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Based on interview, the facility failed to establish and maintain a comprehensive emergency preparedness (EP) program that met the requirements for Critical Access Hospitals (CAH), utilizing an all-hazards approach.

The findings included:

1. The CAH failed to develop and maintain an EP plan to be reviewed and updated every 2 years.

Refer to E 004

2. The CAH failed to establish a documented community and facility-based risk assessment, utilizing an all hazards approach.

Refer to E 006

3. The CAH failed to document the patient population served, patients at risk and services available during an emergency.

Refer to E 007

4. The CAH failed to document efforts to contact and collaborate with local, regional, state and Federal EP officials to ensure its participation in collaborative and cooperative planning efforts during a disaster or emergency situation.

Refer to E 009

5. The CAH failed to implement, document, review and update policies and procedures every 2 years based on the emergency plan.

Refer to E 0013

6. The CAH failed to develop policies and procedures for provision of subsistence needs for hospital staff and patients during an emergency.

Refer to E 0015

7. The CAH failed to document a system to track the location of on-duty staff and sheltered patients during an emergency.

Refer to E 0018

8. The CAH failed to document a means for sheltering in place during an emergency.

Refer to E 0022

9. The CAH failed to ensure it developed policies for maintaining confidentiality of records during an emergency.

Refer to E 0023

10. The CAH failed to develop policies and procedures for the use of volunteers and other staffing strategies in case of an emergency.

Refer to E 0024

11. The CAH failed to develop policies and procedures for prearranged transfer agreements to receive patients during an emergency.

Refer to E 0025

12. The CAH failed to develop a written communication plan that contained how the facility would coordinate patient care within the facility, across healthcare providers and with state and local health departments during an emergency.

Refer to E 0029

13. The CAH failed to include updated contact information for staff, physicians, volunteers and other health facilities as part of the written communication plan.

Refer to E 0030

14. The CAH failed to include updated contact information for Federal, State, regional and local emergency preparedness officials as part of the written communication plan.

Refer to E 0031

15. The CAH failed to ensure it developed a communication plan that included primary and alternate means of communication with facility staff, Federal, State and local emergency management agencies.

Refer to E 0032

16. The CAH failed to ensure it developed a plan for sharing medical information and documentation during an emergency.

Refer to E 0033

17. The CAH failed to ensure it developed a way of providing information about the facility's needs and its ability to provide assistance to the authority having jurisdiction during an emergency.

Refer to E 0034

18. The CAH failed to develop a training and testing program based on the facility ' s risk assessment and communication plan.

Refer to E 0036

19. The CAH failed to train all staff on the EP program, based on facility risk assessment and communication plan.

Refer to E 0037

Based on observation and interview, the facility failed to ensure supplies were not stored past their expiration date for 1 of 4 (11/17/2025) observation days.

The findings included:

1. Observations in the surgical central supply room on 11/17/2025 at 10:35 AM revealed the following expired supplies:

a. Blade shield scalpel holder 12 per box-7 boxes expired 10/31/2025.
b. Central Venous Pressure (CVP; central line) Dressing Tray- 5 expired 3/31/2025.
c. Universal Retrieval System 5 millimeter (ml) Endoscopic Pouch- 2 expired 9/19/2025.

In an interview on 11/17/2025 at 10:35 AM, the Chief Nursing Officer (CNO) verified the expired supplies.

Observations in the surgical overflow supply room on 11/17/2025 at 10:40 AM revealed the following expired supplies:

a. Magnetic Drape 10 inches by 16 inches (10x16)- 1 expired 12/31/2024. 7 drapes expired 5/31/2025.

Observations in Nurse's Station #1 crash cart on 11/17/2025 beginning at 11:20 AM revealed the following expired supplies:

a. Ultrasite injection site cap- 2 expired 7/31/2025.
b. 22 gauge (ga) x 1.00 inch catheter intravenous (IV) needles- 4 expired 9/30/2025.
c. 14 ga x 1.75 inch catheter IV needles- 1 expired 1/31/2024. 1 expired 7/31/2024.
d. 20 ga x 1.00 inch catheter IV needles- 4 expired 8/31/2025.
e. 16 ga x 1.16 inch catheter IV needles- 2 expired 2/28/2025.
f. 18 ga x 1.16 inch catheter IV needles- 4 expired 8/31/2024.
g. 50 ml syringe cap tip- 1 expired 7/31/2024.
h. 60 cubic centimeter (cc) syringe luer lock tip-1 expired 1/5/2024.
i. Primary Plum blood set- 1 expired 2/1/2025. 1 set expired 8/1/2025.
j. Tracheostomy tube cuffed with inner cannula, 2 per box- 1 expired 4/23/2024. 1 cuff expired 2/19/2025.
k. Tracheostomy tube cuffless with disposable inner cannula- 1 expired 12/17/2023.
l. Surgical gloves size 7 ½- 2 pairs expired 8/28/2024.
m. Biogel ultra touch gloves size 8 ½- 2 pairs expired 2/28/2025.

In an interview on 11/17/2025 at 11:25 AM, the CNO verified the expired supplies.

Observations in Nurse's Station #2 medication room on 11/17/2025 beginning at 11:30 AM revealed the following expired supplies:

a. Pneumothorax kit 8 French 16 centimeter (cm)- 1 expired 11/30/2024.
b. Central Venous Catheter (CVC) insertion tray 7 French 20 cm- 2 trays expired 5/16/2024.

In an interview on 11/17/2025 at 11:30 AM, the CNO verified the expired supplies.

Based on policy review, observation and interview, the facility failed to ensure medications were not stored past their expiration date and failed to ensure medication containers were labeled with the date they were opened for 1 of 4 (11/17/2025) observation days.

The findings included:

1. Review of the facility's "SAFE/SECURE STORAGE AND HANDLING OF MEDICATIONS" policy (revised 7/2025) revealed, " ...6. Expired, damaged and/or contaminated medications are segregated until they are removed from the institution. A. Storage areas for these medications are clearly distinct and separate from usable medications..."

Review of the facility's "Policies and Procedures for Hospital Pharmacy Services" policy (revised 9/2025) revealed, " ...Multi-dose vials are dated and discarded according to hospital policy ...Expired, unusable, and improperly labeled medications are removed and returned to the pharmacy..."

2. Observations in the Emergency Department (ED) medication room on 11/17/2025 beginning at 11:10 AM revealed the following opened medications with no label of the open date:

a. Pepto Bismol Ultra 4 fluid ounces x 1.
b. Cough and Chest Congestion DM 4 fluid ounces x 1.
c. Hydrogen Peroxide 8 fluid ounces x 1.

In an interview on 11/17/2025 at 11:15 AM, the Chief Nursing Officer (CNO) verified the medications were opened with no label of open date. The CNO stated opened medications should be labeled with date they were opened.

Observations on Nursing Station #1 crash cart on 11/17/2025 beginning at 11:20 AM revealed the following medications stored past their expiration date:

a. 0.9 percent (%) Sodium Chloride 10 milliliter (ml) syringe-1 expired 4/30/2025.

In an interview on 11/17/2025 at 11:25 AM, the CNO verified the expired medication.

Observations in the Nursing Station #2 medication room on 11/17/2025 beginning at 11:30 AM revealed the following opened medications with no label of the open date:

a. Acetaminophen 160 milligrams (mg) per 5 ml 4 fluid ounces x 1.
b. Milk of Magnesia 16 fluid ounces x 1.
c. Children's Allergy Relief Diphenhydramine 12.5 mg/5 ml oral solution 4 fluid ounces x 1.
d. Children's Ibuprofen 4 fluid ounces x 1.

In an interview on 11/17/2025 at 11:35 AM, the CNO verified the medications were opened with no label of the open date.

Based on policy review, medical record review and interview, the facility failed to ensure nursing staff followed physician orders and policy for wound care for 1 of 1 (Patient #4) patients reviewed with wounds.

The findings included:

1. Review of the facility's "ORDERS: VERBAL, TELEPHONE AND WRITTEN POLICY" policy (reviewed 6/2025) revealed, "...The record should contain both a valid physician's order and documentation that the service was provided ..."

2. Medical record review for Patient #4 revealed an admission date of 11/1/2025 with diagnosis of Sepsis.

a. Review of physician order dated 11/3/2025 revealed Left hip wound to be cleansed with wound cleanser, skin prep (protective barrier) applied to peri-wound, foam dressing placed on wound and changed every 3 days.

Review of nursing documentation beginning 11/3/2025 through 11/19/2025 revealed left hip dressing was changed on 11/3/2025 and 11/19/2025.

There was no documentation nursing staff changed the left hip wound dressing every 3 days as ordered.

b. Review of a physician order dated 11/3/2025 revealed the left lateral ankle wound was to be cleansed with wound cleanser, skin prep applied to peri wound area, areas of tissue loss covered with xeroform (non-adhesive, petrolatum impregnated gauze) then abdominal (ABD) pad (wound dressing with thick absorbent layer), wrapped with kerlix (type of stretchy bandage roll) and secured with tape. Dressing to be changed daily and as needed for soiling.

Review of nursing documentation beginning 11/3/2025 through 11/19/2025 revealed the left lateral ankle dressing was changed 11/3/2025, 11/8/2025, 11/12/2025, 11/15/2025 and 11/19/2025.

There was no documentation nursing staff changed the left lateral ankle wound dressing every day as ordered.

c. Review of physician orders dated 11/3/2025 revealed the right foot wound was to be cleaned with cleanser, covered with 4 X 4 adaptic (non-adhering wound dressing), ABD, kerlix and tape; Dressing to be changed daily.

Review of nursing documentation beginning 11/3/2025 through 11/19/2025 revealed the right foot dressing was changed 11/3/2025, 11/4/2025, 11/6/2025, 11/8/2025, 11/11/2025, 11/15/2025 and 11/18/2025.

There was no documentation nursing staff changed the right foot wound dressing every day as ordered.

In an interview on 11/19/2025 at 2:00 PM, the Vice President of Clinical services verified wound care for Patient #4 was not documented as ordered by the physician.

Based on policy review, observation and interview, the facility failed to ensure hand hygiene was performed according to facility policy to prevent the spread of infectious bacteria for 3 of 4 (11/18/2025, 11/19/2025 and 11/20/2025) observations days.

The findings included:

1. Review of the facility's "HAND HYGIENE" policy (reviewed/revised 2/2025) revealed, " ...personnel should always wash ...Before contact with wounds or IV [intravenous] sites ...After glove removal ...After contact with objects visibly or likely to be contaminated with blood or body fluids whether or not gloves are worn ...After each direct patient contact ..."

2. Observations in Patient #5's room on 11/18/2025 at 9:00 AM, revealed Registered Nurse (RN) #1 was performing medication administration. RN #1 picked an object up off the floor, put on gloves, and proceeded to administer medications to Patient #5. RN #1 failed to perform hand hygiene after picking an object up off the floor.

Observations in Patient #4's room on 11/19/2025 at 10:00 AM, revealed Licensed Practical Nurse (LPN) #1 was performing wound care to two wounds (left ankle and left hip) on Patient #4. LPN #1 donned gloves and removed the dirty dressing from the left ankle wound. LPN #1 then proceeded to clean the left ankle wound without performing hand hygiene and changing gloves. LPN #1 completed the dressing change for the left ankle. With the same pair of gloves on, LPN #1 proceeded to clean the left hip wound without performing hand hygiene and changing gloves. LPN #1 provided wound care to two wounds for Patient #4 with the same pair of gloves on throughout the entire procedure. LPN #1 performed no hand hygiene during wound care, after removing a dirty dressing and when moving from one wound to the other.

Observations in the Emergency Room (ER) on 11/19/2025 at 10:31 AM, revealed RN #2 initiated an IV line on Random Patient (RP) #1. RN #2 performed hand hygiene then touched the table where supplies were located and rolled the table to the Patient's bedside. RN #2 then adjusted the Patient's bed rails and donned clean gloves. RN #2 failed to perform hand hygiene after touching objects that were possibly contaminated, before donning clean gloves.

Observations in Operating Room (OR) #1 on 11/20/2025 at 9:44 AM revealed RN #3 picked an instrument up off the floor with her left hand. RN #1 removed her left glove and donned a new glove. RN #3 did not perform hand hygiene after removing the glove. RN #1 proceeded to remove dirty linens from the OR table and placed them in a dirty linen container. RN #3 then removed gloves and donned a new pair of gloves without performing hand hygiene.

In an interview on 11/20/2025 at 11:15 AM, the Chief Nursing Officer (CNO) verified hand hygiene should be performed after glove changes, after touching wounds or contaminated objects.

Based on interview, the facility failed to develop and maintain an Emergency Preparedness (EP) plan to be reviewed and updated every 2 years.

The findings included:

During an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified the facility had not developed a comprehensive EP plan to be reviewed and updated every 2 years.

Based on interview, the facility failed to ensure a documented facility-based and community-based risk assessment was completed utilizing an all hazards approach.

The findings included:

During an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified the facility had not completed a facility and community based risk assessment.

Based on interview, the facility failed to document the patient population served, strategies to address vulnerable patient populations and services available during an emergency.

The findings included:

During an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified the facility's Emergency Preparedness plan did not address patient population serviced, ways to address vulnerable patient populations and services available during an emergency.

Based on interview, the facility failed to document efforts to contact and collaborate with local, regional, state and Federal EP officials to ensure its participation in collaborative and cooperative planning efforts during a disaster or emergency situation.

The findings included:

During an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified the EP plan did not document contacts or collaboration with other emergency officials.

Based on interview, the facility failed to implement, document, review and update policies and procedures every 2 years based on the emergency plan.

The findings included:

During an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified policies and procedures related to the emergency plan had not been reviewed and updated every 2 years.

Based on interview, the facility failed to develop policies and procedures for provision of subsistence needs for patient and staff, failed to develop policies and procedures for alternate energy sources and sewage and waste disposal during an emergency.

The findings included:

In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified no policies or procedures were developed for subsistence needs, alternate energy sources and sewage and waste disposal during an emergency.

Based on interview, the facility failed to document a system to track the location of on-duty staff and sheltered patients during an emergency.

The findings included:

In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there was no documentation of ways to track on-duty staff and sheltered patients during an emergency.

Based on interview, the facility failed to document means to shelter in place for patients, staff and volunteers during an emergency.

The findings included:

In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there was no documentation of means to shelter in place for patients, staff and volunteers during an emergency.

Based on interview, the facility failed to develop policies to address how medical record confidentiality and security would be preserved during an emergency.

The findings included:

In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there were no policies developed to address medical record confidentiality and security during an emergency.

Based on interview, the facility failed to develop policies and procedures for the use of volunteers and other staffing strategies during an emergency.

The findings included:

In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there were no policies related to volunteers and staffing strategies during an emergency.

Based on interview, the facility failed to develop updated policies and procedures for prearranged transfer agreements to receive patients during an emergency.

The findings included:

In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there were no updated policies related to transfer agreements during an emergency.

Based on interview, the facility failed to develop written communication plans that contained how the facility would coordinate patient care within the facility, across healthcare providers and with state and local health departments during an emergency.

The findings included:

In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there was not a communication plan that documented coordination of patient care within the facility, with other providers and outside departments during an emergency.

Based on interview, the facility failed to include updated contact information for staff, physicians, volunteers and other health facilities as part of a written communication plan.

The findings included:

In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there was not a written communication plan with updated contact information.

Based on interview, the facility failed to include updated contact information for Federal, State, regional and local emergency preparedness officials as part of a written communication plan.

The findings included:

In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there was not a written communication plan with updated contact information.

Based on interview, the facility failed to develop a communication plan that included primary and alternate means of communication with facility staff, Federal, State and local emergency management agencies during an emergency.

The findings included:

In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there was not a written communication plan that included primary and alternate means of communication during an emergency.

Based on interview, the facility failed to develop a communication plan that addressed means for sharing medical information and documentation during an emergency.

The findings included:

In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there was not a written communication plan that included ways to share medical information and documentation during an emergency.

Based on interview, the facility failed to develop a communication plan that included ways to provide information about the facility's needs during an emergency, and the facility's ability to provide assistance to the authority having jurisdiction during an emergency.

The findings included:

In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified there was not a written communication plan that included ways to provide information about the facility's needs and ways to provide assistance during an emergency.

Based on interview, the facility failed to develop a training and testing program based on the facility's risk assessment and communication plan.

The findings included:

In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified the facility's training and testing program was not based on a risk assessment or emergency communication plan.

Based on interview, the facility failed to train all staff on the Emergency Preparedness (EP) program based on facility risk assessment and communication plan.

The findings included:

In an interview on 11/20/2025 at 11:30 AM, the Chief Nursing Officer verified staff were not trained on an EP program based on risk assessment and emergency communication plan.