Baypointe Behavioral Health

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 41623 Based on observations and interviews with staff during a tour of the hospital by Life Safety Code surveyors, it was determined the hospital was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served by this hospital. Findings include: Refer to tags: A0724, K0211, K0351, K0352, K0353, K0363, K0372, K0791, and K0918.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 46290 Based on observations, hospital policy, and interviews, it was determined the hospital failed to ensure it was free of potential safety hazards. This deficient practice had the potential to negatively affect all patients admitted to this hospital. Findings include: Hospital Policy: Health and Safety (Environment of Care) Hospital Policy Number: HS 1.0 Revision Date: 2/3/2025 Policy: ...maintain a Health and Safety (Environment of Care) Program encouraging proper attention toward injury and illness prevention... Procedure: ...1. Providing mechanical and physical safeguards to the maximum extent that is possible. 2. ...safety inspections to find and eliminate unsafe working conditions... 1. A tour of the 500-hall unit was conducted on 1/13/26 at 10:20 AM with Employee Identifier (EI) # 8, Assistant Director. One lightweight brown chair was observed in the day room. The chair was not secured to the floor or wall in a manner that would prevent it from being used to harm self or others. An interview was conducted during the tour with EI # 8, who confirmed the lightweight brown chair could be used to harm self or others and the staff failed to ensure the hospital was free of potential safety hazards for patients and staff.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 49603 Based on observations, dietary procedures, and interview, it was determined the dietary director failed to ensure staff followed the procedure for washing dishes in the three-compartment sink. This had the potential to affect all patients admitted to this hospital. Findings include: Policy: Not provided Procedure: How To Clean and Sanitize in a Three-Compartment Sink ...3. Rinse items in the second sink. Spray with water or dip them into it. Remove all traces of food and detergent ... During observations on 1/15/26, Employee Identifier (EI) # 5, Cook, was observed using the three-compartment sink. The second sink was not used. The surveyor asked why the second sink was not being used. EI # 5 explained that for a couple of months it had not been draining and would back up into the floor, and was told not to use the sink. EI # 5 also stated maintenance had worked on the sink, but it was still not fixed. The surveyor requested to see a work order for the sink, none was provided. On 1/15/26 at 12:06 PM, an interview was conducted with EI # 7, Dietary General Manager, who confirmed staff failed to follow the procedure for washing dishes in the three-compartment sink.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 46290 Based on observations, review of hospital policies, and interviews, the hospital failed to ensure: 1. The patient rooms were clean. 2. The furniture and fixtures were maintained. 3. The dietary department was maintained in a clean and sanitary manner. 4. Patient supplies were not expired. This had the potential to affect all patients served at this hospital. Findings include: Hospital Policy: Health and Safety (Environment of Care) Hospital Policy Number: HS 1.0 Revision Date: 2/3/2025 Policy: ...maintain a Health and Safety (Environment of Care) Program encouraging proper attention toward injury and illness prevention... Procedure: ...1. Providing mechanical and physical safeguards to the maximum extent that is possible. 2. ...safety inspections to find and eliminate unsafe working conditions... Hospital Policy: Disposition of Unused Medications Hospital Policy Number: MM1.5 Revision Date: 2/25/25 Policy: To ensure the safety of patients, staff and others a proper means for disposal of damaged, expired, unused and discontinued medications is necessary. Procedure: ...2. Upon removal of unused and/or expired medications, staff will document the medication destruction... 1. During observations of the patient areas with Employee Identifier (EI) # 8, Assistant Director on 1/13/26 at 10:20 AM, the surveyors identified the following areas of concern: a. Missing paint areas to the walls were observed in patient rooms 503 and 510. Review of the Environment of Care Inspection dated 9/18/2025 and 11/13/2025 revealed documentation of peeling paint and needs painting to room 503. b. Small clear plastic wrappers were observed on the floor in patient rooms 508 and 510. c. Cracked dry wall behind the entry door was observed in patient room 508. An interview was conducted during the tour with EI # 8, who confirmed there was missing paint to the walls, small clear plactic wrappers on the floors, cracked drywall in the patients rooms and the staff failed to provide a safe and clean healthy environment. 41623 2. A tour of the Adult Unit, Rooms 405 through 422, was conducted on 1/13/26 at 10:45 AM with EI # 1, Administrator. In room 422, Lab Procedure room, the surveyor observed the following expired supplies: a. Four red top vacutainer tubes with an expiration date of 12/31/25. b. Two purple top vacutainer tubes with an expiration date of 5/1/25. c. Forty (40) tiger top vacutainer tubes with an expiration date of 9/1/25. d. Thirty (30) gray top vacutainer tubes with an expiration date of 11/30/25. An interview was conducted on 1/13/26 at 11:15 AM with EI # 1, who confirmed the lab testing supplies were expired and available for patient use. 49603 3. A tour of the medication room at the nurse’s station was conducted on 1/13/26 at 10:19 AM with EI # 3, Director of Nursing (DON). The surveyor observed the following expired supplies: a. Three Xeroform Occlusive Gauze Strips with an expiration date of 4/30/25. b. Two Pedi-padz II with an expiration date of 12/2/25. An interview was conducted on 1/13/26 at 11:15 AM with EI # 3, who confirmed the supplies were expired and available for patient use. 50417 4. A tour of the Female Adolescent Unit, Rooms 605 through 608 was conducted on 1/13/26 at 10:19 AM with EI # 3, the following was observed: Room 608 - Patient Room, was observed to have a missing soap dispenser near the bathroom sink with three metal screws visible. Room 609 - Patient Room, was observed to have loose trim on the bottom bathroom wall and a hole in the same wall. Room 615 - Patient Room, was observed to have an approximate 1-inch gap between the metal paper towel dispenser and bathroom wall. An interview was conducted during the tour with EI # 3 who confirmed each observation above.”

“. K3 Building: 0101 K6 Plan Approval: 2004 K7 Survey Under: 2012 Existing K8 HOSP Generator: One Diesel 350 kW SDMO (installed 2006 with remote manual stop station) FACP: EST 2 (Installed 2004) Locking Devices: Full time Smoke Detection: Complete Bed: 74 Census: 31 Type of Structure: 2004 One story protected noncombustible, Type II(111). The facility has a complete automatic sprinkler system. There is no two hour fire rated barrier between the Residential Wing and the remaining part of hospital. During a routine recertification survey conducted on this date, the requirements of 42 CFR, Subpart 482.41, were not met as evidenced by the following deficiencies of the 2012 NFPA 101 Life Safety Code (LSC), the 2012 NFPA 99 Health Care Facilities Code and the standards referenced by these codes, as observed by the LS Surveyor while accompanied by the facility maintenance personnel. .”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 42853 . Based on observation, the facility failed to maintain the means of egress per the requirements of: 2012 NFPA 101, 19.2.1, 7.1.6.2, 7.1.6.3(1), and 7.1.10.1 This deficiency affects only the South West sidewalk (means of egress). Findings include: During a tour of the facility, the surveyors observed a 3” change in elevation (due to tree roots) of the sidewalk (means of egress) from South West exit door of the Residential Wing. A member of the maintenance staff was present when this deficiency was identified. .”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet per the requirements of: 2012 NFPA 101, 19.3.5.1, 9.7.1.1, and 9.7.7 2010 NFPA 13, 6.2.9.7, and 6.2.9.7.1 This deficiency affects the complete sprinkler system. Findings include: During a tour of the facility, the surveyor observed the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet. The list shall include the following: 1. Sprinkler identification number; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating 2. General description 3. Quantity of each type to be contained in the cabinet 4. Issue or revision date of the list A member of the maintenance staff was present when this deficiency was identified. .”

“Sprinkler System - Supervisory Signals CFR(s): NFPA 101 Sprinkler System - Supervisory Signals Automatic sprinkler system supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired. 9.7.2.1, NFPA 72 This Standard is not met as evidenced by: 42853 . Based on observation, the facility failed to provide a NFPA approved tamper switch (electronic supervisory signal) for the automatic sprinkler system valve per the requirements of: 2012 NFPA 101, 19.3.5.1, and 9.7.2.1 2010 NFPA 72, 10.16.2 This deficiency affects the whole sprinkler system. Findings include: During a tour of the facility, the facility failed to install electronic supervising (tamper switch) for the two automatic sprinkler backflow preventer valves. A member of the maintenance staff and the administrator were present when this deficiency was identified. .”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 42853 . Based on observation and review of documentation, the facility failed to maintain the automatic sprinklers per requirements of: 2012 NFPA 101, 19.3.5.1, 9.7.5 and 9.7.8 2011 NFPA 25, 5.3.1.1.1.6, 5.3.1.1.1.3, 7.2.1,Table 7.1.1.2,7.4.2.1 and 14.2.1 This deficiency affects entire facility. Findings include: During a tour of the facility, the facility failed to provide the following: 1. The dry sprinklers installed in 1984, located on the loading dock and in the old walk-in cooler and walk-in freeze had been replaced within 10 years of installation. 2. The 2003 fast-response sprinkler heads found throughout facility had been replaced or a representative sample tested within 20 years of installation. 3. The following documentation for the two private fire hydrants: a. The yearly inspection and maintenance conducted within the past 12 months. b. The five year flow test conducted within the past 5 years. 4. The documentation of conducting the automatic sprinkler internal pipe inspection within the past 5 years. A member of the maintenance staff and the administrator were present when this deficiency was identified. .”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain corridor doors per the requirements of: 2012 NFPA 101, 19.3.6.3.13 (1) (2), and 19.3.6.3.2 (2) This deficiency affects 3 corridor doors. Findings include: During a tour of the facility, the surveyor observed the following: 1. Two Nurses’ Station corridor doors (in Smoke Compartment 1),were “Dutch” style doors with the following: a. The upper leaves were not equipped with latching devices b. The meeting edges of the upper and lower leaves were not equipped with an astragal, a rabbet, or a bevel 2. Room 720 corridor door had a 5/8” diameter unsealed hole (through penetration) located above the door handle A member of the maintenance staff was present when this deficiency was identified. .”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of: 2012 NFPA 101, 19.3.7.3, 8.5.1, 8.5.6.2, and 8.5.6.3 This deficiency affects 1 of 7 smoke barriers. Findings include: During a tour of the facility, the surveyor observed a 1” x 2” unsealed opening (located above a 2” conduit used as a chase) above the ceiling, over the cross-corridor doors of the smoke barrier between the Pharmacy and the Records Room. A member of the maintenance staff was present when this deficiency was identified. .”

“Construction, Repair, and Improvement Operati CFR(s): NFPA 101 Construction, Repair, and Improvement Operations Construction, repair, and improvement operations shall comply with 4.6.10. Any means of egress in any area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency and compliance with NFPA 241. 18.7.9, 19.7.9, 4.6.10, 7.1.10.1 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to provide documentation of daily inspections of areas undergoing construction per the requirements of: 2012 NFPA 101, 19.7.9.2, and 7.1.10.1 2009 NFPA 241 This deficiency affects 3 exits. Findings include: During a tour of the facility, the facility failed to provide documentation of daily inspections of the following areas of exit egress undergoing construction to ensure their ability to be used instantly in case of emergency: 1. The Southeast and Northwest Exits of Smoke Compartment 3 2. The new temporary South Exit from Smoke Compartment 2 A member of the maintenance staff was present when this deficiency was identified. .”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 41792 . Based on review of documentation, the facility failed to maintain the testing of the emergency generator per the requirements of: 2012 NFPA 99, 6.5.4.1.1.2, 6.5.4.1.3, 6.5.4.2, 6.4.4.1.1.3, and 6.4.4.1.3 2010 NFPA 110, 8.3.7.1 This deficiency affects the only generator. Findings include: During a tour of the facility, the facility failed to provide documentation of monthly testing and recording of the generator battery(s) electrolyte specific gravity OR conductance for the past 12 months. A member of the maintenance staff was present when this deficiency was identified. .”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 40119 Based on review of Medical Records (MR), hospital policies and procedures, hospital complaint current summary report, and interview with facility staff, it was determined the hospital failed to ensure: 1. Complaint allegations of abuse were investigated. 2. Ensure PRN (as needed) medication was administered to reduce agitation and promote stabilization of the patient and not administered for past behavior. 3. A physician’s order for the use of restraints was obtained within one hour per the hospital policy. 4. Physician orders for the duration of the restraint was limited for the age of the child. 5. Justification for continued use of the seclusion was documented and seclusion was discontinued at earliest possible time. 6. A face-to-face evaluation for the use of restraints or seclusion was documented within one hour. 7. A description of the patient’s behavior which required a restraint was documented. This did affect Unsampled Patient (UP ) # 2, one of five complaints reviewed, Patient Identifier (PI) # 5, PI # 1, PI # 8, and PI # 4, four of eight MRs reviewed, and had the potential to negatively affect all patients admitted to the hospital. Findings include: Refer to A 119, A 160, A 168, A 171, A 174, A 178, and A 185 for findings.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 40119 Based on observations, review of the hospital 2024 safety management plan, Hospital Maintenance Environmental Rounds 15, 2012 Edition NFPA (National Fire Protection Association) 101 Life Safety Code, and staff interviews, it was determined the hospital failed to: 1. Maintain a clean, sanitary, and safe environment. 2. Ensure exit (egress) doors were in working order. 3. Ensure exit doors were locked with no more than one lock. This did affect Unsampled Patient (UP) # 1, one of three patients interviewed, and had the potential to affect all patients served by this hospital. Findings include: Refer to A 701 for findings.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 40119 Based on review of hospital policies and procedures, hospital complaint current summary report, and interview with facility staff, it was determined the hospital failed to investigate a caregiver allegation of abuse. This did affect Unsampled Patient (UP ) # 2, one of five complaints reviewed and had the potential to negatively affect all patients admitted to the hospital. Findings include: Hospital Policy: Complaint and Grievance Procedure Policy Number: RI 1.13 Revised Date: 1/23 Policy: Any patient/individual or legal representative of the patient/individual has the right to file a formal complaint/grievance as a notice of dissatisfaction... Procedure: ...shall have in effect the Patient Relations Department and the standing Performance Improvement Sub-Committee of Patient Relations for the purpose of handling patient/individual complaints/grievances. ...Step II A. Upon receipt of the patient/individual’s complaint/grievance and related documentation, at the next scheduled meeting, the Patient Relations Sub-Committee shall review the complaint...gather additional information as may be needed for investigating and responding to the complaint. The committee shall respond to the patient/individual within ten (10) working days of receipt of the complaint... Step III A. Upon receipt of the patient/individual complaint/grievance and related documentation, the CEO (Chief Executive Officer) shall review the complaint...shall gather additional information as may be needed for investigating and responding to the complaint. The CEO shall respond to the patient/individual within thirty (30) days of receipt of the compliant... Urgent and Emergent Complaints/Grievances. A. Patient/individual complaints/grievances which reveal immediate concerns regarding the physical or emotional health, safety, and well-being of the patient/individual shall prompt additional, more immediate actions... Hospital Policy: Patient Protection Policy Number: RI 1.1 Revised Date: 9/26/22 Policy: ...rights safeguard and protect the patient while assuring quality care, treatment, and rehabilitation services... Procedure: ...41. Without regard to competency or legal restrictions, all patients shall receive treatment and care in an environment which is safe, humane, and free from physical, verbal, or sexual abuse, neglect, exploitation, or mistreatment... a. Each program actively investigates and maintains investigation documentation for any suspected abuse and/or neglect of patients. 1. Review of the complaint Current Summary report dated 12/8/23 revealed UP # 2’s parent reported the patient “...received a knot to back of forehead due to be drugged by staff down the hallway...” on 12/7/23. Review of the complaint Current Summary report resolution and outcomes dated 12/20/23 revealed the consumer needs specialist documented the patient was discharged AMA (against medical advice) on 12/6/23 and the parent reported the patient claimed that staff dragged the patient from the bed in a sports bra which resulted in a knot on the patient’s head. The parent also verbalized the plan to take the patient for medical attention due to the knot. The consumer needs specialist documented the patient told the physician on 12/4/23 she/he fell and hit head on the bathroom sink. The consumer needs specialist documented no further action was necessary. Further review of the complaint Current Summary report revealed no documentation a complete investigation was conducted for the allegation of abuse. An interview was conducted on 8/16/24 at 8:22 AM with Employee Identifier (EI) # 1, Hospital Administrator, who verbalized it was determined since the patient was discharged on 12/6/23 and the parent didn’t have a specific date of the incident there wasn’t enough information to investigate the complaint further. EI # 1 also verbalized video footage was available, since it is kept for 4 days, but the problem would be not having a specific date and timeframe to review the footage. EI # 1 verbalized if the parent could have provided a specific timeframe the complaint should have been investigated.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 40119 Based on review of Medical Records (MR), hospital policy and staff interview, it was determined the staff failed to ensure PRN (as needed) medication was administered to reduce agitation and promote stabilization of the patient and not administered for past behavior. This deficient practice did affect one of four MRs reviewed with seclusion, including Patient Identifier (PI) # 5. This deficient practice had the potential to affect all patients served by the facility. Findings Include: Hospital Policy: Use of Seclusion and Restraint Policy Number: CTS 4.2 Revised Date: 9/21 Policy: ...When seclusion, restraint, and protective holds are used, the interventions protect the health and safety of the patients while preserving his or her dignity, rights, and well-being. ...Seclusion and/or restraint may be implemented only in an emergency as a safety measure for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff members, or others... Seclusion and restraint shall never be used to discipline a patient or for the convenience of the staff... Seclusion and restraint shall not be used as punishment, coercion, or retaliation. ...The use of medication to decrease agitation and promote stabilization.... do not use chemical restraints, however, use of psychopharmacology may be utilized to help reduce agitation and promote stabilization in patient. 1. PI # 5 was admitted to the hospital on 4/30/24 with diagnoses including Intermittent Explosive Disorder and Physical Abuse of a Child, Victim, Confirmed. Review of the Physician Orders dated 5/23/24 revealed an order for Haldol 5 mg (milligrams) every eight hours prn for severe aggression and Ativan 2 mg every 8 hours prn for severe aggression. Review of the Seclusion Restraint Placement note dated 7/17/24 revealed the patient was in seclusion from 1:15 PM to 2:15 PM due to “consumer began to spit on staff. Claimed, (he/she) didn’t feel safe with (the staff member). The staff mentioned was a new behavioral assistant that also quit this same day.” The criteria for releasing the patient were documented as “...calm and cooperative behavior with no signs of aggression or agitation...” Review of the Seclusion/Restraint Placement Form-Observations dated 7/17/24 revealed the patient was “resting/calm” from 1:45 PM to 2:15 PM and seclusion was discontinued at 2:15 PM. Further review of the Seclusion/Restraint Placement Form-Observations dated 7/17/24 revealed the patient was medicated at 2:15 PM, which was when the seclusion was discontinued, and the patient was “resting/calm”. There was no documentation of the medication the patient was administered. Review of the MR dated 7/17/24 from 2:15 PM to 2:20 PM revealed no documentation the patient started to display the aggression toward the staff and spitting on staff since the patient was documented as “resting/calm” at 2:15 PM while in seclusion. Review of the Administration History revealed Ativan 2 mg and Haldol 5 mg were administered on 7/17/24 at 2:20 PM for “aggression toward staff, spitting.” An interview was conducted on 8/16/24 at 10:56 AM with Employee Identifier (EI) # 1, Hospital Administrator, who confirmed there was no documentation of the reason the Ativan and Haldol medications were administered following the documentation of the patient “resting/calm”.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 40119 Based on review of Medical Records (MR), hospital policy and procedure and staff interview, it was determined the staff failed to obtain a physician’s order for the use of restraints within one hour per the hospital policy. This deficient practice did affect one of six MRs reviewed with a restraint, including Patient Identifier (PI) # 1. This deficient practice had the potential to affect all patients served by the facility. Findings Include: Hospital Policy: Use of Seclusion and Restraint Policy Number: CTS 4.2 Revised Date: 9/21 Policy: ...When seclusion, restraint, and protective holds are used, the interventions protect the health and safety of the patients while preserving his or her dignity, rights, and well-being. ...Seclusion and/or restraint may be implemented only in an emergency as a safety measure for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff members, or others. ...Procedure. ...D. Initiation and ordering of seclusion/restraint. 1. Seclusion/restraint may be initiated only by order of a licensed independent practitioner (LIP) who is primarily responsible for the individual’s care... or in an emergency when a LIP may not be immediately available, and other trained staff members, who are not LIPs, may initiate the use of restraint or seclusion before an order is obtained from the LIP. 2. A LIP is defined as an individual permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the individual’s license... such individuals include: MD (Medical Doctor), DO (Doctor of Osteopathic Medicine), Certified Nurse Practitioner, and a Physician Assistant. 3. As soon as possible, but no longer than 1 (one) hour after the initiation of restraint or seclusion in the absence of a LIP, Trained and qualified staff: ...notifies and obtains an order (verbal or written) from the LIP... 1. PI # 1 was admitted to the hospital on 3/20/24 with diagnoses including Oppositional Defiant Disorder and Adjustment Disorder with Mixed Disturbance of Emotions. Review of the Seclusion Restraint Placement note dated 5/19/24 revealed the patient was in a restraint from 6:00 PM to 6:03 PM by a nurse. Review of the Physician Order dated 5/19/24 at 8:30 PM revealed an order for a restraint from 6:00 PM to 7:00 PM. The restraint order was received two hours and 30 minutes following the initiation of the restraint. An interview was conducted on 8/16/24 at 10:41 AM with Employee Identifier (EI) # 3, Assistant Director, who confirmed the staff failed to obtain a physician’s order for the use of restraints within one hour per the hospital policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 40119 Based on review of medical records (MR), hospital policy and procedure, and interviews with staff, it was determined the hospital failed to ensure the orders for the duration of the restraint was limited for the age of the child. This deficient practice affected one of six MRs reviewed with restraints including Patient Identifier (PI) # 8 and had the potential to affect all children admitted to this hospital. Findings include: Hospital Policy: Use of Seclusion and Restraint Policy Number: CTS 4.2 Revised Date: 9/21 Policy: ...When seclusion, restraint, and protective holds are used, the interventions protect the health and safety of the patients while preserving his or her dignity, rights, and well-being. Procedure: ...D. Initiation and Ordering of Seclusion/Restraint. ...5. Order for initial and continuing use of restraint and seclusion have the following characteristics: Are limited to 1 (one) hour for children and adolescents... 1. PI # 8 was admitted on 3/13/24 with diagnoses including Disruptive Mood Dysregulation Disorder and Attention Deficit Hyperactivity Disorder. Review of the Consumer Admission Fact Sheet dated 3/13/24 revealed PI # 8’s date of birth was 9/14/24, 11 years old. Review of the Physician’s order dated 5/20/24 revealed orders for Restraint - Adult start time at 7:12 PM and stop time at 11:11 PM. Review of the Seclusion Restraint Placement documentation dated 5/20/24 revealed PI # 8 was placed in restraints at 7:12 PM and released at 7:22 PM. An interview was conducted on 8/16/24 at 9:38 AM with Employee Identifier # 4, Compliance Director, who confirmed the order had been written for restraints for four hours and should have been for only one hour per policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 40119 Based on Medical Record (MR) review, hospital policy and procedure and staff interview, it was determined the staff failed to ensure justification for the continued use of the seclusion was documented and seclusion was discontinued at earliest possible time. This deficient practice did affect two of four MRs reviewed with seclusion, including Patient Identifier (PI) # 5 and PI # 1. This deficient practice had the potential to affect all patients served by the hospital who require the use of seclusion. Findings Include: Hospital Policy: Use of Seclusion and Restraint Policy Number: CTS 4.2 Revised Date: 9/21 Policy: ...When seclusion, restraint, and protective holds are used, the interventions protect the health and safety of the patients while preserving his or her dignity, rights, and well-being. ...Seclusion and/or restraint may be implemented only in an emergency as a safety measure for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff members, or others. ...Procedure. ...E. Termination and expiration of order for seclusion (and) restraint. 1. Every effort will be made to terminate seclusion/restraint at the earliest time it is safe to do so... ...I. Monitoring and documentation of patients in seclusion/restraint. ...Continuous monitoring and assessment of the patient’s status at the initiation of restraint or seclusion every 15 minutes thereafter to include: ...Readiness for discontinuation of seclusion/restraint. ...J. Discontinuation of seclusion/restraint. When the criteria for release are met the patient must be released. 1. PI # 5 was admitted to the hospital on 4/30/24 with diagnoses including Intermittent Explosive Disorder and Physical Abuse of a Child, Victim, Confirmed. Review of the Seclusion Restraint Placement note dated 6/11/24 revealed the patient was in seclusion from 10:04 AM to 11:03 AM for spitting on the staff. The behavioral criteria for releasing the patient from seclusion was “...calm and cooperative.” Review of the Seclusion/Restraint Placement Form-Observations dated 6/11/24 revealed the patient was “resting/calm” from 10:45 AM to 11:00 AM. There was no documentation of the justification for continued use of the seclusion. The staff failed to discontinue seclusion at earliest possible time. Review of the Seclusion Restraint Placement Form - Observation dated 7/10/24 revealed the patient was in seclusion from 3:09 PM to 4:08 PM. Further review of the Seclusion/Restraint Placement Form-Observations dated 7/10/24 revealed the patient was documented as “resting/calm” from 3:23 PM to 4:08 PM. There was no documentation of the justification for continued use of the seclusion. The staff failed to discontinue seclusion at earliest possible time. Review of the Seclusion Restraint Placement note dated 6/17/24 revealed the patient was in seclusion from 1:15 PM to 2:15 PM for spitting on the staff. The behavioral criteria for releasing the patient from seclusion was “...calm and cooperative behavior with no signs of aggression or agitation.” Review of the Seclusion/Restraint Placement Form-Observations dated 6/17/24 revealed the patient was “resting/calm” from 1:45 PM to 2:15 PM. There was no documentation of the justification for continued use of the seclusion. The staff failed to discontinue seclusion at earliest possible time. Review of the Seclusion Restraint Placement note dated 7/25/24 revealed the patient was in seclusion from 5:11 PM to 6:10 PM for spitting milk on the staff. The behavioral criteria for releasing the patient from seclusion was “redirectable.” Review of the Seclusion/Restraint Placement Form-Observations dated 7/25/24 revealed the patient was “resting/calm” from 5:56 PM to 6:11 PM. There was no documentation of the justification for continued use of the seclusion. The staff failed to discontinue seclusion at earliest possible time. Review of the Seclusion Restraint Placement note dated 7/26/24 revealed the patient was in seclusion from 10:55 AM to 11:54 AM for hitting and spitting on staff. The behavioral criteria for releasing the patient from seclusion was “...calm and cooperative and show no signs of assaultive behavior.” Review of the Seclusion/Restraint Placement Form-Observations dated 7/26/24 revealed the patient was “resting/calm” from 11:25 AM to 11:55 AM. There was no documentation of the justification for continued use of the seclusion. The staff failed to discontinue seclusion at earliest possible time. Review of the Seclusion Restraint Placement note dated 8/5/24 revealed the patient was in seclusion from 12:25 PM to 1:10 PM for spitting on the staff. The behavioral criteria for releasing the patient from seclusion was “when calm and cooperative.” Review of the Seclusion/Restraint Placement Form-Observations dated 8/5/24 revealed the patient was “resting/calm” from 12:40 PM to 1:10 PM. There was no documentation of the justification for continued use of the seclusion. The staff failed to discontinue seclusion at earliest possible time. An interview was conducted on 8/16/24 at 10:56 AM with Employee Identifier (EI) # 1, Hospital Administrator, who confirmed no documentation of the justification for continued use of the seclusion and the staff failed to discontinue seclusion at earliest possible time. 2. PI # 1 was admitted to the hospital on 3/20/24 with diagnoses including Oppositional Defiant Disorder and Adjustment Disorder with Mixed Disturbance of Emotions. Review of the Seclusion Restraint Placement note dated 5/14/24 revealed the patient was in seclusion from 9:00 AM to 9:59 AM for physical aggression and hitting another patient. The behavioral criteria for releasing the patient from seclusion was “when calm and cooperative.” Review of the Seclusion/Restraint Placement Form-Observations dated 5/14/24 revealed the patient was “resting/calm” from 9:15 AM to 9:59 AM. There was no documentation of the justification for continued use of the seclusion. The staff failed to discontinue seclusion at earliest possible time. Review of the Seclusion Restraint Placement note dated 5/14/24 revealed the patient was in seclusion from 10:20 AM to 11:19 AM for “extreme property destruction...aggression.” The behavioral criteria for releasing the patient from seclusion was “when calm and cooperative.” Review of the Seclusion/Restraint Placement Form-Observations dated 5/14/24 revealed the patient was “resting/calm” from 10:35 AM to 11:19 AM. There was no documentation of the justification for continued use of the seclusion. The staff failed to discontinue seclusion at earliest possible time. An interview was conducted on 8/16/24 at 10:41 AM with EI # 3, Assistant Director, who confirmed no documentation of the justification for continued use of the seclusion and the staff failed to discontinue seclusion at earliest possible time.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 40119 Based on Medical Record (MR) review, hospital policy and procedure and staff interview the staff failed to document a face-to-face evaluation for the use of restraints or seclusion within one hour. This deficient practice did affect two of six MRs reviewed with a restraint or seclusion, including Patient Identifier (PI) # 5 and PI # 4, and had the potential to affect all patients served by the hospital requiring the use of a restraint or seclusion. Findings Include: Hospital Policy: Use of Seclusion and Restraint Policy Number: CTS 4.2 Revised Date: 9/21 Policy: ...When seclusion, restraint, and protective holds are used, the interventions protect the health and safety of the patients while preserving his or her dignity, rights, and well-being. ...Procedure. ...F. In-person Face to Face Evaluation 1. The patient must receive an in-person face to face evaluation within 1 (one) hour of initiation of seclusion/restraint... 2. The evaluation must include: Documentation of the patient’s immediate situation. Documentation of the patient’s behavior. Appropriateness of the intervention measures. Complications resulting from the interventions. The reaction to the intervention. The patient’s medical (physical status) and behavioral condition/psychological condition... The need to continue or terminate the restraint or seclusion. The need for immediate changes to the patient’s course of care... 1. PI # 5 was admitted to the hospital on 4/30/24 with diagnoses including Intermittent Explosive Disorder and Physical Abuse of a Child, Victim, Confirmed. Review of the Seclusion Restraint Placement note dated 5/10/24 revealed the patient was in a restraint from 8:12 AM to 8:15 AM. Review of the Face-to-Face Evaluation dated 5/10/24 revealed the time of the evaluation as 9:30 AM, which was one hour and 18 minutes after the initiation of the restraint. Review of the Seclusion Restraint Placement note dated 5/16/24 revealed the patient was in seclusion from 1:21 PM to 2:21 PM. Review of the Face-to-Face Evaluation dated 5/16/24 revealed the time of the evaluation as 2:33 PM, which was one hour and 12 minutes after the initiation of the seclusion. Review of the Seclusion Restraint Placement note dated 5/21/24 revealed the patient was in seclusion from 8:33 AM to 9:19 AM. Review of the Face-to-Face Evaluation dated 5/21/24 revealed the time of the evaluation as 1:15 PM, which was four hours and 42 minutes after the initiation of the seclusion. Review of the Seclusion Restraint Placement note dated 6/7/24 revealed the patient was in seclusion from 3:12 PM to 4:11 PM. Review of the MR revealed no documentation of a Face-to-Face Evaluation from 6/7/24 to 6/16/24. Review of the Face-to-Face Evaluation dated 6/17/24 revealed the time of the evaluation as 12:14 PM, which was nine days, 21 hours and 2 minutes after the initiation of the seclusion. Review of the Seclusion Restraint Placement note dated 6/11/24 revealed the patient was in seclusion from 10:04 AM to 11:03 AM. Review of the Face-to-Face Evaluation dated 6/11/24 revealed the time of the evaluation as 6:35 PM, which was eight hours and 31 minutes after the initiation of the seclusion. Review of the Seclusion Restraint Placement Form - Observation dated 7/10/24 revealed the patient was in seclusion from 3:09 PM to 4:08 PM. Review of the Face-to-Face Evaluation dated 7/10/24 revealed the time of the evaluation as 4:32 PM, which was one hour and 23 minutes after the initiation of the seclusion. Review of the Seclusion Restraint Placement note dated 7/23/24 revealed the patient was in a restraint from 1:44 PM to 2:15 PM and seclusion from 1:49 PM to 2:49 PM. Review of the Face-to-Face Evaluation dated 7/23/24 revealed the time of the evaluation as 3:31 PM, which was one hour and 47 minutes after the initiation of the restraint and one hour and 52 minutes after the initiation of the seclusion. Review of the Seclusion Restraint Placement note dated 7/25/24 revealed the patient was in seclusion from 3:00 PM to 3:59 PM. Review of the Face-to-Face Evaluation dated 7/25/24 revealed the time of the evaluation as 7:08 PM, which was four hours and 8 minutes after the initiation of the seclusion. Review of the Seclusion Restraint Placement note dated 7/25/24 revealed the patient was in seclusion from 5:11 PM to 6:10 PM. Review of the Face-to-Face Evaluation dated 7/25/24 revealed the time of the evaluation as 8:03 PM, which was two hours and 57 minutes after the initiation of the seclusion. Review of the Seclusion Restraint Placement note dated 8/9/24 revealed the patient was in seclusion from 4:45 PM to 5:30 PM. Review of the Face-to-Face Evaluation dated 8/9/24 revealed the time of the evaluation as 6:41 PM, which was one hours and 56 minutes after the initiation of the seclusion. An interview was conducted on 8/16/24 at 10:56 AM with Employee Identifier (EI) # 1, Hospital Administrator, who confirmed the face-to-face evaluation was not conducted within one hour. 2. PI # 4 was admitted to the hospital on 2/22/24 with diagnoses including Oppositional Defiant Disorder and Attention Deficit Hyperactive Disorder, Combined Type. Review of the Seclusion Restraint Placement note dated 3/4/24 revealed the patient was in a restraint from 12:45 PM to 12:48 PM. Review of the Face-to-Face Evaluation dated 3/4/24 revealed the time of the evaluation as 2:00 PM, which was one hour and 15 minutes after the initiation of the restraint. An interview was conducted on 8/16/24 at 10:52 AM with EI # 3 who confirmed the face-to-face evaluation was not conducted within one hour.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(ii) [there must be documentation in the patient’s medical record of the following:] A description of the patient’s behavior and the intervention used. This Standard is not met as evidenced by: 40119 Based on Medical Record (MR) review, hospital policy and procedure and staff interview the facility staff failed to document a description of the patient’s behavior which required a restraint or seclusion. This deficient practice did affect two of six MRs reviewed with a restraints and seclusion, including Patient Identifier (PI) # 5 and PI # 1. This deficient practice had the potential to affect all patients served by the hospital requiring a restraint. Findings Include: Hospital Policy: Use of Seclusion and Restraint Policy Number: CTS 4.2 Revised Date: 9/21 Policy: ...When seclusion, restraint, and protective holds are used, the interventions protect the health and safety of the patients while preserving his or her dignity, rights, and well-being. ...Seclusion and/or restraint may be implemented only in an emergency as a safety measure for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff members, or others. ...Procedure. ...C. Protective Holds ...6. ...The following should be documented: ...Circumstances that led to the protective hold. ...I. Monitoring and documentation of patients in seclusion/restraint. ...3. Documentation must reflect the circumstances that led to use and clinical justification for use of seclusion/restraint... 4...The following should be documented: ...Circumstances that led to the seclusion and/or restraint... 1. PI # 5 was admitted to the hospital on 4/30/24 with diagnoses including Intermittent Explosive Disorder and Physical Abuse of a Child, Victim, Confirmed. Review of the Seclusion Restraint Placement note dated 5/21/24 revealed the patient was in seclusion from 8:33 AM to 9:19 AM for “assault on staff, imminent threat to others...physical aggression.” There was no documentation of a description of how the patient assaulted the staff, was an imminent threat to others, and the aggressive behavior which required the patient to be placed in seclusion. Review of the Seclusion Restraint Placement note dated 6/7/24 revealed the patient was in seclusion from 8:33 AM to 9:19 AM for “assault on staff, ...physical aggression.” There was no documentation of a description of how the patient assaulted the staff and the aggressive behavior which required the patient to be placed in seclusion. Review of the Seclusion Restraint Placement note dated 8/9/24 revealed the patient was in seclusion from 4:45 PM to 5:30 PM for “assault on staff, ...physical aggressin (aggression).” There was no documentation of a description of how the patient assaulted the staff and the aggressive behavior which required the patient to be placed in seclusion. An interview was conducted on 8/16/24 at 10:56 AM with Employee Identifier (EI) # 1, Hospital Administrator, who confirmed no documentation of a description of behavior which required the patient to be placed in seclusion. 2. PI # 1 was admitted to the hospital on 3/20/24 with diagnoses including Oppositional Defiant Disorder and Adjustment Disorder with Mixed Disturbance of Emotions. Review of the Seclusion Restraint Placement note dated 5/14/24 revealed a restraint was used from 10:12 AM to 10:19 AM and seclusion from 10:20 AM to 11:19 AM for “extreme property destruction...aggression.” There was no documentation of a description of the property damage and aggressive behavior which required the patient to be placed in a restraint. An interview was conducted on 8/16/24 at 10:41 AM with EI # 3, Assistant Director, who confirmed there was no documentation of a description of the property damage and aggressive behavior which required the patient to be placed in a restraint.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 40119 Based on review of medical records (MR), hospital policy and procedure and interviews with staff, it was determined the hospital failed to ensure nursing staff documented the reason for PRN (as needed) medication. This did affect four of eight inpatient MRs reviewed including Patient Identifier (PI) # 3, PI # 2, PI # 1, and PI # 5. This had the potential to negatively affect all patients requiring prn medication administration served by this facility. Findings include: Hospital Policy: Medication...Administration Policy Number: CTS 3.0 Revised Date: 9/22 ...Procedure: ...C. Medication Administration/Assistance. ...8...staff must document information related to a patient receiving a PRN...including: ...complaint... 1. PI # 3 was admitted to the hospital on 11/13/23 with diagnoses including Other Specified Disruptive, Impulse control, and Conduct Disorder and Other Conduct Disorders. Review of the Physician Orders dated 11/13/23 revealed an order for Benadryl 50 mg (milligrams) every six hours prn for “aggression/agitation.” Review of the Administration History revealed Benadryl 50 mg was administered on 11/18/23 at 4:47 PM. There was no documentation of the reason the Benadryl was administered. An interview was conducted on 8/16/24 at 10:54 AM with Employee Identifier (EI) # 3, Assistant Director, who confirmed there was no documentation of the reason the Benadryl was administered. 2. PI # 2 was admitted to the hospital on 5/2/24 with diagnoses including Other Specified Disruptive, Impulse control, and Conduct Disorder and Other Conduct Disorders. Review of the Physician Orders dated 5/3/23 revealed an order for Benadryl 25 mg every six hours prn for “aggression/agitation.” Review of the Administration History revealed Benadryl 25 mg was administered on 5/8/23 at 8:50 AM, 5/15/24 at 2:38 PM, 5/16/24 at 3:16 PM, and 5/18/24 at 11:52 AM. There was no documentation of the reason the Benadryl was administered. An interview was conducted on 8/16/24 at 10:50 AM with EI # 3 who confirmed there was no documentation of the reason the Benadryl was administered. 3. PI # 1 was admitted to the hospital on 3/20/24 with diagnoses including Oppositional Defiant Disorder and Adjustment Disorder with Mixed Disturbance of Emotions. Review of the Physician Orders dated 4/11/24 revealed an order for Vistaril 50 mg every eight hours prn for “aggression/agitation.” Review of the Administration History revealed Vistaril 50 mg was administered on 4/11/24 at 10:50 AM. There was no documentation of the reason the Vistaril was administered. Review of the Physician Orders dated 4/12/24 revealed an order for Benadryl 50 mg every eight hours prn for “aggression/agitation.” Review of the Administration History revealed Benadryl 50 mg was administered on 4/13/24 at 1:36 PM. There was no documentation of the reason the Benadryl was administered. An interview was conducted on 8/16/24 at 10:41 AM with EI # 3 who confirmed there was no documentation of the reason the Vistaril and Benadryl were administered. 4. PI # 5 was admitted to the hospital on 4/30/24 with diagnoses including Intermittent Explosive Disorder and Physical Abuse of a Child, Victim, Confirmed. Review of the Physician Orders dated 4/30/24 revealed an order for Ativan 2 mg every eight hours prn and Haldol 5 mg every six hours prn for acute agitation. There was no indication documented for the prn usage on the Ativan. Review of the Administration History revealed Ativan 2 mg was administered on 5/8/24 at 11:15 AM. There was no documentation of the reason the Ativan was administered. Review of the Administration History revealed Haldol 5 mg was administered on 5/13/24 at 12:07 PM. There was no documentation of the reason the Haldol was administered. Review of the Physician Orders dated 5/23/24 revealed an order for Ativan 2 mg every eight hours prn for “severe aggression.” Review of the Administration History revealed Ativan 2 mg was administered on 7/15/24 at 12:05 PM. There was no documentation of the reason the Ativan was administered. An interview was conducted on 8/16/24 at 10:56 AM with EI # 1, Hospital Administrator, who confirmed there was no documentation of the reason the Haldol and Ativan were administered.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 40119 Based on observations, review of the hospital 2024 safety management plan, Hospital Maintenance Environmental Rounds, 2012 Edition NFPA (National Fire Protection Association) 101 Life Safety Code, and staff interviews, it was determined the hospital failed to: 1. Maintain a clean, sanitary, and safe environment. 2. Ensure exit (egress) doors were in working order. 3. Ensure exit doors were locked with no more than one lock. This did affect Unsampled Patient (UP) # 1, one of three patients interviewed, and had the potential to affect all patients served by this hospital. Findings include: Hospital Plan: Safety Management Plan Plan Number: Not documented Date: 2024 Consistent with its mission...designed a plan to...provide quality services in a hazard free environment... Functional Delivery of Services: In order to provide a safe, healthy environment for individuals/patients, staff, and visitors...follows the guidelines of...NFPA 101 Life Safety Code... NFPA 101 Life Safety Code Date: 2012 Edition ...7.1.10 Means of Egress Reliability. 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. ...19.2 Means of Egress Requirements. 19.2.1 General. Every...exit location...shall be in accordance with Chapter 7... 19.2.2.2.6 Doors that are located in the means of egress...shall comply with all of the following: ...2 Only one locking device shall be permitted on each door. 1. Review of the Hospital Maintenance Environmental Rounds dated 8/8/24 revealed documentation of the last environmental inspection of the hospital and the following: The hospital was “noncompliant” with paint and wall coverings being in good repair... The hospital was “noncompliant” with there being no water damage to ceiling, ceiling tiles, light fixtures and all were clean and stain-free... The hospital was “compliant” with all flooring being in good repair with no loose tiles... The hospital was “compliant” with no evidence of leaks in toliets and shower plumbing... The hospital was “compliant” with all fire doors being unobstructed... The hospital was “compliant” with all lighting fixtures are in good repair... 2. During a tour of the Pre-Adolescent Hall on 8/13/24 at 8:59 AM with Employee Identifier (EI) # 2, Director of Nursing, and EI # 5, Chief Hospital Officer, the following was observed: Room 507: Brown and red grime surrounding the base of the toilet in the bathroom. Brown and black grime on the baseboards of the bathroom and bedroom. Hole in the wall beside the bathroom door measuring approximately one foot by half of a foot. Graffiti drawing, picture of two cherries with 1, 2, 3, 4 written inside of along with a fingerprint, on the wall of the bathroom. “What the here dude” written on the bathroom mirror. Room 508: Brown grime on baseboards of the bedroom. Brown dirt spots on the bedroom window and window blind. Three dark brown spots on the bathroom wall. 2” (two inch) x (by) 4” yellow stain beside the foot of the first bed. 1’ (one foot) yellow stain at the foot of the second bed. Room 509: Brown grime on baseboards of the bedroom and bathroom. Shower head of the bathroom dripped continuously with a green stain down the shower wall and across to the shower drain on the floor. Vent in the bathroom covered in dust. Yellow stains on the window blind of the bedroom. Graffiti drawings of four Hexagrams in the bedroom, one in the center of the room and three on the right side of the room, one Hexagram on the bathroom door, and multiple Hexagrams in a circle on the air conditioning unit. Room 510: Brown grime on the baseboards of the bedroom and bathroom. Room 511: Brown grime on baseboards of the bedroom and bathroom. Graffiti of “it’s Adam and Eve, not Adam and Steve - sum staff dude” and explicit vulgar graffiti written on the bathroom wall. 4” x 1” peeling ceiling tile beside the sprinkler head of the bedroom. Room 512: Brown grime on the baseboards of the bedroom and bathroom. Graffiti drawing of a male reproductive organ with writing of explicit vulgar graffiti and a name of a patient on the wall of the bedroom. Graffiti writing of a patient name “...was here” on the wall of the bathroom. Room 513: Chipped 2” x 3” floor tile beside the bathroom toilet. Brown and yellow grime behind the toilet. Four-bathroom floor tiles bubbled up surrounding the toilet. Brown and yellow stain on the bathroom floor and baseboard next the bathroom sink. Black mold surrounding the outer sections of the shower. Brown grime on the baseboards of the bedroom. Room 514: Brown grime on baseboards of the bedroom and bathroom. Shower head of the bathroom dripped continuously with a green stain down the shower wall and across to the shower drain on the floor. Chipped 6” x 4” area of the floor tile in the bathroom. Room 515: Brown and yellow stain on the bathroom floor and baseboard next the bathroom sink. Black mold surrounding the outer sections of the shower. Brown grime on the baseboards of the bedroom and bathroom. Two chipped floor tiles in the bathroom, one 3” x 2” floor tile next to toilet and one 1” x 1” floor tile in the middle of the bathroom floor. Hallway: Peeling paint on all patient room door frames. Multiple graffiti drawings on the walls leading to the courtyard of the unit. Brown grime on the baseboards. Courtyard: Two of the Three light covers hanging down from the ceiling exposing the electrical components of the light, one leaving a gap of approximately one inch and one leaving a gap of approximately one foot between the cover and the ceiling, which had the potential for a electrocution risk. An interview was conducted with EI # 2, during the tour. EI # 2 confirmed the black substance appeared to be “mold” and confirmed the above findings were not per the hospital policy to maintain a clean, sanitary, and safe environment. 3. During a tour of the Female Adolescent Hall on 8/13/24 at 10:01 AM with EI # 2 and EI # 5 the following was observed: Dayroom: Brown grime on the baseboards in the dayroom and galley area. Brown grime and loose dirt surrounding milk crates holding refrigerator in the galley. Peeling paint by window measuring 4” long. Corner of the right-side wall which connects with back wall of room with holes in the plaster. The right side of the wall when pushed by the surveyor hand could be physically separated from the back wall. Build up dust on the air conditioning unit. Peeling paint on the galley door frame. Peeling paint on the walls. Vulgar graffiti writing on the walls. Hallway: Peeling paint on the walls along the floor baseboards, peeling 1’ section of the baseboard next to patient room 603, missing 4’ section of the baseboard next to patient room 606, missing 2’ section of the baseboard between patient rooms 612 and 614, missing 3’ section of the baseboard between patient room 614 and the outside door. Peeling 2’ section of paint in the corner of wall next to patient room 612. Brown grime on a third of the hallway baseboards. Peeling paint on all patient room door frames. Multiple graffiti drawings on the center wall of the hallway. Exit door at the end of hallway, over 100 feet from another exit, was locked with a magnetic employee badge lock and a keyed lock. Two staff members attempted to unlock the exit door and were unable to open the door, which would have prevented the hospital staff and patients on the unit from exiting the door in the event of an emergency. Room 605: Hole measuring 10” x 6” at the foot of the bed with see through mesh. Room 606: Brown grime on baseboards and multiple areas of chipped paint. Room 607: Soap dispenser in bathroom missing with wall mount of the soap dispenser exposed which posed a ligature risk. Multiple areas of graffiti surrounding bathroom toilet walls, including explicit vulgar graffiti writing which included the date of December 20th, “kill yourself (patient name)”, and “kill yourself bitch.” Hole by bathroom sink measuring 1’. Peeling paint under sink measuring 6”. Two circular holes over the toilet paper holder with a peeling 4’ x 3’ section of paint above the holes and running up the wall. Five red smears on the left side of the shower curtain. Brown grime on baseboards of the bedroom and bathroom. Room 608: Brown grime on baseboards of the bedroom and bathroom. Multiple areas of graffiti on the left side of the wall and the wall at the foot of the patient beds. Room 609: Dead cockroach observed by the patient second bed. Large areas of peeling paint above the head area of both patient beds. Brown grime on approximately half of the baseboards in the room. Room 610: Brown grime on baseboards of the bedroom and bathroom. Room 611: Chipped 2” x 2” section of paint at the bottom of bathroom door jam. Dried line of red brown substance measuring 2 to 3” at the head of the second patient bed. Graffiti of “kill ur (your) self” written in red brown substance on the left side wall of the bedroom with a 5’ long crack in the wall beside the red brown substance. Room 612: Brown grime on baseboards of the bedroom and bathroom. Bathroom shower floor had spotted areas of black mold and there was standing cloudy water over the shower drain. Room 613: Brown grime on baseboards of the bedroom and bathroom. Vulgar graffiti writing with a heart drawing on the right wall and a heart drawing on the left wall of the bedroom. Graffiti writing on the wall of the bathroom which stated, “Ways to kill yourself. 1. Strangle yourself with a blanket or piece of clothing. 2. Drown yourself in the toilet or a bathtub. 3. Stab yourself in the throat with a knife (don’t hesitate). 4. Eat your hygiene products. 5. Swallow lots of bleach. 6. Dive down a 2-3 story building roof. 7. Take over 50 pills. Hope this helps! (Drawing of a heart). “ Room 614: Shower head of the bathroom dripped continuously with a green stain down the shower wall and across to the shower drain on the floor. Hole over the second patient bed measuring 2” x 0.5 “. Explicit vulgar graffiti writing on the wall of the bathroom. Vulgar Graffiti writing and graffiti writing of “days till I get out (patient name)” on the wall of bedroom beside the first patient bed. Room 615: Brown grime on baseboards of the bedroom. Peeling 1’ section of baseboard by the second patient bed. Metal paper towel cover open, unlocked, and bent which could be used by a patient to cut themselves or a potential ligature risk. Room 617: Dust buildup on the bathroom baseboards. Peeling 2” x 4” section of paint on the bedroom wall next to the first patient bed. Crack in wall from under window of bedroom down to baseboard then 6” across the top of the baseboard which when pushed by the surveyor’s hand could be physically separated from the side wall. An interview was conducted with EI # 2 and EI # 5, during the tour. EI # 2 confirmed the black substance appeared to be “mold”, the red smears on the shower curtain of room 607 appeared to be blood, and confirmed the above findings were not per the hospital policy to maintain a clean, sanitary, and safe environment. EI # 5 did confirmed during the tour the writing on the wall of the bathroom of room 613 was from a previous patient and not the current patient who was admitted on 8/11/24. EI # 5 confirmed during the tour, the red brown substance appeared to be dried blood was not from a current patient in the room 611. An interview was conducted with EI # 6, Assistant Maintenance Engineer, who confirmed the exit door was unable to be opened from the inside due to the plunger of the doorknob being bent. EI # 6 confirmed the closest exit in case of an emergency was at the front of the unit and between the closest exit and the exit door, which failed to open, is where the patient rooms are located. EI # 6 confirmed there was no documentation maintenance was notified the exit door was unable to be opened. An interview was conducted on 8/16/24 at 9:55 AM with UP # 1, patient currently in room 611, who verbalized the writing in the red brown substance on the wall was there when he/she was moved into the room and remained in the room the night of 8/15/24. 4. During a tour of the 400 Adolescent Hall on 8/13/24 at 11:42 AM with EI # 2 and EI # 5 the following was observed: Hallway: Peeling paint on all patient room doorways. Room 407: Bathroom shower floor had spotted areas of black mold . Room 409: Shower head of the bathroom dripped continuously with a green stain down the shower wall and across to the shower floor. Room 411: Peeling 2’ section of paint by the bathroom toilet. Room 410: Brown grime on baseboards of the bedroom and bathroom. Room 412: Peeling 2’ section of paint by the second patient bed next the baseboard. Room 414: Peeling 1’ section of the baseboard beside the bathroom toilet. Peeling paint surrounding the left side of the bathroom toilet baseboard. Green stain down the shower wall and across to the shower drain on the floor. Room 415: Brown grime on baseboards around the bathroom toilet. Room 416: Peeling 6” section of paint by the bedroom door. Room 418 (seclusion room): Large sections of peeling paint on all four walls of room. Graffiti written of “I need some pussy. Devil’s advocate” on a board located on the wall of the room. Room 419: Bubbled up 5” section of paint behind the bathroom toilet. Dayroom: Nine of ten air conditioning vents on the ceiling with dust on the vents and the surrounding ceiling tiles. An interview was conducted with EI # 2, during the tour. EI # 2 confirmed the above findings were not per the hospital policy to maintain a clean, sanitary, and safe environment.”