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Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Physical Environment relative to the overall hospital environment being maintained in a manner to ensure the safety and well-being of patients. This deficient practice was evidenced by:
1) Failure to ensure air conditioning and ventilation were maintained in the patient care areas (See Tag A0701);
2) Failure to ensure furnishings at the outpatient clinic were in good repair (See Tag A0701);
3) Failure to ensure the Emergency Power Supply System was routinely inspected and exercised under load (See Tag A0701);
4) Failure to ensure patient supplies and equipment were stored in a climate controlled area (See Tag A0724);
5) Failure to ensure the exterior courtyard was clean and maintained (See Tag A0724);
6) Failure to ensure the facility was free from insects (See Tag A0724); and
7) Failure to ensure the supplies was not expired (See Tag A0724).

Based on record review and interview the facility failed to ensure each patient's right to informed consent. The deficient practice is evidenced by failure of the facility to document the patient was informed of their rights, the risks and benefits of treatment, and the financial policy for 1 (#FF1) of 2 (#FF1, #FF2) records reviewed at the outpatient rehabilitation clinic and 1 (#FF19) of 16 (#FF5-#FF18, #FF20) records reviewed at the inpatient rehabilitation hospital.
Findings:

Review of the medical record for Patient #FF1 failed to reveal the consent form used by the facility which contained the patient's rights, the consent to treatment, and the financial policies.

In interview on 06/16/2025 at 1:58 PM, SFF21OM verified there was no consent on the record.

Review of the medical record for Patient #FF19 failed to reveal the signed consent form used by the facility which contained the patient's rights, the consent to treatment, and the financial policies.

In an interview on 06/23/2025 at 3:35 PM, SFF3MR verified Patient #19 did not sign the consent on the record.




48050

Based on record review and interview, the hospital failed to ensure each patient had the right to formulate an advance directive and have the hospital staff provide care in compliance with these directives for 1 (#FF8) of 16 (#FF5-#FF2)0 patients reviewed.
Findings:

Review of Patient #FF8's medical record revealed Patient #FF8 was admitted on 05/22/2025 for Parkinson's disease with unsteady gait. Patient #FF8 signed on admission that she had an advance directive. Further review failed to reveal documented evidence of the advance directive in Patient #FF8's medical record. SFF14MD ordered full resuscitation on 05/23/2025 for Patient #FF8. Further review of Patient #FF8's medical record showed nursing shift notes documenting Patient #FF8 being a DNR.

In an interview on 06/24/2025 at 8:55 AM, SFF2DON confirmed the above mentioned findings. SFF2DON further verified when patients report they have an advance directive, there is no protocol to ensure the advance directive document is obtained and included in the patient's medical record.

Based on record review and interview, the hospital failed to ensure pharmaceutical services developed policies and procedures that minimized drug errors. This deficient practice was evidenced by the failure of pharmacy to communicate with hospital staff the review of prescribed medications to minimize drug errors such as dosing, high alert drugs, and/or any other adverse drug event.
Findings:

A review of hospital policy, "482.25 Condition of participation: Pharmaceutical services." with no policy number, effective date or approval date revealed in part: "(b) Standard: Delivery of services. In order to provide patient safety, drugs and biological must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law.-Complete (8) Information relating to drug interactions and information of drug therapy, side effects, toxicology, dosage, indication for use, and routes of administration must be available to the professional staff. Available." A review of hospital policy "BRH Pharmacy Policy and Procedure (rev 12/21)," with no policy number or approval date did not reveal any information related to drug interactions and information of drug therapy, side effects, toxicology, dosage, indication for use, and routes of administration must be available to the professional staff."

In an interview on 06/17/2025 at 10:40 AM, SFF5LPN indicated medication orders are faxed to the pharmacist, the pharmacist would make contact with the nursing staff if there was an issue with the order and this contact would be via phone call or fax. SFF5LPN further confirmed contact with the pharmacist is rare and there is no communication related to dosing, potential high alert drugs and/or any other adverse drug events related to drug interactions or in-compatibilities with a patient's prescribed medications.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This deficient practice was evidenced by the failure to ensure documentation of the performance of first dose review by the pharmacist on 16 (#5 - #20) of 20 (#1 - #20) medical records reviewed.
Findings:

A review of pharmacy policies requested and presented by the hospital included, "482.25 Condition of participation: Pharmaceutical services." with no policy number, effective date or approval date and "BRH Pharmacy Policy and Procedure (rev 12/21)," with no policy number or approval date. These policies failed to reveal a process for a first dose review by the pharmacy prior to a prescribed medication being administered.

A review of 16 (#FF5 - #FF20) of 20 (#FF1 - #FF20) medical records did not reveal any documentation of first dose review by pharmacy prior to the patient being administered a prescribed medication.

In an interview on 06/17/2025 at 10:40 AM, SFF5LPN indicated medication orders are faxed to the pharmacist, the pharmacist would make contact with the nursing staff if there was an issue with the order and this contact would be via phone call or fax. SFF5LPN further confirmed there was no documentation as to the pharmacist completing a first dose review.

In an interview on 06/24/2025 at 10:45 AM, SFF2DON confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to ensure drugs and biological not specifically prescribed as to time or number of doses must automatically be stopped after a reasonable time that is predetermined by the medical staff. This deficient practiced was evidenced by the failure to include a prescribed time or number of doses and/or automatic stop dates on all prescribed medications in 16 (#5 - #20) of 20 (#1 - #20) medical records reviewed. Findings:

A review of hospital policy, "482.25 Condition of participation: Pharmaceutical services." with no policy number, effective date or approval date revealed in part: "(b) Standard: Delivery of services. In order to provide patient safety, drugs and biological must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law.-Complete (5) Drugs and biological not specifically prescribed as to time or number of doses must automatically be stopped after a reasonable time that is predetermined by the medical staff. STOP orders have been determined by the Medical Staff."

A review of 16 (#FF5 - #FF20) of 20 (#FF1 - #FF20) medical records failed to reveal prescribed time or number of doses and/or automatic stop dates on all prescribed medications.

In an interview on 06/24/2025 at 10:45 AM, SFF2DON confirmed the above mentioned findings

Based on record review and interview, the hospital failed to document surveillance of the infection control program. The deficient practice is evidenced by:
1) failure to document routine hand hygiene surveillance;
2) failure to provide hand sanitizer for staff/patient use; and
3) failure to ensure the hospital maintained a sanitary environment to prevent infections.
Findings:

1) failure to document routine hand hygiene surveilance

Review of the 2025 Infection Control Plan revealed in part, "Compliance with hand hygiene surveillance will be continuously assessed," and "Must do more hand hygiene surveillance (at least 5 per month) and share with staff."

Documentation of the hand hygiene observations were requested on 06/23/2025 at 11:20 AM, 1:00 PM, and 3:00 PM.

In interview on 06/24/2025 at 10:55 AM, SFF2DON verified she does not keep a formal log of hand hygiene performance checks.

2) failure to provide hand sanitizier for staff/patient use

Observations during a tour of the facility on 06/17/2025 between 9:30 AM to 11:30 AM revealed no hand sanitizer/soap dispenser for staff/patient use in the Room FFs bathroom Further observation revealed a used bar of soap sitting on the sink edge in Room FFs bathroom for staff/patient use.

In an interview on 06/17/2025 and present for the hospital walk-through SFF1CEO confirmed the above mentioned findings.

3) failure to ensure the hospital maintained a sanitary environment to prevent infections

Observations during a tour of the facility on 06/17/2025 between 9:30 AM to 11:30 AM revealed there wasn't a toilet paper dispenser in the Room FFs bathroom Further observation revealed toilet paper roll laying on top of the paper towel holder behind the commode in Room FFs bathroom.

In an interview on 06/17/2025 and present for the hospital walk-through SFF1CEO confirmed the above mentioned findings.



48050

Based on record review and interview, the facility failed to ensure compliance with antibiotic stewardship. The deficient practice is evidenced by failure to ensure coordination around all components of the hospital.
Findings:

Review of the provided "Infection Control Antibiotic Stewardship Q1 Meeting Minutes," dated 05/12/2025, revealed, in part, "Upon review, patients received appropriate antibiotics according to culture sensitivity reports and opportunities where patients could be switched to oral treatment were utilized."

Review of the " 2025 PI [Performance Improvement] Dashboard," provided as the Infection Control Quality Improvement and Performance Improvement (QAPI) measures, failed to reveal any measures associated with antibiotic stewardship.

Review of the provided documentation for the antibiotic stewardship program included a monthly "Infection Control Log" which documented room number, admit date, culture date, culture source, diagnosis, organism, site, antibiotic ordered, isolation initiated, f the infection was hospital acquired and days of antibiotic treatment.

Further review of the "Infection Control Log" revealed on the log for January, there were dash marks under the columns for isolation and hospital acquired instead of a "Y" or "N" answer. The culture date for one of the patients was also not documented.

Review of the February data revealed a patient admitted with Methicillin Resistant Staphylococcus aureus (MRSA) infection of a wound cultured prior to admit and the patient was on Bactrim BID for 10 days, but it was not hospital acquired and the patient was not on isolation.

Review of the March data revealed a patient had a pulmonary infection of the right upper lobe diagnosed by chest x-ray 11 days after admission. There was no documentation of sputum cultures and the patient was placed on levofloxicin for 7 days. The infection was documented as not hospital aquired.

Review of the April data revealed a urine culture 3 days after admission on Patient #FF20 and diagnosed with urinary tract infection, was placed on ciprofloxacin 500 milligrams for 7 days, and the infection was also documented as not hospital acquired.

In interview on 06/23/2025 at 2:00 PM, SFF2DON reviewed verified there were no measures for antibiotic stewardship in the QAPI plan. SFF2DON also verified that the infection control officer was in charge of the antibiotic stewardship program and she was not aware if the pharmacists were involved through communication with the infection control officer. At that time, SFF2DON was asked to provide documentation of the antibiotic stewardship education as referenced in the infection control plan and to provide all data she could get on the antibiotic stewardship program. SFF2DON verified she had no documentation related to reviews performed by the infection control officer, but would inquire about it. SFF2DON was also asked to provide more information about the MRSA infection documented in February and the urinary tract infections in April for Patient #FF12 and #FF20.

In interview on 06/23/2025 at 2:50 PM, SFF2DON verified that the antibiotic stewardship data in the Infection Control Log was not correct. SFF2DON verified the information about Patient #FF20 being placed on ciprofloxacin was not correct and the patient was actually discharged to the nursing home the day after the urine was collected for culture. SFF2DON stated she was still trying to locate the information about the patient with MRSA infection. At this time SFF2DON was asked to provide documentation the nursing home was notified of Patient #FF20's infection.

On 06/23/2025 at 3:00 PM, SFF2DON was asked again for documentation of antibiotic stewardship education of the staff.

In interview on 06/24/2025 at 10:55 AM, SFF2DON verified she did not have any documentation the nursing home was notified of the urinary infection for Patient #FF20. SFF2DON also verified the last positive MRSA culture received by the facility was in September of 2024, and she was not sure why she documented the facility had a patient with MRSA in February. SFF2DON did not provide any additional documentation related to the infection control program and antibiotic stewardship prior to the exit conference.

Based on record review and interview, the hospital failed to provide documentation demonstrating an active antibiotic stewardship program. The deficient practice is evidenced by failure of the facility to provide documentation of improvements, including sustained improvements, in proper antibiotic use, such as through reductions in CDI and antibiotic resistance in all departments and services of the hospital.
Findings:

Review of the 2025 Infection Control Plan revealed the 2024 status for the Antibiotic Stewardship program documented "Antibiotic Stewardship program started with listings of patients and antibiotics. Monitoring for duration and indication. Few antibiotics ordered at Bethesda. No MRDO's [multi-drug resistant organisms] of C-diff in 2023." Review of the 2025 Plan revealed, "Continue with antibiotic stewardship program for optimum patient results. Will need continued education of the staff and medical staff to include duration and reason for antibiotic in order, need to develop teaching tool for patient's discharged on antibiotic, nurses need to promptly notify physician if culture sensitivity and resistance do not concur with current antibiotic. Close observation of the patient's on antibiotic for MDRO, C-diff and appropriate isolation if needed."
Review of the "Infection Control Antibiotic Stewardship Q1 Meeting Minutes," dated 05/12/2025 revealed in part:
· Documentation of antibiotic stop dates with diagnosis: This area has improved significantly, and we will strive to have an indication and a stop date on the chart when prescribing an antibiotic.
· Notification of culture and sensitivity reports: the pharmacist, physician and IC nurse all need to be notified of any repeat cultures to continue tracking patient's treatment and appropriate use of antibiotics.
· Upon review, patients received appropriate antibiotic according to culture sensitivity reports and opportunities where patient could be switched to oral treatment were utilized.
· C-Diff Cases: No cases reported or suspected
· HAI Cases: No cases reported
· CLABSI: No cases reported
· CATI: No cases reported
· Hand Hygiene: Improvement continues in this area. Ongoing education/check-off continue for staff and annually.
· Appropriate Isolation Precautions: Improvement noted in that the isolation caddies all had adequate supplies and signage. Will continue to monitor to ensure this trend continues.

Review of the "2024 Infection Control Review and 2025 Infection Control Plan" revealed the 2025 plan for antibiotic stewardship included , in part, " Continue antibiotic stewardship program for optimum patient results. Will need continued education of the staff to include duration and reason for antibiotic in order . . "

Review of medical records selected revealed one patient (#FF5) of four total patients reviewed on antibitiocs with no stop order. Patient #FF5 has an order for ciprofloxicin 250 milligrams twice a day.

Further review of the "Infection Control Log" revealed on the log for January, there were dash marks under the columns for isolation and hospital acquired instead of a "Y" or "N" answer. The culture date for one of the patients was also not documented. Review of the February data revealed a patient admitted with Methicillin Resistant Staphylococcus aureus (MRSA) infection of a wound cultured prior to admit and the patient was on Bactrim BID for 10 days, but it was not hospital acquired and the patient was not on isolation. Review of the March data revealed a patient had a pulmonary infection of the right upper lobe diagnosed by chest x-ray 11 days after admission. There was no documentation of sputum cultures and the patient was placed on levofloxicin for 7 days. The infection was documented as not hospital aquired. Review of the April revealed doumentation of a urine culture 3 days after admission on Patient #FF20 resulted in a diagnosis of urinary tract infection. Patient #FF20 was placed on ciprofloxacin 500 milligrams for 7 days, and the infection was also documented as not hospital acquired.

On 06/23/2025 at 11:20 AM SFF5LPN was given a copy of the 2025 Infection Control Plan with the antibiotic stewardship education highlighted, and asked to provide documentation related to the education.SFF5LPN was asked to provide all documentation related to the antibiotic stewardship program for review.

In interview on 06/23/2025 at 2:00 PM, SFF2DON also verified that the infection control officer was in charge of the antibiotic stewardship program and she was not aware if the pharmacists were involved through communication with the infection control officer. At that time, SFF2DON was again asked to provide documentation of the antibiotic stewardship education as referenced in the infection control plan and to provide all data she could get on the antibiotic stewardship program. SFF2DON verified she had no documentation related to antibiotic reviews performed by the infection control officer, but would inquire about it. SFF2DON was also asked to provide more information about the MRSA infection documented in February and the urinary tract infections in April for Patient #FF12 and #FF20.

In interview on 06/23/2025 at 2:50 PM, SFF2DON verified that the antibiotic stewardship data in the Infection Control Log was not correct. SFF2DON verified the information about Patient #FF20 being placed on ciprofloxacin was not correct and the patient was actually discharged to the nursing home the day after the urine was collected for culture. SFF2DON states she was still trying to locate the information about the patient with MRSA infection. At this time SFF2DON was asked to provide documentation the nursing home was notified of Patient #FF20's infection.

On 06/23/2025 at 3:00 PM, SFF2DON was asked again for documentation of antibiotic stewardship education of the staff.

In interview on 06/24/2025 at 10:55 AM, SFF2DON verified she did not have any documentation the nursing home was notified of the urinary infection for Patient #FF20. SFF2DON also verified the last positive MRSA culture received by the facility was in September of 2024, and she was not sure why she documented the facility had a patient with MRSA in February. SFF2DON did not provide any additional documentation related to the infection control program and antibiotic stewardship prior to the exit conference.

Based on record review and interview, the hospital failed to ensure all staff received competency-based training and education on antibiotic stewardship.
Findings:

Review of the "2024 Infection Control Review and 2025 Infection Control Plan" revealed the 2025 plan for antibiotic stewardship included , in part, " Continue antibiotic stewardship program for optimum patient results. Will need continued education of the staff to include duration and reason for antibiotic in order . . " Review of the plan for infection control education revealed form October 2024 forward, the education was to be provided by the director of nursing.

On 06/23/2025 at 11:20 AM SFF5LPN was given a copy of the 2025 Infection Control Plan with the antibiotic stewardship education highlighted, and asked to provide documentation related to the education. SFF5LPN was asked to provide all documentation related to the antibiotic stewardship program for review.

On 06/23/2025 at 2:00 PM and 3:00 PM SFF2DON was asked to provide the antibiotic stewardship education.

On 06/24/2025 the SFF2DON provided a copy of the "2025 Virtual Skills/ Competency Fair" provided to the staff as the yearly education. Review of the presentation failed to reveal education related to antibiotic stewardship. There was no additional education or documentation related to the infection control program and antibiotic stewardship prior to the exit conference.