HospitalInspections.org

Based on observation, interview, and record review, the Governing Body (GB-a group of people responsible for the overall direction and management of an organization) failed to ensure a safe environment and effective quality of care was provided for a universe of 51 patients admitted on August 4, 2025, when:

1. The GB did not ensure the environment of care (EOC- the physical hospital), in the pharmacy and kitchen, was safe, functional, and effective space that supports the delivery of high-quality patient care and the well-being of everyone within the hospital when the temperature in the pharmacy department, where patient medication was stored, was not continually monitored after issues with the HVAC (Heating, Ventilation, Air Conditioning) unit were known by the facility and repairs were not scheduled.. (Refer to A-0049)

2. The GB did not ensure a full-time Registered Dietitian was employed to meet the needs of the nutritional needs of the patients. (Refer to A-0049)

3. The GB did not ensure an effective oversight on hospital wide quality improvement opportunities in problem prone areas and an effective quality improvement program. (Refer to A-0049)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on interview and record review, the facility failed to maintain an effective and ongoing hospital wide, Quality Assessment and Performance Improvement (QAPI) program for a universe of 51 patients admitted on August 4, 2025, when:

1. QAPI did not include data and interventions related to issues with the facilities environment of care (EOC- the physical hospital) including: monitoring of temperatures in the pharmacy after the HVAC (Heating, Ventilation, Air Conditioning) unit was known to have required repairs and the only ice machine in the kitchen was not working since April 2025 (Refer to A-0273)

2. QAPI failed to provide oversight of nutritional patient care needs including: comprehensive nutritional assessments did not include patient interview of physical assessment by the Registered Dietitian (RD) for six of 35 sampled patients (Patients 3, 11, 5, 20, 21, and 23); nutrition reassessments for high-risk patients were not performed on time for four of 35 sampled patients (Patients 25, 24, 21 and 3); and a nutritional Plan of Care was not developed for three of 35 sampled patients (Patient 23, 3, and 21). (Refer to A-0273)

3. QAPI did not provide adequate oversight of pharmaceutical services when the facility failed to identify and monitor issues that could lead to a medication error including: inadequate monitoring for a potential drug-to-drug interaction for Patient 4; an incomplete medication order for Patient 29, and inaccurate medication administration and documentation for Patient 6. (Refer to A-286).

The cumulative effects of these systemic problems resulted in the hospital's inability to identify problem prone areas and ensure the provision of quality health care in a safe environment and had the potential to cause adverse health outcomes (undesirable and harmful effects on someone's health) such as ineffective medications which could result in therapeutic (treatment) failure ,food borne illness (food poisoning) which could require continued hospitalization.

Based on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services to meet the needs of patients for three of 35 sampled patients (Patient 4, Patient 6, and Patient 29) when:

1. Eight medications were observed stored outside of the manufacturers' stipulated (required) temperatures range (68-77 Fahrenheit (F- unit of measurement)) in the Pharmacy Department. (Please refer to A-0491).

This failure had the potential for inadequate temperature monitoring, patients receiving ineffective medications which could result in therapeutic (treatment) failure or other adverse clinical outcomes due to exposure to elevated room temperatures.


2. For Patient 29, an unclear PRN (as needed) medication order was not clarified. (Please refer to A-0491)

This failure had the potential to result in preventable medication errors and miscommunication among healthcare professionals.


3. For Patient 6, a medication was inaccurately charted (documented) in the Medication Administration Record (MAR - section of the medical record where administered medications is documented). (Please refer to A-0491).

This failure had the potential to result in preventable medication errors and miscommunication among healthcare professionals.


4. For Patient 6, a medication was not given as ordered due to a technology issue. (Please refer to A-0491).

This failure resulted in a preventable medication error.


5. For Patient 4, monitoring did not occur in accordance with the drug manufacturer's prescribing information (PI - document on how to safely use medications) regarding drug-drug interactions (reactions between multiple drugs which makes drugs less effective, cause unexpected side effects, or increase the action of a particular drugs which may affect the safety or efficacy). (Please refer to A-0500).

This failure had the potential for the patient to experience increased risk of high potassium levels (can cause heart problems requiring immediate medical attention) due to drug-drug interactions and/or adverse clinical outcomes.


6. One of one medication, available for patient use, requiring protection from light was not stored in accordance with manufacturer's stipulations (requirements). (Please refer to A-0505).

This failure had the potential to result in a patient receiving unusable, ineffective, or deteriorated (reduced quality) medication due to preventable light exposure.


The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on observation, interview, and record review, the facility failed to maintain an organized dietary service that are directed and staffed by adequate qualified personnel and to ensure the policy and procedure (P&P) was maintained as evidenced by:

1a. The facility was late on follow-up nutrition assessments for three of 35 sampled patients (Patient 25, 24, 21, and 3) when a patient is labeled, High Nutrition Risk the patient should be seen no less than every 7 days, Moderate Nutrition Risk is no less than every 14 days and low nutrition risk reassessed with changes in condition. (Refer to A-0621)

1b. Six of 35 sampled patients (Patient 3, 11, 5, 20, 21, and 23) did not receive a comprehensive nutritional assessment that included a patient, family or representative interview. (Refer to A-0621)

1c. Facility did not include nutrition interventions on the Plan of Care for three of 35 sampled patients (Patient 23, 3, and 21). (Refer to A-0621)

2a. The kitchen was not in a sanitary condition, which is a repeated finding from a state re-licensing survey that took place 2 months prior for a universe of 51 medically compromised patients who received food and drinks from the kitchen. . (Refer to A-0619)

2b. Ice was not readily available and easily assessable for staff to use on tray line (a process where food is held on a steam table and on ice while staff serve each patient's meal) because the ice machine had been broken since April 2025 for a universe of 51 medically compromised patients who received food and drinks from the kitchen. (Refer to A-0619)

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision of safe and quality nutrition care and dietetic services and resulted in the potential to cause poor nutrition status and food borne illness for a universe of 51 medically compromised patients who received food and drinks from the kitchen.

Based on observation, interview, and record review, the facility failed to ensure the Governing Board (GB-a group of people responsible for the overall direction and management of an organization) provided the necessary oversight to maintain the resources and hospital personnel required to meet the needs of the hospital's patients for a universe of 51 patients admitted on August 4, 2025, when:

1a. The temperature in the pharmacy department, where patient medication was stored, was not continually monitored after issues with the HVAC (Heating, Ventilation, Air Conditioning) unit were known by the facility and repairs were not scheduled.

This failure resulted in the pharmacy department temperature increasing to a high of 80 degrees Fahrenheit (F- unit of measurement) on August 4, 2025, at 8:13 AM, and exposing multiple medications to temperatures exceeding manufacturers' recommendations.

1b. The facility's only ice machine in the kitchen required replacement and had not been replaced since April.
This failure resulted in kitchen staff making their own ice to support the needs of meal preparation and serving of meals, as there was not enough ice to accommodate the needs of 51 patients with a secondary ice maker in the patient care unit.

2. The facility did not employ a full-time Registered Dietitian (RD) for a three-month time to perform comprehensive assessments (a thorough evaluation by gathering information from various sources, analyzing data, and formulating recommendations or action plans), reassessments, and ensure the nutritional needs of patients continually assessed and their needs were met.
This failure resulted in lack of comprehensive assessment and on-going evaluation of patients' nutritional needs and lack of follow-up on ordered nutritional interventions.

3.The GB did not provide oversight of the Quality Assurance Performance Improvement (QAPI) program to ensure problem prone areas of patient care were identified and implementation of interventions were initiated to maintain safe and quality patient care throughout the hospital.

This failure resulted in inadequate monitoring and implementation of performance improvement processes in the pharmaceutical services department and nutritional services department, and the potential for inadequate quality of care.

Findings:

1a. During a record review of the facility document titled, "[Name of Hospital] Work Order", dated August 4, 2025, the document indicated, the temperature in the pharmacy was 80 degrees Fahrenheit at 8:13 AM.

During a concurrent interview and record review, on August 7, 2025, at 5:19 PM, with the GB, the facility "log" titled, "[Name of Hospital] Pharmacy Room Temperature/Humidity" dated July 2025, was reviewed. The "log" indicated, the HVAC was fixed on July 1, 2025, but then continued to have issues maintaining a cool temperature in the pharmacy throughout the month of July 2025 to the survey entrance date on August 4, 2025. The "log" further indicated, temperatures in the room were not being monitored or documented by the facility staff when the pharmacy was closed during the weekend (August 2, 2025 and August 3, 2025). The Regional Chief Executive Officer (RCEO) stated, she knew the HVAC was fixed in July, but she was unaware that the HVAC continued to have problems after it was fixed and was unable maintain a constant cool temperature in the pharmacy. The RCEO further stated that the temperature needs to be monitored during the weekends when the pharmacy is closed to ensure patients' medications are stored within manufacturers' recommendations.

1b. During an observation in the kitchen on August 4, 2025, at 11:45 AM, there was a metal pan with ice and the salads were placed on top of the ice, but there was not enough room for all the salads, so some of the salads were just on the counter. Also, the drinks, fruit cups and the turkey sandwiches were not on ice during tray line.

During an interview with Patient 18 in her room on August 4, 2025, at 4:00 PM, Patient 18 stated she does not like that the milk is served warm. The milk should be cold when served.

During an interview on August 7, 2025, at 5:25 PM, with the GB (GB included with mailnly RCEO, Vice President (VP), Chief Nursing Officer (CNO), and the Medical Director (MD), the RCEO stated, upon her appointment as CEO at this facility at the end of April 2025, she was notified that the ice machine in the kitchen was not working. The RCEO stated there were two other ice machines in the facility, so she did not think it was an immediate need to get the ice machine in the kitchen replaced. The RCEO stated she was not aware that the ice machines in the nursing area and in the staff room did not produce an adequate amount of ice to support the kitchen needs.

A review of the facility's document titled, "[Name of Parent Company] Hospital Governing Board and Bylaws" dated November 21, 2019, indicated, " ...Section 2. Functions and Duties of the Governing Board. The functions, authority and duties of the Governing Board shall be consistent with the standards of the Medicare Conditions of Participation, the Joint Commission on Accreditation of Health Care Organizations (JACHO)or other accrediting body of all applicable laws and regulations. Such functions shall include but not be limited to the following ...h. Physical Plant and Personnel. The Governing Board shall oversee the Hospital's physical plant, resources and personnel required to meet the needs of the hospital's patients, and shall participate in planning to meet the health needs of the community, in accordance with applicable laws and regulations ...k. Expenses. The Governing Board shall have the authority to incur expenses on individual items that do not exceed limits set from time to time by the managers ...".

2. During an interview on August 6, 2025, at 4:15 PM, with Registered Dietitian (RD 2), RD 2 stated she has not been a part of Interdisciplinary Team (IDT-a group of healthcare professionals from various disciplines working together to coordinate patient care) meetings for patients at this hospital and has not been requested to provide tracking or feedback regarding nutritional patient quality measures (diet history,assessments).

During an interview on August 6, 2025, at 4:37 PM, with RD 1, RD 1 stated he does not participate in the IDT meetings for patients and has not been asked to be a part of the IDT. RD 1 stated, he does participate in the QAPI meetings at the facility. RD 1 stated he does provide performance measures when requested but is not included in the discussion or provide feedback because he is not full-time at the facility.

During an interview on August 7, 2025, at 5:30 PM with the GB, the RCEO stated that the facility has utilized two Registered Dietitians to provide nutritional services for the inpatient population as the facility has searched for a full-time RD. The RCEO stated she does not have an answer as to why the RDs are not attending the IDT meetings, or why reassessments are not being performed on time, and nutritional care plans are not being completed. The RCEO stated the facility does not currently have a Chief Nursing Officer (CNO). The RCEO further stated, the whole clinical team reports to the CNO, which may be the reason there has not been oversight of the nutrition department. The Medical Director (MD) stated, it was his expectation that the RD meet with the IDT during patient plan of care meetings.

A review of the facility document titled, "[Name of Parent Company] Hospital Governing Board and Bylaws," dated November 21, 2019, indicated, " ... the Chief Executive Officer shall represent the hospital in all aspects of its operations. He/she shall make periodic reports to the governing board but his/her line of authority shall derive from the managers. The duties of the chief executive officer shall include but not be limited to the following ... Organization and management of the hospital and its services, departments and subdivisions, delegation of duties and establishment of means of accountability of subordinates ..."

3. During a concurrent interview and record review on August 7, 2025, at 5:40 PM, with GB, the facility document titled, "[Name of Hospital] Annual Governing Board Meeting," dated June 3, 2025, was reviewed. The document indicated quality measures were presented to the GB, but there were no recommendations, actions of follow-ups regarding these quality measures noted in the GB minutes. The MD stated, the meeting minutes do not reflect the meeting itself. The MD stated, there meeting minutes should be more robust and include interventions, evaluation and the GB's feedback to reflect the conversation had during the GB meeting.

During a review of the facility document titled, "[Name of Parent Company] Hospital Governing Board and Bylaws," dated November 21, 2019, the document indicated, " ...Section 2. Functions and Duties of the Governing Board. The functions, authority and duties of the Governing Board shall be consistent with the standards of the Medicare Conditions of Participation, the Joint Commission on Accreditation of Health Care Organizations (JACHO)or other accrediting body of all applicable laws and regulations. Such functions shall include but not be limited to the following ...i. Quality Assessment and Performance Improvement. Consistent with applicable law and regulations, the Governing Board shall require the Medical Staff and staffs of the departments/services to implement a hospital wide quality assessment and performance improvement plan which reports on the activities and mechanisms for monitoring and evaluating the quality and safety of patient care at the hospital, for identifying opportunities to improve patient care, and for identifying and resolving problems, including but not limited to, monitoring and auditing of such departments and services lines of the Hospital. The Governing Board, through the Chief Executive Officer and the Medical Staff's Chief of Staff, shall support these activities and mechanisms ... The Governing Board shall consider and, if necessary act upon the results reported from QAPI activities, which activities shall strive to satisfy the following objectives: (i) Quality and safety of patient care provided by members of the Medical Staff the Hospital's employees and all others who provide patient care services at the Hospital; (ii) Use of plans and systemic procedures to objectively assess the quality of care provided at the Hospital; (iii) Implementation of corrective action when problems or opportunities for improvement are identified: and, (iv) The provision of one level of patient care throughout the Hospital ...".

Based on interview and record review, the hospital failed to maintain an effective and ongoing hospital wide, data driven Quality Assessment and Performance Improvement (QAPI) program for a universe of 51 patients admitted on August 4, 2025, when

1. QAPI did not include data and interventions related to issues with the facilities Environment of Care (EOC- the physical hospital) including: monitoring of temperatures in the pharmacy after the HVAC (Heating, Ventilation, Air Conditioning) unit was known to have required repairs and the only ice machine in the kitchen was not working since April 2025.

This failure resulted in patients' medications in the pharmacy being stored in temperatures exceeding manufacturers' recommendations and three months of inadequate ice production in the kitchen to cool patient foods and beverages.

2. QAPI failed to provide oversight of nutritional patient care needs, when there was not a full-time Registered Dietitian (RD) employed, including: comprehensive nutritional assessments did not include patient interview of physical assessment by the Registered Dietitian (RD) for six of 35 sampled patient (Patients 3, 11, 5, 20, 21, and 23); nutrition reassessments for high-risk patients were not performed on time for four of 35 sampled patients (Patients 25, 24, 21 and 3); and a nutritional Plan of Care was not developed for three of 35 sampled patients (Patient 23, 3, and 21).

This failure resulted in assessments being performed without patient interviews, reassessments being missed and the potential to cause poor nutrition status for eight of 35 medically compromised sampled patients and missed opportunities to identify any potential issues of the facility's performance and to create any changes to improve patients' health outcomes and had the potential to cause a preventable adverse patient outcome that could negatively affect patients' health and safety.

Findings:

1. During an interview on August 7, 2025, at 10:45 AM, with the Regional Director of Plant Operations (RPO), the RPO stated that the HVAC compressor was replaced on July 1, 2025, but the unit has tripped the breaker several times since it was repaired, which accounts for the temperature rising to 80 degrees Fahrenheit (F- unit of measurement) on August 4, 2025, at 8:13 AM. The RPO stated that the temperatures were not monitored over the weekend when the pharmacy was closed, so there were no temperatures recorded for August 3, 2025, or August 2, 2025. The RPO stated that the facility has been working on a replacement for the kitchen ice machine since April 2025, and a new ice machine is scheduled to arrive on August 11, 2025. The RPO stated, he does not have the installation for the new ice machine scheduled. The RPO further stated, he does not have documentation of a work order for the HVAC unit or the kitchen ice machine, nor documentation to track the process of resolution of these items. The RPO stated, he is not a part of the quality committee and does not participate in any committees here at this facility.

During a concurrent interview and record review on August 7, 2025, at 3:19 PM, with the Regional Director of Quality, Risk and Compliance (RDQ) and the Quality Management Assistant (QMA), the facility document titled, "Quality Assurance Performance Improvement (QAPI) Committee," dated July 25, 2025, was reviewed. The document included a section titled "EOC" which included monitoring for monthly inspection of fire extinguishers and a "Capital Projects Reporting" section, but the section was blank. There was no other quality indicators tracked in the EOC section. The RDQ stated, QAPI had not been monitoring facility specific repair issues such as the HVAC unit or ice machine.


2. During an interview on August 6,2025, at 4:15 PM, with Registered Dietitian (RD 2), RD 2 stated she has not been a part of Interdisciplinary Team (IDT-a group of healthcare professionals from various disciplines working together to coordinate patient care) meetings for patients at this hospital and has not been requested to provide tracking or feedback regarding nutritional patient quality measures.

During an interview on August 6, 2025, at 4:37 PM, with RD 1, RD 1 stated he does not participate in the IDT meetings for patients and has not been asked to be a part of the IDT. RD 1 stated, he does participate in the QAPI meetings at the facility. RD 1 stated he does provide performance measures when requested but is not included in the discussion or provide feedback because he is not full-time at the facility.

During a concurrent interview and record review on August 7, 2025, at 3:37 PM, with the RDQ and QMA, the facility document titled, "Quality Assurance Performance Improvement (QAPI) Committee," dated July 25, 2025, was reviewed. The document indicated, nutrition performance indicators being tracked in included: the initial nutrition assessment completed within 72 hours, accuracy of meals served to patients and tube feeding (patient requiring nutrition through a tube in the stomach because they are unable to eat food). The RDQ stated she does not have an answer as to why nutrition reassessments, for Patients 25, 24, 21 and 3, were not done and nutrition plan of care for Patients 23, 3, and 21 were not done. The RDQ stated, these quality measure indicators are not being tracked. The RDQ stated, she was not aware Patients 3, 11, 5, 20, 21, and 23 comprehensive nutrition assessment did not include a patient interview or a physical assessment. The RDQ stated, she does not know the reason the RDs do not participate in the IDT meetings. The RDQ stated, that the RDs would report to the Chief Nursing Officer (CNO), but since that role is vacant, the RDs report to the Chief Executive Officer. The RDQ stated, that the CEO does join the QAPI meetings, but the issues have not been identified as process improvement areas.

Durning a review of the facility's document titled, "2025 PERFORMANCE IMPROVEMENT PLAN," undated, the document indicated, " ...The QAPI's responsibilities include, but are not limited to: Establishing a planned and systematic approach to performance improvement. Identifying and monitoring the hospital-wide performance measures. Promoting a hospital culture that values commitment to continuous improvement in safety, quality care and services to patients, families, visitors, community, medical and hospital staffs. Implementing operational activities that are consistent with the Strategic Plan and the Mission, Vision and Values of the hospital and [Name of Parent Company] Healthcare. Providing education on performance improvement approaches. Prioritizing performance improvement projects. Reviewing and approving performance improvement team projects. Monitoring the progress of quality control activities and of designated project teams. Evaluating the effectiveness of action taken to improve a process. Managing the flow of information to ensure follow up. Reporting performance improvement activities to the Governing Board. Maintaining the confidentiality of data and information resulting from performance improvement activities. Assuring that results, findings and improvement information are communicated ..."

Based on interview and record review, the facility failed to identify and track opportunities to reduce medication errors for three of 35 sampled patients (Patients 4, 29, and Patient 6) when: Patient 4 was prescribed multiple medications that may result in hyperkalemia (potassium levels that are too high in the blood, which can cause an irregular heart beat) medication and Patient 4's potassium levels were not monitored, Patient 29 was prescribed a topical anesthetic (numbing medication) and orders were not complete, and medication was inaccurately documented for Patient 6).

These failures had the potential to result in confusion among the health care team and preventable medication errors, which could significantly affect the health and safety of Patient 4, 29 and 6).

Findings:

During an interview on August 7, 2025, at 3:07 PM, with the Regional Director of Quality, Risk and Compliance (RDQ) and the Quality Manager Assistant (QMA), the following pharmaceutical findings were reviewed including: Patient 4 prescribed two medications that had the potential to cause hyperkalemia and Patient 4's potassium levels were not monitored. Patient 29 was prescribed a topical anesthetic and the order did not include a specific site(s) to administer the medication, and a medication that was administered to Patient 6 was not accurately documented by nursing. The RDQ stated, QAPI did not track those specific indicators, but did track medications errors.

During a concurrent interview and record review on August 7, 2025, at 3:25 PM, with the RDQ and the QMA, the facility document titled, "Quality Assurance Performance Improvement (QAPI) Committee," dated July 25, 2025, was reviewed. The document included a pharmacy section which included tracking of medication errors, but did not include specific issues that led to the medication errors with specific analysis and improvement measures to address the medication error issues. The RDQ stated, the pharmacy reports and tracks these issues through Medication Error Reporting and Prevention (MERP) and Pharmacy and Therapeutic Committee (PTC) who then report directly to the Medical Executive Committee (MEC), so those specific issues are not necessarily tracked nor the process improvement plans initiated through QAPI.

During a concurrent interview and record review on August 7, 2025, at 3:45 PM, with the RDQ, the facility document titled, "2025 PERFORMANCE IMPROVEMENT PLAN," undated, was reviewed. The document indicated that all facility committees, including MERP and PTC, report directly to QAPI, then QAPI reports directly to the MEC. The RDQ stated that she miss spoke about which departments report to QAPI. The RDQ further stated, it is ultimately the responsibility that the committees report to QAPI and ensure they are accountable for the reporting of their departments.

Based on observation, interview, and record review, the facility failed to ensure medications were stored within the temperature range (68-77 Fahrenheit (F- unit of measurement)) required by the drug manufacturer's approved labeling and policies were implemented to minimize drug errors for two of 35 sampled patients (Patient 6 and Patient 29) when:

1. Eight medications were observed stored outside of the manufacturers' stipulated (required) temperatures range in the Pharmacy Department.

This failure had the potential for patients receiving ineffective medications which could result in therapeutic (treatment) failure or other adverse clinical outcomes due to exposure to elevated room temperatures for an universe of 51 patients.

2. For Patient 29, PRN (as needed) medication for diclofenac (drug to relieve pain and inflammation) sodium 1% (concentration) order was unclear and not clarified.

This failure had the potential to result in preventable medication errors and miscommunication among healthcare professionals.


3. For Patient 6, a medication daptomycin (an antibiotic) was inaccurately charted (documented) in the Medication Administration Record (MAR - section of the medical record where administered medications are documented); and

This failure had the potential to result in preventable medication errors and miscommunication among healthcare professionals.


4. For Patient 6, a medication pantoprazole (drug to reduce the amount of acid the body produces) was not documented as administered on August 5, 2025, as per the order when the electronic chart sytem had some issues.

This failure resulted in a preventable medication error by missing the dose or receiving an extra dose.

Findings:
1. During a review of the air condition vendor's "QUOTE No. 1491" dated May 9, 2025, the "JOB SUMMARY" indicated "[the name of the vendor] PERFORM AN INSPECTION OF AC [air conditioning] -10 AND FOUND THE COMPRESSOR [device] GROUNDED. THE UNIT HAS ONE OPERATING COMPRESSOR AT THIS TIME. [the name of the vendor] IS PROPOSING TO REPLACE THE FAILED COMPRESSOR."

During a review of the "PHARMACY Room TEMPERATURE/HUMIDITY" logs, the room temperature was logged as 93 Fahrenheit (F- a temperature scale) on June 16, 2025.

During a review of "CAPITAL EXPENTIURE REQUEST" for "SBH-2025-5" dated May 12, 2025, the hospital project "Compressor Replacement Unit 10" was approved by the facility's representatives on June 18, 2025.

During a review of the vendor's invoice for "SBH-2025-5" dated July 1, 2025, the vendor replaced the grounded compressor on AC-10.

During a review of the "PHARMACY Room TEMPERATURE/HUMIDITY" logs, the room temperature was recorded as 80F on July 4, 2025.

During a concurrent observation and interview on August 4, 2025, at 8:46 AM, with Staff Pharmacist 1 (RPH 1) in the Pharmacy Department, the room temperature was measured 78F at that time. RPH 1 acknowledged the pharmacy room temperature of 78F.

During a concurrent observation and interview on August 4, 2025, at 9:01 AM, with RPH 1 in the Pharmacy Department, the following eight injectable medications were observed with the drug manufacturer's product labeling to store at a temperature no greater than 77F: Mycamine (brand name antifungal drug for fungal infections) 100 mg/vial, piperacillin and tazobactam (antibiotic) 3.375 grams per vial, piperacillin and tazobactam 4.5 grams per vial, penicillin G sodium (antibiotic) 5 million units, nafcillin (antibiotic) 2 grams per vial, azithromycin (antibiotic) 500 mg, oxacillin (antibiotic) 2 grams per vial, and ketorolac (anti-inflammatory pain medication) 30 mg. RPH 1 acknowledged the product labeling of the eight injectable medications to store at a temperature no greater than 77F.

During a concurrent observation and interview on August 4, 2025, at 10:06 AM, with the Director of Pharmacy (DOP) in the Pharmacy Department, the number of each of the 8 different injectable vials available for patient use was counted. The DOP stated there were four (4) vials of Mycamine, 40 vials of piperacillin and tazobactam 3.375 grams per vial, 33 vials of piperacillin and tazobactam 4.5 grams per vial, eight (8) vials penicillin G sodium 5 million units, 21 vials of nafcillin 2 grams per vial, 12 vials of azithromycin 500 mg, 31 vials of oxacillin 2 grams per vial, and 15 vials of ketorolac 30 mg.

During an interview on August 4, 2025, at 10:08 AM, with the Maintenance Supervisor (MS), the MS acknowledged that it took "a little bit of time to cool down" the Pharmacy Department.

During a follow up interview on August 4, 2025, at 2:57 PM, with the MS, the MS stated the Pharmacy Department was set to 74F and the air turns on at 6:30 AM every morning.

During a concurrent interview and record review on August 4, 2025, at 3:50 PM, with RPH 1, the hospital work order "362481" indicated the pharmacy room temperature was 80F on August 4, 2025, at 8:13 AM. RPH 1 stated the pharmacy room temperature was 80F on August 4, 2025, at 8:13 AM.

During a concurrent interview and record review on August 7, 2025, at 10:00 AM, with the DOP, the facility's policy and procedures (P&P) titled, "Storage of Medications," dated December 2024, was reviewed. The P&P indicated, "Medications will be stored at appropriate temperatures ...room temperature will be maintained between 20C [Celsius - a temperature scale] (68F) and 25C (77F)." The DOP acknowledged the policy.

During a telephone interview on August 7, 2025, at 11:04 AM, with the Regional Director of Plant Operations (RPO), the RPO could not explain why it took so long to cool down the Pharmacy Department.

During a telephone interview on August 7, 2025, at 11:22 AM, with the RPO, the RPO was unable to articulate why the air conditioner issue since April 2025, was still not fixed.

2. During a review of Patient 29's "History and Physical" (H&P - a comprehensive patient assessment), dated July 28, 2025, was reviewed. The H&P indicated Patient 29 was admitted to the facility on July 27, 2025, with diagnoses of debility (physical weakness, especially due to illness) and fractures (broken bones).

During a review of Patient 29's medical record, the physician's order indicated a medication order dated July 27, 2025, for acetaminophen (pain medication) 500 milligrams (mg - a unit of measurement for dose) every 6 hours PRN mild pain.

During a review of Patient 29's medical record, the physician's order indicated a medication order dated July 27, 2025, for oxycodone (strong pain medication) 5 mg every 4 hours PRN moderate to severe pain.

During a review of Patient 29's medical record, the physician's order indicated a medication order dated July 27, 2025, for diclofenac (drug to relieve pain and inflammation) sodium 1% (concentration) 4 grams each dose to apply topically (on the surface/ directly over the skin) four times daily PRN pain to the affected area.

During a concurrent interview and record review on August 7, 2025, at 9:45 AM, with the Director of Pharmacy (DOP), Patient 29's multiple PRN pain medications were reviewed. The DOP acknowledged the PRN diclofenac medication order was not clear and should have been clarified. A continued review with the DOP, the facility's policy and procedure (P&P) titled, "Clarification of Medication Orders," dated October 2024, was reviewed. The P&P indicated, "I. Clarification or verification - any medication order which does not contain the required elements of a complete order ...must be clarified with the prescribing physician prior to dispensing." The DOP acknowledged the policy.


3. During a review of Patient 6's "History and Physical" (H&P), dated July 28, 2025, the H&P indicated Patient 29 was admitted to the facility on July 27, 2025, with diagnoses of right foot osteomyelitis (bone infection), bacteremia (bacteria in the blood), diabetes (high blood sugar), and hypertension (high blood pressure).

During a review of Patient 6's medical record, the physician's order indicated a medication order dated July 29, 2025, for daptomycin (an antibiotic) intravenously (IV - into the patient's vein) every 48 hours. The daptomycin medication order indicated the first 350 mg bag out of two bags was scheduled to be administered at 5:30 PM. The daptomycin medication order indicated the second 350 mg bag out of two bags was scheduled to be administered at 6:00 PM.

During a review of Patient 6's medical record, the Medication Administration Record (MAR) indicated the first bag of daptomycin 350 mg was administered on July 31, 2025, at 5:24 PM, by Registered Nurse 1 (RN 1). The MAR indicated the second bag of daptomycin 350 mg was administered on July 31, 2025, at 5:24 PM, by RN 1.

During a review of Patient 6's medical record, the MAR indicated the first bag of daptomycin 350 mg was administered on August 2, 2025, at 5:22 PM, by RN 3. The MAR indicated the second bag of daptomycin 350 mg was administered on August 2, 2025, at 5:22 PM, by RN 3.

RN 3 was not available for interview.

During an interview on August 4, 2025, at 9:53 AM, with the DOP, the DOP stated the Pharmacy Department was not currently compounding intravenous (IV - into the patient's vein) medications.

During a concurrent interview and record review on August 5, 2025, at 3:43 PM, with RN 1 and RN 2, Patient 6's medical record was reviewed. RN 1 stated they were an orientee and RN 2 stated they were the preceptor. RN 1 and RN 2 stated the daptomycin medication order indicated the first 350 mg bag out of two bags was scheduled to be administered at 5:30 PM. RN 1 and RN 2 stated the daptomycin medication order indicated the second 350 mg bag out of two bags was scheduled to be administered at 6:00 PM. RN 1 and RN 2 stated the resource nurse told them the daptomycin were two separate medication orders. RN 1 and RN 2 stated they forgot to fix the charting to show both daptomycin medications were administered at the right time.

During a concurrent interview and record review on August 5, 2025, at 3:43 PM, with the RN 1 and RN 2, the facility's P&P titled, "Administration of Medications," dated October 2024, was reviewed. The P&P indicated, "16. Document the administered dose on the MAR after given." RN 1 and RN 2 acknowledged the policy.

During an interview on August 7, 2025, at 2:15 PM, with the Nurse Manager (NM), the NM stated the Pharmacy Department is not compounding medications right now. The NM stated the expectation is for nursing staff to scan medications real-time and not pre-scan medications.

4. During a review of Patient 6's "H&P", dated July 28, 2025, was reviewed. The H&P indicated Patient 29 was admitted to the facility on July 27, 2025, with diagnoses of right foot osteomyelitis, bacteremia, diabetes, and hypertension.

During an interview on August 7, 2025, at 9:42 AM, with the DOP, the DOP stated even if there was a computer glitch on the type of medication order entered, the medication order due should still show up on the Medication Administration Record (MAR).

During a concurrent interview and record review on August 7, 2025, at 12:16 PM, with the Regional Director of Quality, Risk, and Compliance (RDQ), Patient 6's medical record was reviewed. The physician's order indicated a medication order dated August 4, 2025, for pantoprazole (drug to reduce the amount of acid the body produces) 40 mg by mouth daily. The MAR indicated the pantoprazole was first administered on August 4, 2025, at 8:43 AM. The second time the pantoprazole was administered was on August 6, 2025, at 5:38 AM. The RDQ acknowledged the pantoprazole daily dose was not documented as administered on August 5, 2025. The RDQ stated the medication dose was missed due to the way the nurse entered the pantoprazole medication order.

During an interview on August 7, 2025, at 2:15 PM, with the NM, the NM stated the expectation was for nursing staff to read all the "flags" when entering medication orders.

During a concurrent interview and record review on August 7, 2025, at 2:20 PM, with Licensed Vocational Nurse 1 (LVN 1), Patient 6's medical record was reviewed. LVN 1 stated she entered the medication order for pantoprazole 40 mg by mouth daily.

During a review of the facility's P&P titled, "Administration of Medications," dated October 2024, was reviewed. The P&P indicated, "PROCEDURE ...3. Follow the 7 "R's [rights of medication administration]" ...7. Double check the medication(s) to be administered with the MAR for accuracy."

Based on interview and record review, the facility failed to provide patient safety for medication use for one of 35 sampled patients (Patient 4) when potassium level in the blood monitoring did not occur in accordance with the drug manufacturer's prescribing information (PI - document on how to safely use medications) regarding drug-drug interactions (reactions between multiple drugs which makes drugs less effective, cause unexpected side effects, or increase the action of a particular drugs which may affect safety or efficacy) for lisinopril (blood pressure medication) and potassium chloride supplement.

This failure had the potential for the patient to experience increased risk of high potassium levels (can cause heart problems requiring immediate medical attention) due to drug-drug interactions and/or adverse clinical outcomes.

Findings:

During a review of Patient 4's "History and Physical" (H&P - a comprehensive patient assessment), dated July 27, 2025, the H&P indicated Patient 4 was admitted to the facility on July 26, 2025, with diagnoses of debility (physical weakness, especially due to illness), generalized weakness, and right humeral (upper arm) fracture (broken bone). The H&P indicated medications prior to admission were acetaminophen (for mild pain), Norco (combination pain medication with acetaminophen and hydrocodone), and levofloxacin (antibiotic).

During a review of Patient 4's "Basic Metabolic Panel [blood test]" dated July 27, 2025, it indicated a potassium level of 4.4 millimoles per liter (mmol/L - unit of measurement with normal range 3.5 to 5 mmol/L).

During a review of Patient 4's "physician's order" indicated a medication order dated August 1, 2025, for potassium chloride packet 20 milliequivalents (mEq - a unit of measurement for dose) daily. The medical record indicated the patient was given potassium chloride 20 mEq on August 2, 2025, August 3, 2025, August 4, 2025, and August 5, 2025.

During a review of Patient 4's medical record, the physician's order indicated a medication order dated August 1, 2025, for lisinopril (blood pressure medication) 30 milligrams (mg - a unit of measurement for dose) daily. The medical record indicated the patient was given lisinopril 30 mg on August 2, 2025, August 3, 2025, August 4, 2025, and August 5, 2025.

During a concurrent interview and record review on August 5, 2025, at 10:55 AM, with the Director of Pharmacy (DOP), Patient 4's medical was reviewed. The DOP stated there was no potassium monitoring since July 27, 2025.

During a concurrent interview and record review on August 7, 2025, at 10:04 AM, with the DOP, the prescribing information (PI) for potassium chloride packets, provided by the hospital, was reviewed with the DOP. The PI indicated "DRUG INTERACTIONS ...Renin-angiotensin-aldosterone inhibitors [class of drugs including lisinopril]: Monitor for hyperkalemia [high potassium levels] ..."7 DRUG INTERACTIONS ...7.2 Renin-Angiotensin-Aldosterone System Inhibitors. Drugs that inhibit the renin-angiotensin-aldosterone system (RAAS) including angiotensin converting enzyme (ACE) inhibitors [class of drugs including lisinopril] ...Closely monitor potassium in patients receiving concomitant [at the same time] RAAS therapy."
The DOP further stated there was no policy on monitoring.

During a telephone interview on August 7, 2025, at 2:57 PM, with the DOP, the DOP stated the medications documented prior to admission were acetaminophen, Norco, and levofloxacin. The DOP acknowledged that there was no documentation of potassium chloride and lisinopril being administered prior to admission.

During a review of the facility's policy and procedure (P&P) titled, "Policy Creation, Review and Revision," dated January 2025, "3. Develop policies using recommendations and practice guidelines set forth by any of the following: a. State or federal law, rules or regulations ...c. Professional organizations; d. Industry best practices; e. Evidence-based medicine."

During a review of the facility's P&P titled, "Clarification of Medication Orders," dated October 2024, "II. Interpretation - a Pharmacist must review all medication orders for the following ...5. Real or potential interactions between the prescribed medication and other medications."

Based on observation, interview, and record review, the facility failed to ensure one of one medication (Mycamine (brand name antifungal medication to treat fungal infections), available for patient use, requiring protection from light was stored in accordance with manufacturer's stipulations (requirements).

This failure had the potential to result in a patient receiving unusable, ineffective, or deteriorated (reduced quality) medication due to preventable light exposure for a universe of 51 patients.

Findings:

During a review of the Prescribing Information (PI - document on how to safely use medications) for Mycamine (brand name antifungal medication to treat fungal infections), dated December 2024, the PI document indicated "Storage ...Protect from light."

During a concurrent observation and interview on August 4, 2025, at 9:01 AM, with Staff Pharmacist 1 (RPH 1), an inspection of the pharmacy was conducted. One single-dose vial of Mycamine 100 milligrams (a unit of measurement for dose) for injection (into the patient's vein) with the product labeling on the vial "Protect from light" observed stored on open shelving under overhead lighting outside of the medication carton. RPH 1 acknowledged the Mycamine product labeling on the loose vial indicated to protect from light and the medication was stored outside of the medication carton under overhead lighting without protection from light.

During a concurrent interview and record review on August 7, 2025, at 10:00 AM, with the Director of Pharmacy (DOP), the facility's policy and procedures (P&P) titled, "Storage of Medications," dated December 2024, was reviewed. The P&P indicated "Medications must be stored under proper conditions of ...light ...as determined ...manufacturer's labeling, as well as in compliance with applicable federal and state laws/regulations." The DOP acknowledged the policy.

Based on observation, interview, and record review, the facility failed to effectively organize the food and dietetic services department when:

1. The kitchen was not in a sanitary condition, which is a repeated finding from a state re licensing survey the took place 2 months prior.

2. Ice was not readily available and easily accessible for staff to use on the tray line (a process where food is held on a steam table and on ice while staff serve each patient's meal) because the ice machine had been broken since April 2025.

This lack of effective organization had the potential to cause food borne illness to 51 medically compromised patients who received food from the kitchen which may contribute prolonged hospitalization.

Findings:

1. During an observation in the kitchen and concurrent interview with the Dietary Supervisor (DS) on August 4, 2025, at 8:48 am, the outside of the steamer had food splash and grease build-up, there was a shelf storing oils and bulk seasonings that was lined with paper and the paper was saturated with oil and crumbs. The floors under the cooking line (consisting of the stove, fryer and steamer) had a build-up of grease and old food. The DS stated they need one more staff person, they do not currently have enough staff to keep up with the deep cleaning.

During an observation in the kitchen on August 4, 2025, at 9:09 am, there was a metal table that held the rack to store the food domes (Keep meals insulated from kitchen to patient), that was covered in rust, in the dry storage room there was a liquid yellow colored spill on the bottom shelf on the right side when you walk in. There were multiple red bins on the shelves used to store dry goods that had food debris.

During a subsequent observation in the kitchen on August 4, 2025, at 9:17 am, the walk-in freezer floor had food under the shelves on the floor and in the back corners. There were also clear bins used to organize frozen food, and the bins had food debris.

During an interview on August 7th, 2025, at 3:10 pm, the DS stated that all the areas identified should be kept clean.

During a review of the facility policy titled "Food: Preparation", dated February 2023, it indicated "all foods are prepared in accordance with FDA [Food and Drug Administration] Food Code."

During a review of the FDA Food Code, dated 2022, 4-601.11 indicated "(C) Non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris." In addition, "The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted."

2. During an observation in the kitchen on August 4, 2025, at 11:34 am, there was a metal pan with ice and the salads were placed on top of the ice, but there was not enough room for all the salads, so some of the salads were just on the counter. Also, the drinks (soda,juice, water and milk), fruit cups and the turkey sandwiches were not on ice during tray line.

During an interview with Patient 18 in her room on August 4, 2025, at 4:00 pm, Patient 18 stated she does not like that the milk is served warm. The milk should be cold when served.

During a review of the facility policy titled "Food: Preparation", dated February 2023, indicated, "13. All foods will be held at appropriate temperatures, less than 41 degrees Fahrenheit (F- unit of measurement) for cold food holding.

During a review of the facility's email provided, dated April 18, 2025, indicated the Maintenance Supervisor (MS) emailed [company name] customer service to request a quote for a new ice machine. [Company name] responded with a quote on April 22, 2025.

Based on observation, interview, and record review, the facility failed to effectively supervise the nutritional aspects of patient care and perform and document nutrition assessments as per the facility's policy and procedure (P&P) when there was not a Registered Dietitian (RD 1 and RD 2) available on site at necessary times (RD 1 worked completely remote and RD 2 worked 6-8 hours per month at the facility) to accurately assess and monitor patients' nutritional status when :

1. The facility was late on follow-up nutritional assessments for four of 35 sampled patients (Patient 25, 24, 21, and 3) when a patient is labeled, High Nutrition Risk the patient should be seen no less than every 7 days, Moderate Nutrition Risk is no less than every 14 days and low nutrition risk reassessed with changes in condition.

2. Six of 35 sampled patients (Patient 3, 11, 5, 20, 21, and 23) did not receive a comprehensive nutritional assessment that included a patient, family or representative interview.

3. Facility did not include nutrition interventions on the Plan of Care (an individualized plan for the medical care of a patient) for three of 35 sampled patients (Patient 23, 3, 21).

These failures had the potential to cause poor nutrition status for eight of 35 medically compromised sampled patients (Patient 3,5, 11, 20, 21, 23, 24, and 25).

Findings:
1. During a review for Patient 25, document titled "Adult Nutritional Assessment", dated July 23, 2025, indicated, "Nutritional Risk Assessment, Nutritional Risk Level: High."

During a medical record review for Patient 25, document titled, "Dietitian Follow-up", dated August 4, 2025, by RD 1 was completed 12 days after the initial Nutritional Assessment. "Pt [patient] has a height of 5'0", BMI (Body Max Index) of 17.4 (underweight), actual body weight of 40.5 kg [kilogram]. Pt has had an average meal intake of 41% for the past three days. Pt is not likely meeting a majority of estimated needs. There is also no documentation of [brand name] supplement intake. Also concerning that pt's (patients) weight has down trended. Pt (patient) was weighing 41.1 kg on July 24, 2025 ... Pt remains a high-risk acuity, due to poor appetite underweight."

During a medical record review for Patient 21 and concurrent interview with the Regional Director of Quality, Risk and Compliance (RDQ), on August 7, 2025, 11:45 am, document titled "Adult Nutritional Assessment", dated July 18, 2025, indicated, "Nutritional Risk Assessment, Nutritional Risk Level: Moderate." Follow-up due on August 1, 2025. RDQ stated there was no nutrition Follow-up in the medical record.

During a medical record review for Patient 24, document titled "Adult Nutritional Assessment", dated July 25, 2025, indicated, "Nutritional Risk Assessment, Nutritional Risk Level: High."

During a medical record review for Patient 24, document titled, "Dietitian Follow-up", dated August 4, 2025, by RD 1 completed 10 days after the initial Nutritional Assessment.

During a medical record review for Patient 3, document titled "Adult Nutritional Assessment", dated July 26, 2025, indicated, "Nutritional Risk Assessment, Nutritional Risk Level: High."

During a medical record review for Patient 3, document titled, "Dietitian Follow-up", dated August 4, 2025, by RD 1 completed 9 days after the initial Nutritional Assessment.

During an interview with the Registered Dietitian 1 (RD 1) on August 6, at 4:37 pm, he stated he has limited time to do work for the facility because he has another full-time job, he prioritized the initial assessments over the follow-ups. RD 1 stated it was hard to meet the dates for follow-ups because of his full-time schedule at another facility. He stated there needs to be major changes to the nutrition care system to provide the best care for patients, they need to have a full-time registered dietitian on-site to be able to facilitate those changes.

During an interview with the Registered Dietitian 2, (RD 2) on August 6,2025, at 5:15 pm, RD 2 stated she worked at the facility 6-8 hours per month. RD 2 stated that all nutrition assessments and follow-up assessments should be done on time.

During a review of the facility's policy and procedure (P&P), titled "Nutrition Care Process- Nutrition Assessment", dated August 2024, the P&P indicated "3. Nutrition risk level-assigned by the dietitian during the assessment and reassessment process (a) guides the frequency of follow-up monitoring. Level: Low Risk- Monitor Reassess with changes in condition, Moderate Risk- Monitor no less than every 14 days, High Risk- Monitor no less than every 7 days.

2. During an interview with the Registered Dietitian 1 (RD 1) on August 6, 2025, at 4:37 pm, RD 1 stated he logs in to do nutrition assessments for the facility late at night, Saturdays and Sundays are the best days for him and he usually starts working at 7:00 pm or 8:0 0pm, and sometimes until 1:00 am. RD 1 stated it's about 50% hit or miss if he can reach either the patient by phone or a nurse to get more information on the patient for the patient assessments since he works completely remotely. RD 1 further stated the patients usually don't answer the phone.

During an interview with the Registered Dietitian (RD 2) on August 6, 2025, at 5:10 pm, RD 2 stated nutrition assessments always include a review of the patient chart and interview with the patient. RD 2 comes up with a plan of care and makes sure the patient agrees with the plan.

During a subsequent interview with RD 1 on August 7, 2025,at 4:28 pm, RD 1 stated if he works late at night then obviously, he does not speak to the patients and the night nurses do not know as much about the patients as the daytime nurses.

During an interview with the Medical Doctor (MD), on August 7, 2025, at 5:03 pm, MD stated he expects all his staff including RD to speak with the patients when doing an assessment.

During a medical record review of Patient 3, document titled "Dietitian Follow-up", dated August 4, 2025, at 11:00 pm, there was no indication in the note that the RD spoke with the patient, nurse or family member.

During a medical record review of Patient 11, document titled "Dietitian Follow-up", dated August 6, 2025, at 9:04 pm, no indication in the note that the RD spoke with the patient, nurse or family member.

During a medical record review of Patient 5, document titled "Adult Nutritional Assessment", dated August 5, 2025, at 8:30 pm, no indication in the note that the RD spoke with the patient, nurse or family member.

During a medical record review of Patient 20, document titled "Dietitian Follow-up", dated August 6, 2025, at 9:27 pm, no indication in the note that the RD spoke with the patient, nurse or family member.

During a medical record review of Patient 21, document titled "Adult Nutritional Assessment", dated July 18, 2025, at 10:46 pm, no indication in the note that the RD spoke with the patient, nurse or family member.

During a medical record review of Patient 23, document titled "Adult Nutritional Assessment", dated August 5, 2025, at 10:38 pm, no indication in the note that the RD spoke with the patient, nurse or family member.

During a review of the facility policy titled, "Patient Assessment/Reassessment", dated December 2024, indicated "Procedure: 1. Information may be obtained from the patient, a family member, or other service providers (registered nurse,medical doctors etc).

During a review of the facility policy, titled "Nutrition Care Process- Nutrition Assessment", dated August 2024, indicated "Nutritional Assessment: 1. It is the Registered Dietitians responsibility to complete a comprehensive nutritional assessment on all patients ..."

During a review of the standard of practice document from ASPEN (American Society for Parenteral and Enteral Nutrition) document titled "Clinical Guidelines: Nutrition Screening, Assessment, and Intervention in Adults", dated January 2011, indicated, "Nutrition assessment has been defined by A.S.P.E.N. as "a comprehensive approach to diagnosing nutrition problems that uses a combination of the following: medical, nutrition, and medication histories; physical examination; anthropometric measurements; and laboratory data. A nutrition assessment provides the basis for a nutrition intervention. Nutrition assessment performed by a nutrition support clinician is a rigorous process that includes obtaining diet and medical history, current clinical status, anthropometric data, laboratory data, physical assessment information, and often functional and economic information; estimating nutrient requirements; and, usually, selecting a treatment plan."

3. During an interview with the Registered Dietitian 1 (RD 1) on August 6, 2025, at 4:37 pm, RD 1 stated he has never completed a plan of care for a patient, and he does not participate in the Interdisciplinary Team (IDT-a group of healthcare professionals from various disciplines working together to coordinate patient care) Meetings for patients.

During a review of the Medical Record for Patient 3, document titled "Adult Nutritional Assessment", dated July 26, 2025, indicated "Nutritional Risk Assessment: Nutrition risk level- High. Nutrition diagnosis: inadequate oral intake related to acute illness as evidence by need for EN (enteral nutrition- the delivery of nutrients and fluids directly into the stomach or small intestine through a tube) via PEG Tube (percutaneous endoscopic gastrostomy tube, is a feeding tube placed through the abdominal wall directly into the stomach) to meet estimated needs. Comments: unable to perform a physical exam, however pt (patient) is TF (Tube Feed) dependent. Has a BMI (body mass index) of 21.8, may benefit from on site evaluation from RD (registered dietitian) when possible, to rule out protein calorie malnutrition.

During a review of the medical record for Patient 3, document titled, "Plan of Care", dated July 25, 2025- July 29, 2025, indicated there was no nutrition interventions included in the plan of care.

During a review of the Medical Record for Patient 21, document titled "Adult Nutritional Assessment", dated July 18, 2025, indicated "Nutritional Risk Assessment: Nutrition risk level- Moderate"

During a review of the medical record for Patient 21, document titled, "Plan of Care", dated July 17 - 21, 2025, indicated there were no nutrition interventions included in the plan of care.

During a review of the Medical Record for Patient 23, document titled "Adult Nutritional Assessment", dated August 4, 2025, indicated "Nutrition risk level- High, Nutrition Diagnosis: inadequate energy intake related to sub-optimal oral intake AEB (as evidenced by) pt (patient) consumed 41% average meal intake of meals, likely not meeting estimated needs."

During a review of the medical record for Patient 23, document titled, "Plan of Care", dated August 2-6, 2025, indicated there was no nutrition interventions included in the plan of care.

During a review of the policy titled "Care Planning", dated December 2024, the P&P indicated, "care, treatment and services are planned to ensure that they are individualized to the patients' needs. The Hospital staff shall provide an individualized, interdisciplinary (a group of professionals from different fields who collaborate to provide comprehensive patient care) plan of care for all patients. 3. Care planning will be implemented through the integration of assessment findings. 5. The plan of care is maintained and updated based upon ongoing patient assessments and the patient's response to care, treatment and services."