for ventilation, and that no air filtration or containment barriers were used. AR 7 stated she developed coughing, difficulty breathing, headaches, and nausea, was prescribed antibiotics twice, required a stronger inhaler, and took time off from work.

During an interview on 11/04/2025 at 2:04 p.m. with the Director of Engineering (DED), the DED stated repairs began on 09/09/2025 without notifying the Infection Prevention Department (the program responsible for preventing healthcare-associated infections) or the Department of Health Care Access and Information (HCAI, the California agency responsible for construction oversight in healthcare facilities). The DED stated a second leak above the ED Nursing Station had been present since 07/07/2025 and remained unrepaired.

During an interview on 11/05/2025 at 2:10 p.m. with the Engineering Supervisor (ES), the ES stated no Infection Control Risk Assessment (ICRA) was completed and the Infection Prevention Department was not involved in either repair project.

During an interview on 11/04/2025 at 4:08 p.m. with the Infection Prevention Manager (IPM), the IPM stated the Infection Prevention Department had not been notified of either project. The IPM stated both projects would have been classified as Class III ICRA (Infection Control Risk Assessment, a specific level of stringent precautions for healthcare construction/renovation, requiring active dust control like HEPA vacuums [uses a specialized vacuum with a High-Efficiency Particulate Air- {HEPA} filter to capture at least 99.97% of tiny particles {down to 0.3 microns} like dust, pollen, mold], sealing vents, negative air pressure, sealed waste containers, and thorough post-work cleaning before barriers are removed, used for moderate-to-high dust activities or higher-risk patient areas, ensuring dust/pathogens don't spread to vulnerable patients), requiring HEPA filtration (stands for High-Efficiency Particulate Air and is a type of mechanical air filter that can trap at least 99.97% of airborne particles 0.3 microns in size), containment barriers, and air sampling (testing air for contaminants such as mold spores or bacteria). The IPM stated staff could have been exposed to bacteria.

During a review of the facility's policy and procedure titled, "Environment of Care Safety Management Plan," dated 10/23/2024, the policy indicated a pre-construction risk assessment must be completed, and that repairs require collaboration with Infection Prevention regarding air quality, odor, and infection-control risks. The policy indicated HEPA filtration and containment barriers are required during such projects.

During a review of the facility's policy and procedure titled, "Infection Prevention Measures During Construction and Renovation Projects," dated 10/24/2018, the policy indicated the Infection Prevention Department must be notified prior to repair projects, an ICRA must be completed, containment barriers and air-filtration systems must be implemented, and an Infection Prevention Construction Permit must be obtained prior to beginning work.

Based on interview and record review, the facility did not fully implement the methods and mechanisms required to ensure that patients are free from all forms of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse), in accordance with the facility's policy and procedure regarding abuse, for two of 83 sampled patients (Patients 1 and 8) when:

1. The facility did not conduct a thorough investigation, when Patient 1 alleged that a male registered nurse (RN 1) pushed her (Patient 1) onto the bed and held her down, then locked her (Patient 1) in the room all night long.
2. The facility did not interview or assess Patient 8 (Patient 1's roommate) to verify if Patient 8 witnessed any type of abuse or if Patient 8 sustained abuse or injury by RN 1.

This deficient practice resulted in a lack of thorough investigation by the facility and the inability to determine whether or not abuse occurred, which placed other patients at risk of potential abuse or harm.

Findings:

During an interview on 11/3/2025 at 2:45 p.m. with the Nurse Manager (NM 1) for the Medical surgical Unit, NM 1 stated that on 10/29/2025 at around 9:30 a.m., she (NM 1) was informed by a staff nurse and charge nurse that Patient 1 alleged that at 4 a.m. on 10/29/2025, a nurse (RN 1, registry nurse [a type of temporary or contract nurse that works through a staffing agency - also known as a nurse registry, to fill short-term staffing needs at various healthcare facilities]) pushed her (Patient 1) down on her bed and locked her in the room. NM 1 spoke to Patient 1's family member (FM 1), who reported that at 4 a.m., Patient 1 tried to wander out of the room (Patient 1's room), then RN 1 pushed Patient 1 on to the bed and held Patient 1 down, for an unspecified amount of time. RN 1 proceeded to lock Patient 1 inside the room. Per NM 1, FM 1 stated she (FM 1) asked Patient 1 for more details, and it turned out that RN 1 was sitting outside Patient 1's room, in the hallway during the night shift. NM 1 said that FM 1 spoke to Patient 8, who shared the room with Patient 1. According to FM 1, Patient 8 stated that RN 1 could have talked in a gentler manner to Patient 1. Per NM 1, FM 1 did not believe the incident happened as Patient 1 described it. FM 1 did not wish to call the police department.

During the same interview on 11/3/2025 at 2:45 p.m. with the Nurse Manager (NM 1) for the Medical surgical Unit, NM1 said that she (NM 1) did not interview Patient 1, because Patient 1 did not speak English. NM 1 reported the incident to the house supervisor, who informed her (NM 1) that RN 1 was a registry nurse and would not return. NM 1 stated she (NM 1) did not interview Patient 8 (Patient 1's roommate) to verify if she (Patient 8) witnessed any mistreatment against Patient 1. In addition, Patient 8 was not assessed for any injuries. NM 1 stated she (NM 1) did not get a chance to interview RN 1 or any other potential witnesses, such as other staff on the unit. NM 1 stated there was currently no conclusion to the investigation. The incident had been escalated to the house supervisor and the Director of the Medical Surgical Unit, and to the Human Resources Department. In addition, the incident was reported through the hospital's event reporting system.

During an interview on 11/3/2025 at 3:15 p.m. with the Director of the Medical Surgical Unit (DIR 1), DIR 1 stated the following: On 10/29/2025 at 9:30 a.m., FM 1 reported that a nurse (RN 1), during the night shift, was being rough with Patient 1. DIR 1 instructed NM 1 to investigate the allegation. DIR 1 notified the nursing office of the allegation. The investigation was completed by NM 1. Patient 1 was assessed and there were no bruises present. DIR 1 stated he (DIR 1) did not know that only one person (FM 1) had been interviewed during the investigation. DIR 1 stated he (DIR 1) was not aware that only one person (FM 1) had been interviewed and no staff working during the night shift were interviewed.
DIR 1 stated that interviewing only one person was not a complete investigation. A complete investigation should be done to verify if the allegation was valid. Potential witnesses, such as other patients and staff should have been interviewed to verify if someone saw or hear something. A timeline of the allegation should have been done. That was not the proper way to conduct an investigation (referring to the incomplete investigation by NM 1). DIR 1 said the allegation was reported to the department of human resources. DIR 1 stated he (DIR 1) thought the allegation or incident was closed instantly. DIR 1 did not know the conclusion or the results of the investigation.

During an interview on 11/4/2025 at 2 p.m. with the Manager of Accreditation, Regulatory & Licensing (MARL), MARL stated she (MARL) was informed of Patient 1's allegation of abuse on 10/29/2025 at 12 noon. MARL said she (MARL) did not get a chance to interview Patient 1 because NM 1 informed her that Patient 1 had already been discharged. MARL stated she did not speak with Patient 1's roommate (Patient 8) and no other staff members were interviewed. MARL was not sure if Human Resources department investigated the incident (Patient 1's allegation of abuse). At the time of the interview on 11/4/2025, MARL said the facility was unable to determine if the allegation was substantiated (means that an investigation has found enough evidence to prove the claim is true). MARL also stated the facility terminated the contract with RN 1, who was a registry nurse.

During a concurrent interview and record review on 11/4/2025 at 2:36 p.m. with NM 1, Patient 1's medical record, was reviewed. NM 1 verified Patient 1 had actually been discharged on 10/29/2025 at 3:24 p.m., not at 11 a.m., as previously thought, because when she spoke with FM 1, at 11 a.m., Patient 1 was dressed, packed and ready to go. So, NM 1 assumed Patient 1 had been discharged at 11 a.m.

During an interview on 11/5/2025 at 3:30 p.m. with NM 1, NM 1 stated she (NM 1) did not interview Patient 8 (Patient 1's roommate) regarding the abuse allegation, nor was Patient 8 assessed for any possible injury. In addition, NM 1 stated she (NM 1) miscommunicated with the Manager of Accreditation, Regulatory & Licensing (MARL), when NM 1 informed MARL that Patient 1 had been discharged at 11 a.m. on 10/29/2025, when in fact Patient 1 was discharged at 3:24 p.m.

During a concurrent interview and record review on 11/5/2025 at 3:30 p.m. with the MARL, Patient 1's discharge summary, was reviewed. The MARL stated she was informed of the incident through the hospital's event reporting system on 10/29/2025 at 11 a.m. MARL also said she spoke with NM 1, who informed her (MARL) that Patient 1 had been discharged at 11 a.m., which was the reason why MARL did not interview Patient 1. The MARL reviewed Patient 1's discharge summary which indicated that Patient 1 had actually been discharged at 3:24 p.m., not 11 a.m., on 10/29/2025. The MARL stated there were no other investigations related to Patient 1's allegation.

During an interview on 11/6/2025 at 10:30 a.m. with the Manager of Human Resources (MHR) and the Senior Human Resources Generalist (SHRG), the MHR and SHRG stated the following about Registered Nurse (RN 1). RN 1 was originally hired as a traveler nurse (a registered nurse who takes short-term assignments, to fill staffing needs) in the medical-surgical intensive care unit (a specialized healthcare unit that provides intensive care to critically ill patients who have undergone surgery or have complex medical conditions) on 6/9/2025. On 7/12/2025, RN 1 converted to a registry nurse (a nurse who worked for a staffing agency to fill temporary or contract positions). The MHR stated that RN 1 was currently suspended while waiting for the registry agency to conclude its' investigation of the allegation of abuse. The MHR and the SHRG stated that they (MHR and SHRG) did not interview RN 1, nor did they conduct their own investigation into the allegation. They (MHR and SHRG) were waiting to get feedback from the registry agency. The SHRG stated that the investigation should be a collaborative effort, however, the SHRG was not aware that only one person (FM 1) had been interviewed during the investigation. The SHRG stated that other staff and patients should have been interviewed to see if there were any witnesses of the alleged abuse.

During a review of Patient 1's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/28/2025, the H&P indicated the following: Patient 1 had a history of hypothyroidism (thyroid does not make enough thyroid to meet the body's needs), hypertension (high blood pressure), and hyperlipidemia (high levels of fat in the blood). Patient 1 had a chronic right inguinal hernia (when part of the intestine or fatty tissue pushes through a weak spot in the abdominal shall into the groin area) as well. Patient 1 has had persistent pain at her right inguinal hernia. Patient 1 was admitted to the medical surgical floor.

During a review of Patient 1's nurse's notes, documented by RN 5 and NM 1, titled, "Daily Focus Assessment Report," dated 10/29/2025, the nurse's notes indicated the following:

-At 10 a.m., MD (physician) was notified of the following: Patient (Patient 1) reported to staff that night shift male staff members were "manhandling" the patient (Patient 1), "pushed her onto her bed," and "locked her in her room." "Patient (Patient 1) denies any injury, but prefers to have female nursing staff going on ..."
-At 10:38 a.m., Spoke with family member (FM 1) ...at length regarding alleged abuse ...FM 1 summarized her mom's (Patient 1) allegation, stating that Patient 1 stated she (Patient 1) was pushed onto the bed and locked in her room all night. FM 1 stated that Patient 1 said the nurse was sitting outside her room all night and may have perceived herself to be locked in. FM 1 stated that Patient 1 had been on morphine (a strong pain killer) that night and wondered if that caused a lot of her (Patient 1) confusion. FM 1 did not feel that the nurse was intentionally doing anything wrong but that was her mom's (Patient 1) perception. FM 1 stated if Patient 1 had a female nurse, FM 1 does not think this (allegation of abuse) would have occurred as Patient 1 was more comfortable to female than males ...
-At 10:44 a.m., family member (FM 1) stated that she (FM 1) only wanted to provide feedback about giving staff more education on de-escalation (It involves methods like active listening, empathy, and verbal communication to calm a patient, and it helps create a safer environment for both patients and staff) of confused elderly females ...FM 1 is happy with care provided and kept restating that she (FM 1) does not want anyone to get in trouble ...I (NM 1) reassured FM 1 that we are looking into the event because patient safety is our top priority ...
-At 10:44 a.m., FM 1 declined escalating (to report the abuse allegation) to the police department.

During a review of Patient 1's "Patient Discharge Instruction," dated 10/29/2025 at 2:49 p.m., the Patient Discharge instructions indicated Patient 1 was given instructions regarding activity, diet, and medication.

During a review of Patient 8's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/19/2025, the H&P indicated Patient 8 had "medical problems significant for gastric and colon adenocarcinoma (cancer in the stomach and large intestines) ... diabetes mellitus type 2 (high sugar in the blood), who presented ... for symptoms of acute abdominal pain, nausea (an unpleasant feeling of sickness in the stomach accompanied by the urge to vomit), and vomiting starting two (2) days prior to presentation."

During a review of the facility's policy and procedure (P&P) titled, "Abuse: Prevention, Identification, Investigation, and Protection," dated 8/27/2025, the P&P indicated the following: In accordance with our covenant of promoting and ensuring patients' rights, the Hospital is committed to take those steps within its control to prevent and protect patients from abuse and to investigate any suspected or actual incidence of abuse to patients. The Hospital shall make certain that all alleged violations are immediately and thoroughly investigated, and shall prevent further potential abuse while the investigation is in progress ...Procedure:

1. If there is an allegation of patient abuse, the patient/resident will immediately be evaluated and assessed to make certain they are healthy, safe and uninjured.
2. The alleged offender will be immediately removed from the vicinity of the patient and all patient care areas ...
3. All patients/residents within the area/vicinity of the alleged abuse will be assessed to ensure no one else is impacted.

Based on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI, a data-driven, proactive approach to improving the quality of care and services) program team, in which the Risk Manager (RM) was a member, failed to ensure proper data collection and analysis of patient safety events, when the facility failed to thoroughly investigate and analyze an unusual occurrence (any occurrence which threatens the welfare, safety, or health of patients, personnel or visitors) involving patient allegation abuse for one of 83 sampled patients (Patient 1). Patient 1 alleged that a registered nurse (RN 1) pushed her (Patient 1) onto the bed, held her down and locked her in the room (Patient 1's room which is shared with another patient [Patient 8]).

This deficient practice had the potential for patients to be at higher risk of harm and a missed opportunity to identify areas of improvement, track trends, or implement systemic changes and ensure patient safety.

Findings:

During an interview on 11/3/2025 at 2:45 p.m. with the Nurse Manager (NM 1) for the Medical surgical Unit, NM 1 stated that on 10/29/2025 at around 9:30 a.m., she (NM 1) was informed by a staff nurse and charge nurse that Patient 1 alleged that at 4 a.m. on 10/29/2025, a nurse (RN 1, registry nurse [a nurse who works through a private agency that places nurses in temporary positions]) pushed her (Patient 1) down on her bed and locked her in the room. NM 1 spoke to Patient 1's family member (FM 1), who reported that at 4 a.m., Patient 1 tried to wander out of the room, then RN 1 pushed Patient 1 on to the bed and held Patient 1 down for an unspecified amount of time. RN 1 proceeded to lock Patient 1 inside the room.

During the same interview on 11/3/2025 at 2:45 p.m. with the Nurse Manager (NM 1) for the Medical surgical Unit, NM 1 stated FM 1 asked Patient 1 for more details regarding Patient 1's allegation, and it turned out that RN 1 was sitting outside Patient 1's room, in the hallway during the night shift. NM 1 said FM 1 spoke to Patient 8, who shared the room with Patient 1. NM 1 relayed that according to FM 1, Patient 8 stated that RN 1 could have talked in a gentler manner to Patient 1. Per NM 1, FM 1 did not believe the incident happened as Patient 1 described it. FM 1 did not wish to call the police department. NM 1 did not interview Patient 1, because Patient 1 did not speak English. NM 1 said she (NM 1) reported the incident to the house supervisor, who informed her (NM 1) that RN 1 was a registry nurse and would not return. NM 1 stated she (NM 1) did not interview Patient 8 (Patient 1's roommate) to verify if she (Patient 8) witnessed or suffered any abuse from RN 1. In addition, Patient 8 was not assessed for any injuries or signs of abuse. NM 1 stated she (NM 1) did not get a chance to interview RN 1 or any other potential witnesses, such as other staff on the unit. NM 1 stated there was currently no conclusion to the investigation. The incident had been escalated to the house supervisor and the Director of the Medical Surgical Unit, and to the Human Resources Department. In addition, the incident was reported through the hospital's internal reporting system.

During an interview on 11/3/2025 at 3:15 p.m. with the Director of the Medical Surgical Unit (DIR 1), DIR 1 stated the following: On 10/29/2025 at 9:30 a.m., FM 1 reported that a nurse (RN 1), during the night shift, was being rough with Patient 1. DIR 1 instructed NM 1 to investigate the allegation. DIR 1 notified the nursing office of the allegation. The investigation was conducted by NM 1. Patient 1 was assessed and there were no bruises present. DIR 1 stated he (DIR 1) was not aware that only one person (FM 1) had been interviewed during the investigation and no staff working during the night shift were interviewed. DIR 1 stated that interviewing only one person was not a complete investigation. A complete investigation should be done to verify if the allegation was valid. Potential witnesses, such as other patients and staff should have been interviewed to verify if someone saw or heard something. A timeline of the allegation should have been done. DIR 1 said the manner in which NM 1 proceeded with the investigation was not the proper way to conduct an investigation. DIR 1 stated the allegation was reported to the facility's department of human resources. DIR 1 stated he (DIR 1) thought the allegation or incident was closed instantly. DIR 1 did not know the conclusion or the results of the investigation.

During an interview on 11/4/2025 at 2 p.m. with the Manager of Accreditation, Regulatory & Licensing (MARL), MARL stated she (MARL) was informed of Patient 1's allegation of abuse on 10/29/2025 at 12 noon. MARL did not get a chance to interview Patient 1 because NM 1 informed MARL that Patient 1 had already been discharged. MARL stated she did not speak with Patient 1's roommate (Patient 8) and no other staff members were interviewed. MARL was not sure if Human Resources investigated the allegation. At the time of the interview on 11/4/2025, MARL said the facility was unable to determine if the allegation was substantiated (means that an investigation has found enough evidence to prove the claim is true). The facility terminated the contract with RN 1, who was a registry nurse.

During an interview on 11/5/2025 at 3:30 p.m. with NM 1, NM 1 stated she (NM 1) did not interview Patient 8 (Patient 1's roommate) regarding the abuse allegation, nor was Patient 8 assessed for any possible injury. In addition, NM 1 stated she (NM 1) miscommunicated with the Manager of Accreditation, Regulatory & Licensing (MARL), when NM 1 informed MARL that Patient 1 had been discharged at 11 a.m. on 10/29/2025, when in fact Patient 1 was discharged later that day (10/29/2025) at 3:24 p.m.

During an interview on 11/6/2025 at 10:30 a.m. with the Manager of Human Resources (MHR) and the Senior Human Resources Generalist (SHRG), the MHR and SHRG stated the following about Registered Nurse (RN 1). The MHR said that RN 1 was currently suspended while waiting for the registry agency to conclude its' investigation of the allegation of abuse. The MHR and the SHRG stated that they (MHR and SHRG) did not interview RN 1, nor did the facility's Human Resources Department (manages the organization's employees for the entire employee lifecycle) conduct their own investigation of the abuse allegation. The MHR and SHRG stated they were relying on the registry agency (who employed RN 1) to conduct the investigation and were waiting to get feedback from the registry agency as to the results of the investigation. The SHRG stated that the investigation should have been a collaborative effort, however, the SHRG was not aware that only one person (FM 1) had been interviewed during the investigation. The SHRG stated that other staff and patients should have been interviewed to see if there were any witnesses to the alleged incident.

During an interview on 11/6/2025 at 2:53 p.m. with the MARL, the MARL stated the following: MARL was informed of the abuse allegation made by FM 1 on 10/29/2025 at approximately 8:45 a.m., by the Risk Manager (RM) and via the facility's internal incident reporting system. "The Risk Manager (RM) triaged (the process of assessing and prioritizing) the incident and forwarded it to me (MARL). I (MARL) contacted the Nurse Manager (NM 1) and asked if Patient 1 was still on the unit. NM 1 stated Patient 1 had been discharged, on 10/19/2025 at 11 a.m." MARL said NM 1 was in charge of the investigation. MARL stated the investigation should have included interviewing other staff present on the unit during the time of the alleged allegation. In addition, the Human Resources Department (HRD) should have conducted their own investigation. HRD should determine whether or not the allegation was substantiated. HRD placed RN 1 on a "Do not send" list. The MARL stated the investigation was closed when Patient 1 was discharged on 10/29/2025 and there was no conclusion to the investigation. There was no team involvement to investigate the allegation. No root cause analysis (assessment conducted to prevent recurrence of an event by identifying reason[s] underlying an undesirable condition or problem in the system) was done. The incident was just reported to the regulatory agency as an "unusual occurrence" under adverse events (a patient safety that resulted to harm to a patient) on 10/29/2025 at 4:48 p.m.

During an interview on 11/6/2025 at 3:15 p.m. with the Vice President of Quality and Risk Management (VPQRM), the VPQRM stated the allegation of abuse was forwarded to the Human Resources Department for investigation. VPQRM was not part of the investigation. The VPQRM stated that the Risk Manager (RM) was responsible for the investigation.

During an interview on 11/6/2025 at 3:22 p.m. with the Risk Manager (RM), the RM stated the following: NM 1 was designated to conduct the investigation into the abuse allegation made by Patient 1. NM 1 spoke to FM 1, who did not want to escalate the allegation. FM 1 believed the incident did not occur as Patient 1 described. Patient 1 may have believed she (Patient 1) was trapped. The RM stated HRD was involved in the investigation, however, RM was not aware that HRD was relying on the Registry Agency (a business that acts as a referral service for nurses) to conduct the investigation. RM reviewed the facility's policy regarding adverse events and unusual occurrences and stated that HRD should conduct their own investigation. In addition, the RM was not aware that only one person (FM 1) had been interviewed to investigate the abuse allegation. The RM stated that Patient 1's roommate (Patient 8) should have been interviewed, as well, to determine if Patient 8 witnessed or also suffered any abuse by RN 1. Other staff on the unit should have been interviewed to determine if they saw anything (abuse). The RM stated that the investigation could have been better. Interviewing one person did not constitute a thorough investigation, per the facility's policy. The investigation was insufficient and therefore, the allegation could not be substantiated.

During a review of Patient 1's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/28/2025, the H&P indicated the following: Patient 1 had a history of hypothyroidism (thyroid does not make enough thyroid to meet the body's needs), hypertension (high blood pressure), and hyperlipidemia (high levels of fat in the blood). Patient 1 had a chronic right inguinal hernia (when part of the intestine or fatty tissue pushes through a weak spot in the abdominal shall into the groin area) as well. Patient 1 has had persistent pain at her right inguinal hernia. Patient 1 was admitted to the medical surgical floor.

During a review of Patient 1's nurse's notes titled, "Daily Focus Assessment Report," dated 10/29/2025, the nurse's notes indicated the following:

-At 10 a.m., MD (physician) was notified of the following: Patient (Patient 1) reported to staff that night shift male staff members were "manhandling" the patient (Patient 1), "pushed her onto her bed," and "locked her in her room." "Patient (Patient 1) denies any injury, but prefers to have female nursing staff going on ..."
-At 10:38 a.m., "Spoke with family member (FM 1) ...at length regarding alleged abuse ...FM 1 summarized her mom's (Patient 1) allegation, stating that patient (Patient 1) said she was pushed onto the bed and locked in her room all night. FM stated that patient (Patient 1) said the nurse was sitting outside her room all night and may have perceived herself to be locked in. Family member (FM 1) stated that patient (Patient 1) has been on morphine (a strong pain killer) and family member (FM 1) wonders if that caused a lot of her (Patient 1) confusion. Family member (FM 1) does not feel that the nurse was intentionally doing anything wrong but her mom's (Patient 1) perception. Family member (FM 1) stated if patient (Patient 1) had a female nurse, family (FM 1) does not think this (allegation of abuse) would have occurred as patient (Patient 1) is more comfortable to female than males ..."
-At 10:44 a.m., FM 1 stated that she (FM 1) only wanted to provide feedback about giving staff more education on de-escalation of confused elderly females ...FM 1 is happy with care provided and kept restating that she (FM 1) does not want anyone to get in trouble ... "I (NM 1) reassured FM 1 that we are looking into the event because patient safety is our top priority ..."
-At 10:44 a.m., FM 1 declined escalating to the police department.

During a review of Patient 1's "Patient Discharge Instruction," dated 10/29/2025 at 2:49 p.m., the Patient Discharge instructions indicated Patient 1 was given instructions regarding activity, diet, and medication.

During a review of the facility's policy and procedure (P&P) titled, "Adverse Events and Unusual Occurrences: Governmental Reporting," dated 8/27/2025, the P&P indicated the following: "The purpose of this policy is to establish a process through which all incidents, adverse events and sentinel events, can be identified, understood and diminished or eliminated, when possible; to reduce likelihood of similar events from recurring. Definition(s): Adverse Event: A patient safety event that resulted in harm to the patient. Immediate Crisis Management: The process by which HPMC immediately respond to an event, which includes actions within 24 hours of the event to: attend to the needs of the patient and staff involved, secure the area, gather facts and notify all appropriate people. Incident Response Team: is a rapid response team that may consist of (but not limited to) the Risk Management Department, Quality Department, Chief Executive Officer, Chief Nursing Officer, Vice President of Human Resources, Manager of Patient Relations, and House Supervisor. The team will oversee the immediate crisis management (including investigation) and the root cause analysis process. It is the Policy of the Hospital to respond to all adverse events and sentinel events with an immediate investigation and response which would include a thorough and credible root cause analysis (RCA) to identify the underlying causes and the opportunities for improvement to the systems and processes that will reduce the probability of such event recurring. It is the policy of the Hospital to comply with the requirements for reporting unusual occurrences and adverse events as required by federal and state law ...An event shall be completed and reported via the Event Reporting System (ERS). Event reports may be received by different individuals within the Hospital. These individuals must immediately contact the Manager of Risk Management (or designee) and provide information regarding the adverse event. The Manager of Risk Management (or designee) will investigate the situation/event to collect all pertinent information. The Manager of Risk Management (or designee) will consult with the Human Resources Department, department leader, and any other pertinent personnel ...The Risk Management Department (or designee) will lead a multidisciplinary team in the completion of the root cause analysis to include: identification of "root" causes and contributing factors, development of risk reduction strategies, action plans and measurement strategies for improvement, "quick fixes" are immediately implemented. Any occurrence ...or unusual occurrence which threatens the welfare, safety, or health of patients ...shall be reported as soon as reasonably practicable ...to the local health officer ...Examples of unusual occurrences which require reporting include ...suspected criminal acts by patients, employees or visitors that adversely affect delivery of patient care."

During a review of the facility's policy and procedure (P&P) titled, "Quality Assessment / Performance Improvement Plan (QAPI) 2025," dated 6/25/2025, the P&P indicated the following: "The purpose of the organizational Quality Assessment and Performance Improvement Plan (QAPI Plan) at (name of the facility) is to ensure that the Governing Body, medical staff, and professional service staff demonstrate a consistent endeavor to deliver safe, effective, and optimal patient care and services in an environment of minimal risk. In keeping with (name of the facility) mission to provide "Quality Care with Compassion and Respect," the organizational QAPI Plan allows for a hospital-wide systematic, coordinated, continuous, and data-driven approach to improving performance focusing upon processes and mechanisms that address these values. Goals: The primary goals of the (name of the facility) QAPI Plan are based on annual performance and are to: Continually and systematically plan, design, measure, assess, and improve performance of priority focus areas and patient safety, to improve healthcare outcomes, and to reduce and prevent medical/health care errors. Actions: To achieve these goals the plan strives to: Incorporate quality and performance improvement throughout the facility. Provide a systematic mechanism for (name of the facility) staff, departments, and professions to function collaboratively in their efforts toward performance improvement...Plan and incorporate processes for conducting thorough and credible comprehensive systematic assessments (root cause analyses), focusing on process and system factors in response to sentinel events and other critical incidents as defined by the hospital. Immediate actions to take in the event of a potential or actual adverse patient-related incident may include but not necessarily be limited to the following actions to protect the patient population: Immediately remove or eliminate the source of harm, hazard or threat to the welfare, health, or safety of patients. Perform a physical and mental assessment of the patient by a registered nurse to ensure any patient negative effect is identified and addressed as necessary. Should the incident be related to caregiver actions, immediately remove the caregiver from patient care...After immediate actions are concluded, conduct an apparent or root cause analysis to identify apparent and/or root causes of the event and establish corrective actions accordingly. These actions may include, but may not be limited to, process and policy revisions, education and training."

Based on interview and record review, the facility failed to ensure nursing staff performed head-to-toe assessments (a comprehensive physical examination that systematically evaluates a patient's body from head to feet to establish a baseline, monitor changes, and identify health issues. This includes checking vital signs [temperature, heart rate, blood pressure], assessing the skin, and examining all body systems like the respiratory, cardiovascular, neurological, and gastrointestinal systems. The assessment helps providers understand the patient's current health status and needs) for two of 83 sampled patients (Patients 1 and 8), in accordance with the facility's policy and procedure regarding nursing assessments and reassessments.

This deficient practice had the potential for the inability of nursing staff to identify changes in patients' condition.

Findings:

During a concurrent interview and record review on 11/4/2025 at 2:36 p.m. with the Nurse Manager (NM 1) for the medical surgical unit, Patient 1's medical record on patient assessment, was reviewed. The NM 1 stated that patients should be assessed every shift, when there were changes in a patient's condition, or after having surgery in order to identify changes in a patient's condition, act upon those changes and notify the physician. NM 1 verified that Patient 1's pain, mental, respiratory, heart, gastrointestinal, or genitourinary status was not assessed by a nurse during the night shift from 10/28/2025 through 10/29/2025.

During a review of Patient 1's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/28/2025, the H&P indicated the following: Patient 1 had a history of hypothyroidism (thyroid does not make enough thyroid to meet the body's needs), hypertension (high blood pressure), and hyperlipidemia (high levels of fat in the blood). Patient 1 had a chronic right inguinal hernia (when part of the intestine or fatty tissue pushes through a weak spot in the abdominal shall into the groin area) as well. Patient 1 has had persistent pain at her right inguinal hernia. Patient 1 was admitted to the medical surgical floor.

During a review of Patient 1's "Daily Assessment Inquiry," dated from 10/27/2025 through 10/30/2025, the Report indicated Patient 1's pain, mental, respiratory, heart, gastrointestinal (stomach and intestines), or genitourinary (urinary) status, was not assessed by a nurse during the night shift, from 10/28/2025 through 10/29/2025.

During a concurrent interview and record review on 11/5/2025 at 3:14 p.m. with NM 1, Patient 8's assessment record, was reviewed. NM 1 verified that Patient 8's pain, mental, respiratory, heart, gastrointestinal, or genitourinary status was not assessed by a nurse during the night shift from 10/28/2025 through 10/29/2025. NM 1 stated it was the standard of care to assess patients every shift to monitor patients for any changes of condition and to escalate any issues to the physician in a timely manner.

During a review of Patient 8's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/19/2025, the H&P indicated "patient (Patient 8) had medical problems significant for gastric and colon adenocarcinoma (cancer in the stomach and large intestines) ... diabetes mellitus type 2 (high sugar in the blood), who presented ... for symptoms of acute abdominal pain, nausea (an unpleasant feeling of sickness in the stomach accompanied by the urge to vomit, and vomiting starting two (2) days prior to presentation.

During a review of Patient 8's "Daily Assessment Inquiry," dated from 10/28/2025 through 10/29/2025, the Report indicated Patient 8' pain, mental, respiratory, heart, gastrointestinal, or genitourinary status was not assessed by a nurse during the night shift from 10/28/2025 through 10/29/2025.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment, Nursing," dated 6/25/2025, the P&P indicated the following: Purpose: To determine the care required to meet a patient's initial needs as well as continued needs as the patient responds to care delivered. Reassessment:

1. An RN (registered nurse) will assess each patient's care needs before delegating appropriate aspects of the patient's nursing care, and patients will be reassessed by an RN at least every shift to document changes in the patient's condition and/or diagnosis, and to determine the patient's response to interventions.

2. Nursing reassessments of a patient will reflect at a minimum a review of patient-specific data, pertinent changes, and response to interventions ...Nursing reassessments will be documented in electronic health record (EHR) under daily nursing assessment.

Based on interview and record review, the facility failed to provide one of seven sampled staff members (Registered Nurse [RN] 1) orientation (A structured, unit-specific orientation helps nurses understand and adhere to the specific policies, procedures, and safety protocols of that unit, which reduces errors and improves patient outcomes) to the medical surgical unit (M/S, department for patients who need close attention but are not critically ill) and to evaluate RN 1's competency (a process to evaluate their knowledge, skills, and abilities in order to ensure they can provide high-quality, safe patient care. This evaluation goes beyond basic education and includes assessing their proficiency in specific clinical tasks, using hospital equipment, and adhering to the organization's standards and protocols), when RN 1 started working in the M/S unit on 7/12/2025, in accordance with the facility's policies regarding orientation and competency assessment.

This deficient practice had the potential for RN 1's inability to perform unit specific duties and placed patients' health and safety at risk.

Findings:

During a concurrent interview and record review on 11/6/2025 at 10:30 a.m. with the Manager of Human Resources (MHR) and the Senior Human Resources Generalist (SHRG), Registered Nurse (RN) 1's personnel file, was reviewed. The MHR and SHRG stated the following about Registered Nurse (RN 1): RN 1 was originally hired as a traveler nurse (a registered nurse who takes short-term assignments, to fill staffing needs) in the medical-surgical intensive care unit (a specialized healthcare unit that provides intensive care to critically ill patients who have undergone surgery or have complex medical conditions) on 6/9/2025. On 7/12/2025, RN 1 converted to a registry nurse (a nurse who worked for a staffing agency to fill temporary or contract positions) and was assigned to work in the medical surgical unit (department for patients who need close attention but are not critically ill).

During the same concurrent interview and record review on 11/6/2025 at 10:30 a.m. with the Manager of Human Resources (MHR) and the Senior Human Resources Generalist (SHRG), the MHR and SHRG reviewed RN 1's personnel file and stated there was no evidence that RN 1 received an orientation (A structured, unit-specific orientation helps nurses understand and adhere to the specific policies, procedures, and safety protocols of that unit, which reduces errors and improves patient outcomes) to the medical surgical unit, nor any evidence that RN 1's competency (a process to evaluate their knowledge, skills, and abilities in order to ensure they can provide high-quality, safe patient care. This evaluation goes beyond basic education and includes assessing their proficiency in specific clinical tasks, using hospital equipment, and adhering to the organization's standards and protocols) was evaluated. The MHR stated that orientation and competency should be done on the unit to ensure nursing staff know what to do and were able to function at appropriate levels. The MHR also said an initial evaluation for RN 1 was not done and should have been done on the first day RN 1 worked on the unit on 7/12/2025. The evaluation was done on 10/29/2025, the last day RN 1 worked. The MHR stated that as of 10/29/2025, RN 1 was suspended while waiting for the registry agency to conclude its' investigation for an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse), which involved RN 1.

During an interview on 11/6/2025 at 10:45 a.m. with the Health Care Educator (HCE) and the Director of Education (DOED), the HCE and DOED stated that they (HCE and DOED) did not provide any education or competencies to registry nurses. Unit orientation, competency and initial evaluation should be performed by the unit in which the registry nurse worked.

During an interview on 11/6/2025 at 4:01 p.m. with the Nurse Manager (NM 1) for the medical surgical (M/S) unit, NM 1 stated she (NM 1) did not know if RN 1 was oriented to the M/S unit or if a competency assessment was done for RN 1. NM 1 stated Unit orientation and evaluation of competency should be done to ensure RN 1 was able to care for patients, safely.

During a review of the facility's policy and procedure (P&P) titled, "Competency Assessment," dated 8/27/2025, the P&P indicated the following: Competency - The integration of knowledge, skills, and abilities to ensure effective job performance. Competency is validated by demonstration of observable and measurable behaviors which are critical to ensure successful performance. Competency is demonstrated by the ability to successfully perform the expectations of one's job. Departmental Competencies - Competencies specific to a department. Typically, the department head and leadership are responsible for developing these competencies with assistance from the Education department based on the patient population to the specific area. Policy: All staff and contractors who interact with patients will demonstrate competency as required by regulatory standards ...state, federal and hospital policy. All departments must have a process to evaluate staff competency at the time of hire and ongoing for the duration of their employment ...Initial competency assessment process continues with the organizational, departmental, and job specific orientation and training of personnel. Basic competencies will be assessed during orientation to the department/job and for employees in clinical areas, prior to the independent delivery of patient care by the employee. Individual departments/services with the assistance of the Education department will define the competencies and job expectations for each position ...Each supervisor/manager/administrative director will be responsible for ensuring that the competency of all employees is assessed, maintained, demonstrated, and improved continually.
Admin (Administrative) Directors/Managers/Supervisors are responsible for:
1. Developing department wide and job specific competencies in collaboration with the Education Department ...
2. Ensuring their staff are competent to perform clinical duties.
3. Documenting employee competency ...
4. Providing ongoing employee feedback concerning competency.
5. Communicating with education when in-service training and educational programs are needed based on competency data.
6. Working with Education and Human Resources to ensure up to date and accurate competency files ...

During a review of the facility's blank checklist titled, "New Employee Orientation - Unit Checklist Tour," the checklist indicated, the form must be completed and signed on New Employee Orientation Day during the employee's department tour. Employees that do not meet the orientation requirements will be suspended from duty until checklist is signed and returned to HR (Human Resources).

Based on interview and record review, the facility failed to:

1.a. Ensure that the nursing office confirmed one of 83 sampled patient's (Patient 9's) spouse and primary representative (RP 1) information was documented on Patient 9's mortuary's "Authorization for Release of Remains," in accordance with the facility's policy and procedure (P&P) titled, "Decedent Affairs."

This deficient practice led to Patient 9's next of kin and secondary representative (RP 2) to sign the form instead of RP 1, who had the legal authority to do so.

1.b. Ensure one of 83 sampled patient's (Patient 9) physician was notified of Patient 9's changes in mental status and blood pressure (BP, amount of force needed to move blood throughout the body and organs, with normal range of 120/90 millimeters of Mercury [mmHg, a unit of measurement]), in accordance with the facility's policy and procedure (P&P) titled, "Provider Notification."

This deficient practice resulted in a delay of Patient 9's care, when Patient 9 remained in the medical surgical unit for more than 24 hours before being transferred to the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries) for closer monitoring and blood pressure support.

2. Ensure its nursing staff assessed a patient's ability to void (urinate) after foley catheter (Foley catheter [brand name] for urinary indwelling catheter - a flexible tube inserted into the bladder that remains there to provide continuous urinary drainage) removal for one of 83 sampled patients (Patient 5), in accordance with the facility's policy and procedure regarding foley catheter removal.

This deficient practice had the potential to put Patient 5 at risk for urinary retention (inability to completely empty the bladder) and urinary tract infection (UTI, an infection in any part of the urinary system).

Findings:

1.a. During a record review of Patient 9's "History and Physical (H&P)," dated 10/29/2024, the H&P indicated Patient 9 was admitted to the facility for weakness and pain. Patient 9's medical history included stroke (loss of blood flow to a part of the brain) and hypertension (HTN, high blood pressure). The record did not indicate Patient 9 had a durable power of attorney (DPOA, legal document where a patient designates someone to make decisions for them if unable to).

During a record review Patient 9's "Facesheet (front page of the chart that contains a summary of basic information about the patient)," dated 11/1/2024, the Facesheet indicated Patient 9 had a spouse (RP 1) and next of kin (RP 2) listed as emergency contacts.

During a record review of Patient 9's "Progress Note SOAP (subjective, observation, assessment, plan)," dated 10/31/2024, the "Progress Note SOAP" indicated Patient 9's RP 1 was recognized as the spouse and was involved in Patient 9's plan of care.

During a record review of Patient 9's "Notice of Death," dated 11/2/2024, the record indicated Patient 9's RP 1 was made aware of Patient 9's death.

During an interview on 11/3/2025 at 2:30 p.m. with Registered Nurse (RN) 2, RN 2 stated an emergency contact would be the spouse or the designated decision maker, children, and blood relatives. RN 2 stated she would contact the spouse or designated decision maker first if there was no DPOA.

During a concurrent interview and record review on 11/6/2025 at 10:42 a.m. with House Supervisor (HS, nurse who oversees the hospital, patients, and emergencies), Patient 9's "Mortuary Release Form," dated 11/4/2024, was reviewed. The record indicated the release was signed by the mortuary. The form also included the mortuary's form for "Authorization for Release of Remains," where Patient 9's RP 2 was listed as the "Representative," the relationship was marked as "Next-of-Kin (Closest Living Relative)," and RP 2 signed the form. Patient 9's RP 1 was not listed and did not sign the form.

During the same interview and record review on 11/6/2025 at 10:42 a.m. with HS, HS stated the next of kin was considered the emergency contact. HS stated the next of kin was usually the spouse, parent, or other living relative. HS stated she would have gone with RP 1 (as the primary contact person) and RP 1 should have been the one to sign the document (Authorization for Release of Remains) instead of RP 2. HS also stated the nursing office was responsible for making sure the form received from the mortuary was correct, and they would check for discrepancies such as name or to update information so that the correct family contact was notified.

During a review of the facility's policy and procedure (P&P) titled, "Decedent Affairs," dated 7/27/2022, the P&P indicated, "Prior to releasing remains to mortuary transporter, the Nursing Office shall ensure that the "Release Authorization" form is completed in full by the mortuary and is properly signed. The following relatives may sign a "Release Authorization" (listed in order of who may consent).

a. An agent named in the Advanced Directive
b. Surviving spouse/domestic partner
c. Adult child (in the case of multiple adult children, one child may sign if they represent the wishes of the majority of the adult children)
d. Surviving parent
e. Adult sibling (in the case of multiple adult siblings, one sibling may sign if they represent the wishes of the majority of the adult siblings)
f. Surviving adults in degree of kinship."

1.b. During a record review of Patient 9's "History and Physical (H&P)," dated 10/29/2024, the H&P indicated Patient 9 was admitted to the facility for weakness and pain. Patient 9's medical history included stroke (loss of blood flow to a part of the brain) and hypertension (HTN, high blood pressure).

During a record review of Patient 9's "Daily Assessment Inquiry," dated 11/1/2024, the record indicated at 8:20 a.m., Patient 9 had trouble breathing and was placed on oxygen, was drowsy, and Patient 9's nurse received orders to transfer Patient 9 to the ICU.

During a record review of Patient 9's "Progress Note SOAP," dated 11/1/2024, the record indicated Patient 9 was transferred to the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries) for hemodynamic (body's fluid volume) support.

During an interview on 11/6/2025 at 10:42 a.m. with House Supervisor (HS, nurse who oversees the hospital, patients and emergencies), HS stated for neurological or blood pressure changes, nurses should call the doctor, and everyone knows about it. HS stated the staff know the protocol and if they can't get in touch with the doctor, they can escalate to the HS, who can call the doctor. HS also stated if the nurses did not call the doctor, it's a "medical error" and the patient could deteriorate.

During a concurrent interview and record review on 11/6/2025 at 11:55 a.m. with Nurse Manager (NM) 1, Patient 9's "Daily Focus Assessment Report," dated 10/29/2024 to 11/1/2024, was reviewed. The record indicated Patient 9 was alert on these dates except for 10/31/2024 at 9:06 p.m., when Patient 9 was confused. NM 1 stated she would be concerned if Patient 9 was alert and then became confused. NM 1 stated the nurses were expected to call the provider or call a rapid response (RRT, a group of trained team professionals who provide immediate assistance when patient's condition suddenly worsens) when there is a change in patient's condition. NM 1 confirmed she (NM 1) did not see any notification to the physician about Patient 9's confusion.

During a concurrent interview and record review on 11/6/2025 at 2:48 p.m. with NM 1, Patient 9's "Vitals Inquiry," dated 10/31/2024, was reviewed. The record indicated on 10/31/2024 at 12:00 a.m., Patient 9's BP was 88/53. Patient 9's BP was checked four hours later at 4:00 a.m. and it was 109/61. NM 1 stated the BP was too low (at 12 a.m.- 88/53) and should have been rechecked. NM 1 stated Patient 9's condition could have worsened and led to a RRT (Rapid Response team activation). NM 1 confirmed there was no notification to the physician of Patient 9's low BP.

During a review of the facility's policy and procedure (P&P), titled "Provider Notification," dated 8/27/2025, the P&P indicated, "The nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the medical staff regarding significant changes or deterioration in the patient's condition including abnormal labwork results. If providers do not respond, nurses are responsible for escalating the issue through the proper channels ...For changes in patient condition the nurse notifies the responsible provider utilizing appropriate channels and chain of command, using SBAR (situation, background, assessment, recommendation) report ...Document in the medical record the date, time and name of each provider notified, actions taken and/or patient's response to treatment."

2. During a review of Patient 5's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 11/2/2025, the H&P indicated Patient 5 was admitted to the facility from an outside hospital with left sided flank (the side of the body between the ribs and hips) pain on 11/1/2025. The H&P also indicated Patient 5 was pending surgery to treat nephrolithiasis (kidney stones).

During a review of Patient 5's "Operative Report (surgery report)," dated 11/3/2025, the "Operative Reported" indicated on 11/3/2025, Patient 5 underwent left ureteroscopy (a medical procedure to break up or remove kidney stones) with double J stent (a then J-shaped tube placed inside the ureter [the duct connecting from the kidney to the bladder] to allow urine to flow) placement. The "Operative Report" also indicated a foley catheter (Foley catheter [brand name] for urinary indwelling catheter - a flexible tube inserted into the bladder that remains there to provide continuous urinary drainage) was placed during the procedure and to be removed when Patient 5 was alert and awake.

During a concurrent interview and record review on 11/7/2025 at 9:23 a.m. with the Nurse Manager (NM 1) of Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery) Unit, Patient 5's "Nursing Assessment," dated 11/3/2025, was reviewed. The "Nursing Assessment" indicated Patient 5's foley catheter was removed on 11/3/2025 at 9:30 p.m. NM 1 stated the following: nurse should wait for Patient 5 to void after foley catheter (Foley catheter [brand name] for urinary indwelling catheter - a flexible tube inserted into the bladder that remains there to provide continuous urinary drainage) removal to make sure Patient 5 was able to void and there was no urinary retention (inability to completely empty the bladder). There was no nursing documentation to show Patient 5 was able to void (to urinate) after foley catheter removal prior to discharge. There was potential risk for Patient 5 not being able to void after getting home and suffering urinary retention and infection leading to Patient 5's return to hospital.

During a review of the facility' s policy and procedure (P&P) titled, "Nurse-Driven Indwelling Urinary Catheter (a flexible tube inserted into the bladder that remains there to provide continuous urinary drainage) Management," dated 6/2023, the P&P indicated, "Following removal of the indwelling urinary catheter, the nurse shall assess the patient's ability to void ... Following the removal of the indwelling urinary catheter, the patient's urine output must be monitored closely to be sure he/she is voiding in good amounts and without difficulty."

Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment in the Emergency Department (ED, the hospital area for treating urgent and serious conditions) for 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) and staff. The facility failed to implement required infection control and environmental safety measures during plumbing repairs in the ED Admitting and Phlebotomy areas (the section of the ED where patients are registered and blood samples are collected) as required by facility's policy titled, "Infection Prevention Measures During Construction and Renovation Projects," and failed to notify the Department of Health Care Access and Information (HCAI, the state agency responsible for reviewing and approving construction plans and safety protocols in healthcare facilities) as required by the FREER Manual- Revised August 2025 (a regulatory guide published by the California Department of Health Care Access and Information [HCAI], It provides instructions for healthcare facilities on how to manage construction, maintenance projects, and helps outlines the necessary steps to obtain clearances, permits, and approvals) , published by HCAI.

This deficient practice resulted in approximately 60 patients per day and multiple staff members being exposed to hazardous environmental conditions during the repair period from 09/09/2025 through 10/15/2025. These conditions included sewer-like odors, airborne particles (microscopic solid or liquid substances suspended in the air that may pose respiratory risks), and visible mold-like substances (fungal growths that can release spores and cause health issues). Staff reported experiencing symptoms such as headaches, nausea, coughing, and respiratory distress (difficulty breathing or shortness of breath). One staff member required medical evaluation and treatment (clinical assessment and care provided by a licensed healthcare professional).

On 11/5/2025 at 4:24 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Executive Officer (CEO), Vice President of Quality (VPQ), Chief Operating Officer (COO), Chief Medical Officer (CMO), Chief Financial Officer (CFO), Manager of Accreditation, Regulatory & Licensing (MARL), and Chief Nursing Officer (CNO). The facility failed to ensure that appropriate safety measures were implemented, prior to repair work involving plumbing and cutting through wet drywall (a construction material used for interior walls) that had brown and dark spots. During an interview on 11/04/25 at 4:08 p.m. with the Manager of Infection Prevention (a healthcare professional responsible for preventing and controlling infections in the facility), the Manager of Infection Prevention confirmed that the brown and dark spots could have indicated the presence of mold (a type of fungus that can pose health risks), which should have been tested and treated.

The repair work took place in a patient care area that included a phlebotomy station (a designated area where healthcare professionals collect blood samples from patients) and the admitting area (the section of a hospital where patients are first registered and processed for care). The initial repair was prompted by staff reports of a sewer-like odors (a smell similar to raw sewage) in the admission/phlebotomy station, which caused headaches among staff working in the area. Additionally, a second repair project was ongoing at the Emergency Department (ED, the hospital area for treating urgent and serious conditions) Nursing Station (the central area in the ER where nurses coordinate patient care and documentation).

The facility failed to ensure that the following safety measures and assessments were in place:

-Establishing containment (setting up physical barriers) around the repair area to prevent the spread of debris and contaminants (substances that may be harmful to health) throughout the patient care environment.
-Posting signage (putting up warning or informational signs) indicating that the repair project had been assessed by Infection Prevention Services.
-Notifying the Department of Health Care Access and Information (HCAI, a California state agency responsible for healthcare facility oversight) to obtain necessary clearances, plan approvals, and building permits.
-Conducting environmental testing (analyzing air and surfaces for harmful substances) after brown and dark spots were identified on drywall, to confirm that the ED admitting area was free of contaminants, air pollutants, or disease-causing organisms.
-Informing facility leadership (administrative decision-makers) of staff reports regarding a sewer-like odor, which persisted from 9/9/2025 through 10/15/2025.

As a result of these failures, 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) and staff were potentially exposed to environmental contamination (the presence of harmful substances in the environment). These individuals had been present daily in the phlebotomy station located in the ED admitting area during the repair period (from 9/9/2025 to 10/15/2025).

On 11/7/2025 at 5:28 p.m., the first Immediate Jeopardy (IJ) was removed in the presence of the Chief Executive Officer (CEO), Chief Operating Officer (COO), Chief Medical Officer (CMO), Chief Financial Officer (CFO), Chief Nursing Officer (CNO), and Vice President of Quality (VPQ). The survey team verified and confirmed the elements of the IJ Removal Plan through observation, interview, and record review while onsite. The IJ Removal Plan included several key components:

Communication and Pathway Algorithm: Created for use between the Administrative Nursing Supervisor (ANS), Engineering Department, and Infection Prevention Department during repairs and construction.

In-Service Training: Conducted on the communication and pathway algorithm with ANS, Engineering, and Infection Prevention departments. Education was tracked using a standardized sign-in roster and added to new employee onboarding.

Biweekly Construction Update Meetings: Included the Infection Prevention Department and affected department leaders to ensure communication on all repair and construction activities. The Director of Engineering was responsible for this.

Pre-Construction Risk Assessment (PCRA): Implemented on 11/5/2025, led by the Engineering Department with required participation from Infection Prevention, Safety Officer, and leadership from affected areas. This included assessments for construction activities, noise, air quality, life safety measures, infection control, vibration, utility, flooding, and security. The Director of Engineering was responsible for this.
Monthly Audits: Conducted to ensure all construction projects have a PCRA and reported to the Quality Management Committee and Environment of Care Committee. The Director of Engineering was responsible for this.

Policy Modification: The Infection Prevention policy was modified to include guidelines on patient and staff movement during construction activities. The Chief Nursing Officer was responsible for this.

Safeguards for Patients and Staff: Implemented in the second area, including plastic barriers and air quality testing. The Manager of Infection Prevention and the Director of Engineering were responsible for this.

Third-Party Vendor Consultation: The Engineering Department consulted a third-party vendor on air quality testing and swabbing. The Director of Engineering was responsible for this.

Supervisor Training: In-serviced on Chain of Command, Escalation of Concern, Authority to Restore Patient Safety, and Standard of Behavior policies. Education was tracked using a standardized sign-in roster. The Director of Education was responsible for this.

Findings:

During a review of the work order (a formal request for maintenance or repair services) for the Emergency Department's Admitting/Phlebotomy area (patient registration and blood collection), dated 9/9/2025, the work order indicated: "An unusual odor is emitting from the sink located inside the Emergency Room draw station."

During a review of a follow-up work order entered by the Engineer Plumbing (ENG) 1, dated 9/11/2025, the work order indicated, "Searched in the ceiling and found some cast iron pipe and fittings completely corroded and cracked causing major sewer gas odors. Replaced several sections of the cast iron pipe and fittings."

During an interview on 10/23/2025 at 2:10 p.m. with Engineering Staff (ENG 2), ENG 2 stated that a strong sewer odor was reported in late August 2025. On 09/09/2025, engineers opened the wall near the sink in the Emergency Department (ED) Admitting area (the patient registration section of the ED) and discovered a leaking pipe and wet drywall (a construction material used for interior walls) with dark brown and black spots, which ENG 2 stated had to be cut out. ENG 2 further stated that this was not the source of the sewer-like odor. ENG 2 stated that the actual source of the odor was identified as another leaking pipe located above the ceiling of the Admitting/Phlebotomy area (the section where patients are registered and blood samples are collected). ENG 2 confirmed that the repair began on 09/09/2025 and was completed on 10/31/2025 without the use of construction barriers (temporary physical partitions used to isolate construction zones and prevent the spread of contaminants).

During a concurrent observation and interview conducted on 11/04/2025 at 11:55 a.m. with the Emergency Department Manager (EDM) in the Emergency Department (ED) Nursing Station (the central area where nurses coordinate patient care), a transparent plastic sheet was observed taped across the ceiling, with a drainage tube discharging into a hand-washing sink. Water was visible inside the transparent plastic. The EDM confirmed that a second leak above the ED Nursing Station remained under repair and stated that the leak had been present since early July 2025. No signage was posted to restrict use of the sink, and no Infection Control Risk Assessment (ICRA, a structured, multidisciplinary process used to evaluate and mitigate infection risks during construction or maintenance in patient care areas) had been completed.

During an interview on 11/04/2025 at 10:50 a.m. with the Admitting Representative (AR 1), AR 1 stated that the sewer-like odor persisted for approximately 2½ months and caused staff symptoms including headaches and nausea. AR 1 stated that patients also complained of the odor during blood draws. AR 1 confirmed that no containment (physical barriers to isolate the work area), air filtration (equipment used to remove airborne particles), or infection control oversight was present during the repairs.

During an interview on 11/04/2025 at 11:49 a.m. with Phlebotomist (Phleb 1), Phleb 1 stated that patients continued to be seen in the affected area during the repair period and that no directive was issued to stop using the area. Phleb 1 confirmed that no containment was in place.

During an interview on 11/04/2025 at 2:04 p.m. with the Director of Engineering (DED), the DED confirmed that the repairs began on 9/09/2025 without notifying Infection Prevention or Department of Health Care Access and Information (HCAI, the state agency responsible for reviewing and approving construction plans and safety protocols in healthcare facilities). The DED also confirmed that a second leak above the ED Nursing Station had been ongoing since 7/07/2025 and remained unrepaired due to pending pipe fabrication.

During a concurrent interview and record review on 11/4/2025 at 3:15 p.m. with the COO and the DED, the FREER Manual (Revised August 2025), published by the California Department of Health Care Access and Information (HCAI), was reviewed. The manual indicated that plumbing repairs involving the replacement or rearrangement of valves, pipes, or fixtures were not considered Excluded Work (routine maintenance that does not require regulatory reporting). These types of repairs were classified as New Work (construction or repair activities that alter the original configuration of building systems) and therefore required submission of the OSHPD-102 form (a regulatory form used to notify HCAI of construction or repair work in healthcare facilities) and formal review by HCAI (California Department of Health Care Access and Information) prior to the start of work. The COO stated they were not aware that piping exchange (replacement of plumbing pipes) required reporting to HCAI.

During an interview on 11/5/2025 at 11:05 a.m. with AR 7, AR 7 stated the ED admitting area had a strong sewer odor starting 9/9/2025 until 10/15/2025. AR 7 stated she did not feel safe in that area. AR 7 stated there was lot of smoke in the room when ENG 2 was in the room working on the ceiling. AR 7 stated there was one small window 10 x10 inches open for ventilation, and there was no placement of containment or air ventilation (a temporary control measure used to contain and remove airborne contaminants from the work area and prevent their spread to sensitive patient care areas). AR 7 stated she was not told to work in another area and was not informed of the work being done. AR 7 stated she had headaches, felt nauseated, and had to see a doctor for cough and trouble breathing; AR 7 was given antibiotics twice, used a stronger inhaler, and took days off from work.

During a concurrent interview and record review on 11/5/2025 At 11:30 a.m. with the Director (DPL) of Phlebotomy/Lab Services (SPL), the Census Report (data that tracks the number of patients in a facility at a specific time or over a period), dated from 9/9/2025 through 10/31/025, was reviewed. The report indicate approximately 60 patients were seen per day at the phlebotomy /blood draw area. The DPL confirmed that there were about 60 patients seen daily in the Phlebotomy/Lab Services (SPL) during the repair construction on 9/9/2025 through 10/31/2025.

During an interview on 11/05/2025 at 2:10 p.m. with the Engineering Supervisor (ES), ES confirmed that no Control Risk Assessment (ICRA, a structured, multidisciplinary process used to evaluate and mitigate infection risks during construction or maintenance in patient care areas) was completed and that the Infection Prevention Department was not involved in either the admitting area or nursing station repair projects. ES stated that environmental testing, when conducted, would typically check for spores (tiny fungal particles that float in the air), asbestos (a group of minerals that can cause lung damage when inhaled), and other airborne contaminants.

During an interview on 11/04/25 at 4:08 p.m. with the Infection Prevention Manager (IPM), the IPM confirmed that the infection prevention team had not been informed of either project and had not been made aware of the issue regarding the black and brown spots, which were suggestive of mold. The IPM stated, "Both would have been classified as Class III ICRA (Infection Control Risk Assessment, a specific level of stringent precautions for healthcare construction/renovation, requiring active dust control like HEPA vacuums [uses a specialized vacuum with a High-Efficiency Particulate Air- HEPA filter to capture at least 99.97% of tiny particles (down to 0.3 microns) like dust, pollen, mold], sealing vents, negative air pressure, sealed waste containers, and thorough post-work cleaning before barriers are removed, used for moderate-to-high dust activities or higher-risk patient areas, ensuring dust/pathogens don't spread to vulnerable patients) projects, requiring HEPA filtration (stands for High-Efficiency Particulate Air and is a type of mechanical air filter that can trap at least 99.97% of airborne particles 0.3 microns in size), containment barriers, and air sampling." The IPM explained that, had the team been informed, they would have recommended air sampling, confinement of the area, and relocation. The IPM confirmed that no air sampling or surface testing had been conducted since the completion of the work. The IPM stated that staff could have been exposed to bacteria.

During a concurrent interview and record review on 11/6/2025 at 4:08 p.m. with the IPM, the "Infection Control Construction Permit" form, undated, was reviewed. The form indicated the following requirements for Class III construction activity (moderate to high-risk construction or renovation work in healthcare settings):

1. Notify Infection Control: Inform the Infection Prevention department before beginning any work.
2. Isolate HVAC System: Shut off or isolate the heating, ventilation, and air conditioning (HVAC) system in the work area to prevent contamination of the air ducts.
3. Install Critical Barriers or Control Cube: Set up physical barriers (e.g., plastic sheeting or temporary walls) or use a containment cube to isolate the construction zone before work begins.
4. Maintain Negative Air Pressure: Use air filtration units equipped with HEPA (High-Efficiency Particulate Air) filters to keep the air pressure lower inside the work area than outside, preventing dust and contaminants from escaping.
5. Do Not Remove Barriers Prematurely: Keep barriers in place until the project is fully completed and the area has been thoroughly cleaned by the Environmental Services Department.
6. Use HEPA-Filtered Vacuums: Clean the area using vacuums equipped with HEPA filters to trap fine particles.
7. Wet Mop with Disinfectant: Clean floors and surfaces using a disinfectant solution and wet mopping technique to reduce airborne dust.
8. Careful Removal of Barriers: Remove temporary barriers slowly and carefully to minimize the spread of dust and debris.
9. Contain Construction Waste: Place all construction debris in tightly sealed containers before transporting it through the facility.
10. Cover Transport Carts: Ensure that carts or containers used to move waste are covered and sealed with tape.
11. Remove or Isolate HVAC System (Duplicate of #2): Reiterates the need to isolate HVAC systems in the work area.
12. Place Dust Mats: Install sticky or absorbent mats at the entrance and exit of the work area to capture dust from shoes and equipment.
-The IPM stated that the repair work conducted in the Emergency Department (ED) Admitting and Phlebotomy area, from 9/3/2025 to 10/31/2025, should have been classified as Class III. IPM stated that for any Class III construction or repair project, the Infection Prevention department must be notified in advance so that an environmental risk assessment can be conducted.

During a review of the facility's policy and procedure (P&P) titled, "Environment of Care Safety Management Plan," dated 10/23/2024, the P&P indicated the following: A pre-construction risk assessment is completed by Engineering and Infection Prevention prior to any building projects ...Employee concerns are vital to a robust risk assessment process. Employees are encouraged to report any unsafe or potentially unsafe condition that is found on hospital grounds. Concerns may be voiced to an employee's supervisor, the Human Resources department, the Safety Officer, Risk Manager, Compliance Hotline or the EOC Chairperson ... Facilities must collaborate with Infection Prevention to manage risks associated with air quality, odor, and infection control during repairs. The policy required the use of HEPA filters and proper containment ... The Director of Facilities, in concert with Administration and Infection Prevention, will ensure planning for remodels, renovations, alterations, modifications and new facilities takes into consideration patient safety, diagnosis and treatment facilities and special services appropriate to the needs of the community ... Areas used by the patient are safe, clean, functional, and comfortable. This includes lighting, ventilation and cleanliness. Areas are free from offensive odors ... Engineers, Infection Prevention personnel, Nursing staff, EVS staff and contractors will establish and observe Infection Prevention protocols during demolition, construction, renovation and general maintenance projects ... When planning for demolition, construction, renovation or general maintenance, the hospital will conduct a pre-construction risk assessment for air quality requirements, infection control and sanitation, utility requirements, noise, vibration, dust and other hazards that affect care, treatment and services. The hospital takes action based on the risk assessment to minimize risks during construction, such as:

1. Ensure that barrier materials as required are constructed and maintained properly, HEPA filtered vacuum and portable HEPA filter units for control of airborne contamination are provided unless otherwise contracted.
2. Inspect project during the course of construction, at completion and prior to occupancy of area.
3. Provide education on Infection Prevention protocol for construction and renovation to general contractor and prime contractors and their personnel, as appropriate.

During a review of the facility's policy procedure (P&P) titled, "Infection Prevention Measures During Construction and Renovation Projects," dated 10/24/2018, the P&P indicated the following: To prevent the acquisition of healthcare associated infections related to environmental contamination in patients/visitors/healthcare workers during hospital demolition, construction and renovation ... Risk assessments will be conducted and permits signed before construction begins. Engineering Department will: Notify the Infection Prevention department and review all projects with the Infection Prevention Manager prior to beginning the project. Notify Environmental Services prior to beginning project regarding requirements for personnel and supplies to ensure project and adjacent areas are cleaned/disinfected/pest controlled ... Ensure that barrier materials as required are constructed and maintained properly, HEPA filtered vacuum and portable HEPA filter units for control of airborne contamination are provided unless otherwise contracted. Obtain Infection Prevention Construction Permit from Infection Prevention before construction/renovation begins. Infection Prevention Permit must be obtained whether work is performed by external contractor or by hospital employees. Obtain signatures of responsible party from general contractor and any prime contractor or hospital project manager, as appropriate. Infection Prevention Department will:

a. Review all construction/renovation plans. An Infection Control Risk Assessment (ICRA) must be completed for all projects (Appendix A). Infection Prevention will determine class with Engineering input.
b. Provide Infection Prevention Construction Permit (Appendix A), as required.
c. Provide construction/renovation projects with a risk category of Class 111 and/or IV with containment inspection/approval by Infection Prevention prior to start of work.
4. Barriers required per class: Class II:
1) seal unused doors with duct tape
2) block off and seal air vents
c. Class 111:
1) All in Class II, and in addition:
2) Airtight plastic barrier extending from floor to ceiling with seams sealed with duct tape to prevent dust and debris from escaping or drywall barriers erected with joints covered or sealed. These barriers must also be provided at elevator shafts or stairways within the field of construction.
3) Airtight plastic barriers are to be placed at penetration of ceiling envelopes, chases and ceiling spaces to stop movement of air and debris when utilizing as a return air plenum/duct.
4) When openings are made into existing ceilings or access panels are opened in occupied areas for work above ceilings, provide polystyrene enclosure around ladder, sealing off opening, fitted tightly to ceiling and floor.
5) Any ceiling access panels opened for investigation beyond sealed areas will be replaced immediately when unattended.

During a review of the facility's policy and procedure (P&P) titled, "Infection Prevention Measures During Construction and Renovation projects," dated 10/24/2018, the P&P indicated, "Engineers, Infection Prevention personnel, Nursing staff, EVS staff and contractors will establish and observe Infection Prevention protocols during demolition, construction, renovation or general maintenance projects. Risk assessments will be conducted and permits signed before construction begins. Responsibilities: Engineering Department will: Notify the Infection Prevention department and review all projects with the Infection Prevention Manager prior to beginning the project. Notify Environmental Services prior to beginning project regarding requirements for personnel and supplies to ensure project and adjacent areas are cleaned/disinfected/pest controlled. Notify all affected departments/services when there is planned/unplanned disruption in water supply and assist in providing alternate sources ... Ensure that barrier materials as required are constructed and maintained properly, HEPA filtered vacuum and portable HEPA filter units for control of airborne contamination are provided unless otherwise contracted ... Obtain Infection Prevention Construction Permit from Infection Prevention before construction/renovation begins. Infection Prevention Permit must be obtained whether work is performed by external contractor or by hospital employees. Obtain signatures of responsible party from general contractor and any prime contractor or hospital project manager, as appropriate."

Based on observation, interview, and record review, the hospital failed to:

1. Implement its infection prevention and control program in a manner that protected 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) from potential infection risks while these patients were treated in the Emergency Department (ED). The facility did not have a policy or procedure to address cross-contamination risks associated with leaking piping in patient care areas and failed to conduct an Infection Control Risk Assessment (ICRA) when a leak was identified in the ED. Clinical staff continued to use a handwashing sink where water from a ceiling leak was actively diverted into the basin. There was no signage indicating restricted use of the sink, and the Infection Prevention Department was not notified.

This deficient practice placed 57 of the 83 sampled patients (Patients 27 - 83) at risk of exposure to waterborne pathogens (disease-causing microorganisms that are transmitted through contaminated water) and environmental contaminants (harmful substances present in the surrounding environment), increasing the potential for transmission of infectious agents (organisms such as bacteria, viruses, or fungi that can cause disease).

2. Ensure one of seven (7) sampled staff members (Admitting Supervisor [Sup 1]) had annual tuberculosis (TB, an infectious disease that affects the lungs) testing, in accordance with the facility's policy and procedure regarding tuberculosis screening for employees.

This deficient practice had the potential to spread tuberculosis if TB status of an employee was unknown, which may infect patients, staff, and visitors in the hospital.

Findings:

1. During a concurrent observation and interview on 11/04/2025 at 11:55 a.m. with the Emergency Department Manager (EDM) in the Emergency Department (ED) Nursing Station (the central area where nurses coordinate patient care), a sink was observed in active use by clinical staff for hand hygiene. A transparent plastic sheet was observed taped across the ceiling, with a drainage tube discharging into a hand-washing sink. Water was visible inside the transparent plastic. The EDM confirmed that the leak had been present since early July 2025. No signage was posted to restrict use of the sink, and no Infection Control Risk Assessment (ICRA, a structured, multidisciplinary process used to evaluate and mitigate infection risks during construction or maintenance in patient care areas) had been completed.

During an interview on 11/4/2025 at 12:00 p.m. with Director of the Engineering Department (DED) in the nurse station's sink area, DED stated that a leak was identified in early July, caused by erosion of the piping above the nurse station. The DED explained that this would be a major repair project requiring fabrication of the defective pipe and welding it in place. The DED confirmed that a piece of tubing, extending from the ceiling into the sink at the nurse station was installed by the Engineering Department to divert the leaking water into the sink. The DED also confirmed that the Infection Prevention Department was not notified regarding the continued use of the sink while the tubing was actively discharging leaked water into it.

During a review of the ED's "Work Order (a formal document or request used to initiate, track, and complete maintenance or repair tasks for equipment, facilities, and safety issues)," dated 7/7/2025, the work order indicated, "Incident, hazard, recall, critical air handler leaking from the ceiling in E.R. by the Tube Station."

During a concurrent interview and record review on 11/6/2025 at 10:22 a.m. with the Infection Prevention Manager (IPM), the facility's policy and procedure (P&P), "Infection Prevention Measures During Construction and Renovation," dated 10/24/2018, was reviewed. The P&P indicated the following:

-The Environment of Care (EOC) Safety Management Plan outlines the methods and practices used to design, implement, and monitor a program to minimize safety risks for patients and all others who enter. The objective of the EOC Safety Management Plan is to provide a guideline for the development of a safety management program that will enable the hospital:
-To develop standards to monitor, assess, measure, and improve EOC performance.
-To monitor the effectiveness of the safety program.
-Department leaders are responsible for providing a safe working environment for staff and safe provisions for the care of patients through full implementation of established EOC programs and activities. Leaders ensure department compliance with Environment of Care policies and procedures and develop department-specific safety policies and procedures. The EOC committee is responsible for monitoring the review of organizational safety policies and procedures on a triennial basis. Policies are available to all employees on the hospital intranet site. IPM stated that the facility's Environment of Care (EOC) and the Infection Prevention Department are responsible for ensuring that the facility follows its written policies to stop infections from spreading inside the hospital and to other places. IPM confirmed that the facility does not have a P&P that addresses the prevention of the spread of waterborne pathogens (disease-causing microorganisms that are transmitted through contaminated water) or mold during a water leak.

During a review of the facility's policy and procedure (P&P) titled, "Infection Prevention Measures During Construction and Renovation Projects," dated 10/24/2018, the P&P indicated, "Engineers, Infection Prevention personnel, Nursing staff, EVS staff and contractors will establish and observe Infection Prevention protocols during demolition, construction, renovation or general maintenance projects. Risk assessments will be conducted and permits signed before construction begins."

2. During a concurrent interview and record review on 11/6/2025 at 11:18 a.m. with the Employee Health Nurse (EHN), the EHN reviewed the Admitting Supervisor's (Sup 1) personnel file and stated the following: Sup 1 was hired on 1/8/2024. Initial TB (Tuberculosis, an infectious disease that affects the lungs) testing was conducted on 12/14/2023. Sup 1 was due for annual TB testing on 12/2024, however, the test was not done because there were issues with the vendor. EHN stated Sup 1 resigned on 10/3/2025. Sup 1 continued to work at the facility from 12/2024 to 10/3/2025 without the annual TB testing.

During the same interview on 11/6/2025 at 11:18 a.m. with the Employee Health Nurse (EHN), the EHN stated that employees were required to be tested for TB upon hire and annually to detect if employees had TB. Employees were at high risk for contracting TB because of the population of patients that came to the Emergency Department. Annual testing was necessary to identify employees with TB and to start treatment, if necessary, to prevent the spread of infection.

During a review of Sup 1's health file, the health file indicated Sup 1 was tested for TB on 12/14/2023. Sup 1 was hired on 1/8/2024. Sup 1 resigned on 10/3/2025.

During a review of the facility's policy and procedure (P&P) titled, "Tuberculosis Screening, Employee," dated 8/27/2025, the P&P indicated the following: Purpose: To ensure the employee is free and clear of active infection during the pre-placement health process and for the duration of employment. Annual Screening: Medical duration will continue for the duration of employment ... Quantiferon (test for tuberculosis [an infectious disease that affects the lungs]).

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment (a clean, safe, and healthy space that minimizes the risk of disease by managing and controlling factors like preventing human contact with harmful substances to break the cycle of disease transmission) and prevent potential sources of infection for 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83), and staff members who were present in the affected area (Emergency Department's Admitting/phlebotomy, which involves the initial administrative processing and the critical first step of diagnostic testing for patients presenting to the emergency room) daily, when:

1. The facility did not consult the Infection Preventionist (IP, a healthcare professional responsible for overseeing infection prevention and control activities) for an assessment prior to initiating construction repairs (the process of fixing or restoring an existing structure to its original or functional condition by replacing or renewing its components) following water damage.

This deficient practice resulted in no assessment or safety recommendations from the Infection Prevention Department (IPD) prior to the Engineering Department starting the repair project, potentially placing patients and staff at risk of exposure to contaminants released during construction.

2. The facility did not implement appropriate environmental controls, such as providing ventilation (the intentional movement of air to dilute or remove airborne contaminants) to the affected area during the repair of drywall (a construction material used for interior walls, which can harbor mold [a type of fungus that can pose health risks] when wet) and tile with visible dark brown staining. These actions were not performed in accordance with the facility's "Environment of Care Safety Management Plan" and "Infection Prevention Measures During Construction and Renovation Projects" policy and procedures.

This deficient practice had the potential to expose patients, staff, and visitors to airborne contaminants (microscopic particles or biological agents suspended in the air that may cause illness) and HAIs (Healthcare-Associated Infections, conditions acquired by patients while receiving treatment in a healthcare setting), increasing the overall infection risk (the likelihood of exposure to and transmission of infectious agents).

Findings:

1. During an interview on 10/23/2025 at 2:10 p.m. with Engineering staff (ENG 2), ENG 2 stated that a strong sewer odor was reported in late August. The engineering department inspected the area and suspected it was coming from the sink drain, so a plumbing engineer poured chemicals into the drain. However, ENG 2 stated that the odor was not resolved. On 9/9/2025, they opened the wall by the sink and discovered a leaking pipe. ENG 2 stated that the drywall was wet and had dark brown and black spots, which had to be cut out. Despite the repair to the sink area, the odor persisted. Later, they discovered another pipe leaking above the ceiling, which was the source of the odor. They had to remove the ceiling tile and cut through the piping to remove the damaged pipe. ENG 2 confirmed that the repair started 9/9/2025 through 10/31/2025 when the repair was completed. ENG 2 confirmed that the repair was completed without construction barriers (temporary, physical partitions that separate construction zones from patient care areas to control the spread of dust, debris, and disease-causing agents ensuring patient safety and maintaining a sterile environment).

During an interview on 11/04/2025 at 10:50 a.m. with the Admitting Representative (AR 1), AR 1 stated that there had been a persistent sewer-like odor (a smell similar to raw sewage) in the Emergency Department (ED) Admitting/Phlebotomy area (the section of the ED where patients are registered and blood samples are collected) for approximately two and a half months. AR 1 reported that the odor caused symptoms among staff, including headaches and nausea, and that patients also expressed discomfort due to the strong smell. AR 1 stated that during the repair process, the Engineering Department (the team responsible for maintaining the hospital's physical infrastructure, including plumbing and repairs) only covered the computers in the area. AR 1 confirmed that no physical barriers or containment (structures used to isolate the work area and prevent the spread of contaminants) were set up. AR 1 further stated that one staff member required hospital evaluation due to symptoms. AR 1 reported that this concern was communicated to the former Admitting Manager (MA). However, AR 1 stated that the MA did not provide any directions to staff, as she (MA) was no longer employed at the facility after the report was made.

During an interview on 11/04/2025 at 11:49 a.m. with Phlebotomist (Phleb 1), Phleb 1 stated that patients continued to be seen in the affected area during the repair period and that patients complained of a strong odor during blood draws. Phleb 1 confirmed that no physical barriers or containment (structures used to isolate the work area and prevent the spread of contaminants) were set up during the repair work. Phleb 1 further stated that no directives were issued to stop using the area during the construction activities.

During an interview on 11/05/2025 at 11:05 a.m. with AR 7, AR 7 stated that during the repair work on 09/09/2025, there was a significant amount of smoke in the room while work was being performed in the ceiling. AR 7 confirmed that no containment (physical barriers used to isolate the work area and prevent the spread of contaminants) or air filtration (equipment used to remove airborne particles and maintain air quality) was set up during the repair. AR 7 reported experiencing symptoms including coughing and difficulty breathing and stated that they had to miss work due to illness resulting from the exposure.

During an interview on 11/04/2025 at 2:04 p.m. with the Director of Engineering (DED), the DED confirmed that the repairs in the emergency département's Admitting/phlebotomy area began on 09/09/2025 without notifying Infection Prevention or Department of Health Care Access and Information (HCAI, the state agency responsible for reviewing and approving construction plans and safety protocols in healthcare facilities). The DED also confirmed that a second leak above the ED Nursing Station had been ongoing since 7/07/2025 and remained unrepaired due to pending pipe fabrication. The DED also confirmed that the Infection Prevention Department was not notified prior to the engineering department placing an apparatus to divert the leaking water into the sink at the ED's Nursing station.

During an interview on 11/05/2025 at 2:10 p.m. with the Engineering Supervisor (ES), ES confirmed that no Control Risk Assessment (ICRA, a structured, multidisciplinary process used to evaluate and mitigate infection risks during construction or maintenance in patient care areas) was completed and that the Infection Prevention Department was not involved in either the admitting area or nursing station repair projects.

During an interview on 11/04/25 at 4:08 p.m. with the Infection Prevention Manager (IPM), the IPM confirmed that the Infection Prevention Department (IPD) had not been informed of either project and had not been made aware of the issue regarding the black and brown spots, which were suggestive of mold. The IPM stated, "Both would have been classified as Class III ICRA (Infection Control Risk Assessment, a specific level of stringent precautions for healthcare construction/renovation, requiring active dust control like HEPA vacuums [uses a specialized vacuum with a High-Efficiency Particulate Air- HEPA filter to capture at least 99.97% of tiny particles (down to 0.3 microns) like dust, pollen, mold], sealing vents, negative air pressure, sealed waste containers, and thorough post-work cleaning before barriers are removed, used for moderate-to-high dust activities or higher-risk patient areas, ensuring dust/pathogens don't spread to vulnerable patients) projects, requiring HEPA filtration (High Efficiency Particulate Air, a type of mechanical air filter, designed to trap airborne particles), containment barriers (temporary, often modular structures used to isolate construction zones from patient areas, preventing the spread of dust, debris, and airborne contaminants), and air sampling (the process of collecting and analyzing airborne particles, like dust, mold, and bacteria, to protect patients and staff from potential contamination and infection) and relocation." The IPM stated that the IPD should have been informed of both repair projects, because there must be an ICRA assessment completed prior to initiating the repair in the patient care area. The IPM stated that staff could have been exposed to bacteria.

During a concurrent interview and record review on 11/6/2025 at 4:08 p.m. with the IPM, the "Infection Control Construction Permit" form, undated, was reviewed. The form indicated, "Requirement for Class III construction activity (moderate to high-risk construction or renovation work in healthcare settings): Notify Infection Control: Inform the Infection Prevention department before beginning any work." IPM stated, "If a project is classified as Class III or IV, an Infection Prevention Construction Permit is required before work begins, along with documented infection control measures and oversight."

During a review of the facility's policy and procedure (P&P) titled, "Infection Prevention Measures During Construction and Renovation Projects," dated 10/24/2018, the P&P indicated the following: To prevent the acquisition of healthcare associated infections related to environmental contamination in patients/visitors/healthcare workers during hospital demolition, construction and renovation ... Risk assessments will be conducted and permits signed before construction begins. Engineering Department will: Notify the Infection Prevention department and review all projects with the Infection Prevention Manager prior to beginning the project. Notify Environmental Services prior to beginning project regarding requirements for personnel and supplies to ensure project and adjacent areas are cleaned/disinfected/pest controlled ... Ensure that barrier materials as required are constructed and maintained properly, HEPA filtered vacuum and portable HEPA filter units for control of airborne contamination are provided unless otherwise contracted. Obtain Infection Prevention Construction Permit from Infection Prevention before construction/renovation begins. Infection Prevention Permit must be obtained whether work is performed by external contractor or by hospital employees. Obtain signatures of responsible party from general contractor and any prime contractor or hospital project manager, as appropriate. Infection Prevention Department will: Review all construction/renovation plans. An Infection Control Risk Assessment (ICRA) must be completed for all projects (Appendix A). Infection Prevention will determine class with Engineering input.

2. During a review of the work order (a formal request for maintenance or repair services) for the Emergency Department's Admitting/Phlebotomy area (patient registration and blood collection), dated 9/9/2025, the work order indicated, "An unusual odor is emitting from the sink located inside the Emergency Room draw station."

During a review of a follow-up work order entered by the Engineer Plumbing (ENG) 1, dated 9/11/2025, the work order indicated, "Searched in the ceiling and found some cast iron pipe and fittings completely corroded (a pipe that has deteriorated due to chemical reactions, leading to a breakdown of its material) and cracked causing major sewer gas odors. Replaced several sections of the cast iron pipe and fittings."

During an interview on 10/23/2025 at 2:10 p.m. with Engineering Staff (ENG 2), ENG 2 stated that a strong sewer-like odor (a smell similar to raw sewage, which may indicate plumbing failure or contamination) was reported in late August 2025. On 09/09/2025, engineering staff opened the wall near the sink in the Emergency Department (ED) and discovered a leaking pipe. ENG 2 stated that the drywall (a construction material used for interior walls that can harbor mold when wet) was saturated and exhibited dark brown and black discoloration, which had to be cut out. Despite the initial repair to the sink area, ENG 2 stated that the odor persisted. A subsequent inspection revealed a second leaking pipe located above the ceiling, which was identified as the source of the odor. ENG 2 stated that ceiling tiles were removed, and the damaged pipe was cut out and replaced. ENG 2 confirmed they did not use a ventilation system (equipment designed to circulate and filter air to reduce airborne contaminants) during the repair work which occurred from 09/09/2025 through 10/31/2025.

During an interview on 11/04/2025 at 10:50 a.m. with the Admitting Representative (AR 1), AR 1 stated that there had been a persistent sewer-like odor (a smell similar to raw sewage) in the Emergency Department (ED) Admitting/Phlebotomy area (the section of the ED where patients are registered and blood samples are collected) for approximately two and a half months. AR 1 reported that the odor caused symptoms among staff, including headaches and nausea, and that patients also expressed discomfort due to the strong smell. AR 1 further stated that one staff member required hospital evaluation due to symptoms.

During an interview conducted on 11/04/2025 at 11:49 a.m. with Phlebotomist (Phleb 1), Phleb 1 stated that patients continued to be seen in the affected area during the repair period and that patients complained of a strong odor during blood draws. Phleb 1 confirmed that no air ventilation system was set up during the repair in the ED admitting/phlebotomy area.

During an interview on 11/05/2025 at 11:05 a.m. with AR 7, AR 7 stated that during the repair work on 09/09/2025, there was a significant amount of smoke in the room while work was being performed in the ceiling. AR 7 confirmed that there were no air filtrations system (equipment used to remove airborne particles and maintain air quality) set up during the repair. AR 7 reported experiencing symptoms including coughing and difficulty breathing and stated that they had to miss work due to illness resulting from the exposure.

During a concurrent interview and record review on 11/6/2025 with the Infection Prevention Manager (IPM), the "Infection Control Construction Permit" form, undated, was reviewed. The form indicated the following requirements for Class III construction activity (moderate to high-risk construction or renovation work in healthcare settings): Isolate HVAC System: Shut off or isolate the heating, ventilation, and air conditioning (HVAC) system in the work area to prevent contamination of the air ducts ... Maintain Negative Air Pressure: Use air filtration units equipped with HEPA (High-Efficiency Particulate Air) filters to keep the air pressure lower inside the work area than outside, preventing dust and contaminants from escaping ... Use HEPA-Filtered Vacuums: Clean the area using vacuums equipped with HEPA filters to trap fine particles." IPM stated that there should a set-up of an air ventilation system, especially when staff and patients were reporting a strong sewer like odor.

During a review of the facility's policy and procedure (P&P) titled, "Infection Prevention Measures During Construction and Renovation Projects," dated 10/24/2018, the P&P indicated, " To prevent the acquisition of healthcare associated infections related to environmental contamination in patients/visitors/healthcare workers during hospital demolition, construction and renovation ... Ensure that barrier materials as required are constructed and maintained properly, HEPA filtered vacuum and portable HEPA filter units for control of airborne contamination are provided unless otherwise contracted."

During a review of the facility's policy and procedure (P&P) titled, "Environment of Care Safety Management Plan," dated 10/23/2024, the P&P indicated the following: A pre-construction risk assessment is completed by Engineering and Infection Prevention prior to any building projects ... Facilities must collaborate with Infection Prevention to manage risks associated with air quality, odor, and infection control during repairs. The policy required the use of HEPA filters and proper containment ... Ensure that barrier materials as required are constructed and maintained properly, HEPA filtered vacuum and portable HEPA filter units for control of airborne contamination are provided unless otherwise contracted."