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Based on observation, record review and interview, facility ' s registered nurses failed to conduct complete and accurate assessment on patients with impaired skin integrity and failed to provide treatment as prescribed by the patient ' s physician in two of 8 sampled patients. Patients #s 1 and 5

Findings:

Patient #1

On 09/15/2025 at 10:00 a.m. Patient #1 was observed in bed with side rails up and oxygen in place at three liters / minute via nasal canula. The patient was discharged for home and awaiting transportation with spouse at bedside.

The Facility ' s Chief Nursing Officer and Registered Nurse (52B) examined the patient ' s skin. Observation showed the patient ' s buttocks and coccygeal area with excoriated skin. There was no evidence of dressing / treatment in place to the patient ' s excoriated areas.


Review of the patient ' s clinical record (demographic data), showed the patient was admitted to the facility on 09/14/2025 with diagnosis of recurrent urinary tract infection, decreased appetite and weakness.


Review of the patient ' s nursing emergency room skin integrity assessment completed on 09/14/2025 at 11:55 a.m. showed the following documentation: "skin integrity risk assessment completed, no skin assessment integrity risk identified."

Review of the Patient Initial Interview document, dated 09/14/2025 at 4:15 p.m. showed the following entry "Medical history integument; healing bruising to bil upper ext."

Review of physician ' s progress notes (physical examination) showed the following documentation: "Skin warm and dry. Normal skin color"

Review of a completed discharge summary dated 09/15/2025 at 09:18 a.m. showed the following documentation: "Skin integrity intact"

During an Interview on 09/15/2025 at 10:05 a.m. the patient ' s spouse stated, the patient is discharged to home. While at home prior to coming to the hospital while being pulled up in bed, the skin to the patient ' s buttock came off. While at home the spouse dressed it but did not do it while the patient was in the hospital.

During an interview on 09/15/2025 at 2:30 p.m. Registered Nurse (55E) assigned to the patient stated, a Foley catheter was inserted on the patient while in the emergency room with redness to the patient ' s buttocks observed. The patient ' s buttocks were reddened as a result of a soaked diaper, but the redness was not documented, neither was the excoriation of the patient ' s buttocks and coccygeal areas.

Patient #5
A review of the clinical record (demographic data) showed the patient was admitted to the facility on 09/12/2025 with admitting diagnosis of cellulitis of right calf, diabetes mellitus and insect bite.

Review of the patient ' s record showed a history and physical dictated on 09/12/2025 by the physician assistant at 7:00 pm and signed by the physician on 09/15/2025 with the following entry: "Chief complaints: Complains of pain in calf with edema and serosanguineous drainage, necrosis to the middle of the wound."

Plan included admission to the hospital, Hibiclens shower daily, warm compresses to left lower inner calf every 4 hours and Invanx I gram intravenous every 24 hours.

Review of the patient ' s clinical record showed the following verbal order from the patient ' s physician: 09/13/2025 at 8:05 pm; "Apply warm compresses to the right inner calf q 4 hours."

Review of the patient ' s clinical record (nurses progress notes) showed warm compresses were applied to the patient ' s right inner calf on the following days and times:

09/13/2025 at 1:08 pm, 7:05 pm and 10:03 pm

09/14/2025 at 7:30 pm.

There was no further documentation in the patient's record that the physician ' s order of applying warm compresses to the patient ' s right inner calf every 4 hour was carried out.

During an interview on 09/16/2025 at 2:37 p.m. with Licensed Practical Nurse ( 54D) who was assigned to the patient on the day shift on Sunday 09/14/2025, Monday 09/15/2025 and Tuesday 09/16/2025 , the nurse stated "I did not give it today because the patient had a surgical consult but I gave it on the 15th right before breakfast, at lunch and at supper but I did not document."

Based on observation and interview, the facility failed to maintain a clean and sanitary environment for one of one storage room, one of one respiratory suite, one of one pharmacy, and one of one surgical suite observed.

Findings:

STORAGE ROOM
Observation on 09/15/2025 at 11:20 a.m. of a storage room near the outpatient suite revealed three boxes of pillows stored directly on the floor and not on pallets to prevent cross contamination.

During an Interview on 09/15/2025 Outpatient Registration Personnel (56F) stated housekeeping puts the stuff in the boxes on the floor.

RESPIRATORY SUITE
Observation on 09/15/ 2025 at 12:00 p.m. of the facility ' s respiratory suite, room which stored clean ventilators prepared for patients' usage showed the ceiling tiles directly above the ventilators with brown water stains and a hole in one of the ceiling tiles.

On 09/15/2025 at 12:15 p.m. Registered Nurse (52 B) summoned the Facility ' s Maintenance Supervisor to the room. The maintenance supervisor removed two of the water-stained ceiling tiles which showed an accumulation of blackened material.
Facility ' s Maintenance Supervisor (57G) stated "Those are mildew, but it is dry. "

During an Interview on 09/15/2025 at 12:0 8 p.m. the respiratory therapist stated "the water stains to the ceiling tiles have been there a long time (months.)"

PHARMACY
During a tour of the facility ' s pharmacy on 09/17/2025 at 8:40 a.m. with the Pharmacy Supervisor, the following items were observed stored directly on the floor in boxes:

Five boxes of Sodium Chloride 1000 mis with potassium, and two boxes' of 1000 CCs Normal Saline.

Observation on 9/17/2025 at 8:42 a.m. the bathroom located in the pharmacy suite flooring tiles with brown stain from around the toilet to the handwashing sink.

Registered Nurse (52B) stated "It looks moldy."

UNSECURED MEDICATIONS
Observation on 09/15/2025 11:18 a.m. of the facility ' s outpatient area (examination room #1) showed three vials of intravenous Benadryl medication (lot # 6035012) stored in an unlocked drawer. The drawer and door were opened, and staff were not present in the area. The medication was not in view of direct care staff.

During an nterview on 09/15/2025 at 11:19 a.m., Registered Nurse (52B) stated the medications were brought over by emergency room staff and left unsecured.

Based on observation, record review and interview, the facility failed to implement its policy and procedure to ensure staff participate in quarterly fire drills in 5 of 8 staff record reviewed: Registered Nurse 51A, Registered Nurse (52C), Registered Nurse (58H), Licensed Practical Nurse (54 D), and Dietary Supervisor (59I).

On 09/15/2025 during tour of the facility, the following staff were observed on various units providing care and services to patients: Registered Nurse 51A, Registered Nurse (52C), Registered Nurse (58H), Licensed Practical Nurse (54 D), and Dietary Supervisor (59I).

Review of the facility ' s life safety plan (not dated) directs staff as follows: "Fire drills are conducted once per shift per quarter announced and unannounced. Drills are reviewed for opportunities for improvement; drills are conducted by the Safety Manager and documented as well as sign in sheet."

Review of fire drill logs provided by facility ' s Safety Officer showed the most current drill was conducted 06/13/2025.

Review of the log showed no documentation that the following staff participated in the fire drill conducted on 06/13/2025:

Registered Nurse 51A, Registered Nurse (52C), Registered Nurse (58H), Licensed Practical Nurse (54 D), and Dietary Supervisor (59I).

The facility ' s Safety Officer reviewed the log with the Surveyor and confirmed that the above staff did not participate in fire drill held on 6/13/2025.

During an interview on 09/16/2025 at 12:30 p.m. the facility ' s Safety Officer stated, "I did not do fire drills for January and March, I am lacking in drills for this year."

Based on observation and interview, the facility failed to ensure supplies stored in 1 of 3 emergency crash carts and outpatient area for patients care and services were not expired.


Findings:

An observation in facility ' s nurses' station, on 09/15/2025 at10:12 a.m. in the presence of Facility ' s Chief Nursing Officer showed the following supplies stored in the emergency crash cart were expired:

Two intravenous lines, Lot # 32134582 expired on 3/30/2025

Two intravenous starter kit, Lot # 2J3185 expired on 4/24/2025

One intravenous starter kit, Lot # 2J31112expired on 4/24/2025

10 needles with syringes attached 0.75 inches, lot # 2214515 expired 7/31/2025


Review of the log for the crash cart revealed documentation that it was last checked on 09/15/2025 and staff did not identify the expired supplies.


During an Interview on 09/15/2025 at 10:20 a.m. the facility ' s Chief Nursing Officer (51A) stated, "the cart is checked by the charge nurse every shift, but the lock for the cart is not broken when checked and pharmacy checks it monthly."

During an Interview on 09/15/2025 at 10:29 a.m. the facility ' s Charge Nurse stated ' We don't break the lock; we check the top. We only break the lock once monthly."


OUTPATIENT

Observation on 09/15/2025 at 11:16 a.m. of the facility ' s outpatient suite storage drawers showed 16 syringes with needles attached (lot # 7268010) expired on 9/30/2022.

Catheter stabilization device (Lot number JUDxF468) expired 9/28/2022.

Two bottles povidone Iodine lot # 208JA 8 expired 1/22

During an interview on 09/15/2025 at 11:20 a.m. Registered Nurse (52 B) stated things are brought from the emergency room to outpatient and purchasing staff do not check the drawer for expired supplies.

BCLS EMERGENCY TRAINING

Based on observation, record review and interview, the facility failed to ensure direct care staff participate in basic cardiac life support training in 2 of 7 staff ' s personnel and training records reviewed. Registered nurse #s 51A and 53C.

On 09/15/2025 - 09/17/ 2027 (duration of the survey) Registered nurse (51A) was observed in the facility.

Review of Registered Nurse (51A ' s) personnel and training record showed the most recent basic cardiac life support training on file was dated 09/12/2022 - 09/2024. There was no evidence of a current certificate which was not expired.

Registered Nurse (#53C)

On 09/15/2025 at 10:10 a.m. Registered Nurse (53C) was observed on the medical surgical unit of the facility providing care and services to patients.

Review of Registered Nurse (53C ' s) personnel and training record showed the most recent basic cardiac life support training on file was dated 09/13/2022 - 09/2024. There was no evidence of a current certificate which was not expired.

During an Interview on 09/16/2025 at 11:15 a.m. the facility ' s Chief Nursing Officer stated the facility is aware of staff having expired basic cardiac life support training.