Unity Psychiatric Care - Huntsville

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 41623 Based on a review of facility policies and procedures, Medical Staff Bylaws, observations, document review, and interviews, it was determined the Governing Body failed to ensure compliance with the Conditions of Participation was maintained and that quality patient care was provided in a safe environment. These deficient practices had the potential to affect all patients served by this facility. Findings include: Refer to tags: A-0049, A-0115, A-0144, A-0286, A-0297, A-0502, A-0724”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 41623 Based on medical record review, facility policies and procedure, video surveillance review, Emergency Medical Services Incident Reports, Hospital B Emergency Department records, and interview with facility staff, it was determined the facility failed to ensure patients were cared for in a safe setting by failing to ensure: 1. Every 15 minute observation checks were performed and documented by facility staff per policy. 2. The Community Action Plan was updated or had Interventions added to decrease the risk of repeated falls. 3. A ligature risk free environment was maintained. Refer to tags: A-0144”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 41623 Based on review of the Governing Body meeting minutes and Medical Staff Bylaws, it was determined the facility failed to ensure the medical staff was accountable to the governing body to ensure the safety of patients including implementing measures for fall prevention. This deficient practice did affect a total of 81 falls of patients between 4/24/25 and 10/29/25 and had the potential to negatively affect all patients admitted to this facility. Findings include: Medical Staff Bylaws of Behavioral Healthcare at Huntsville Approved: 1/1/2011 ...4.D: Medical Staff Role in Performance Improvement Functions: 1. Medical Staff functions that focus on systemic monitoring and performance improvement, shall at a minimum, include measurement, assessment and improvement of the following; a. Medical assessment and treatment of patient... 2. Sentinel event data and patient safety data are used as part of the performance improvement mechanisms, measurement, and assessment. Organization wide performance improvement activities in which the Medical Staff participates include the following: ...b. Coordination of care, treatment, and services ... as relevant to the care, treatment, and services of an individual patient; c. Accurate, timely, and legible completion of patients’ medical records... d. Communication of findings, conclusions, recommendations, and actions to improve performance to appropriate staff members and the Board... 1. Review of the Governing Body Meeting minutes from April 2025 to October 2025 revealed the following documentation: a. On 4/24/25, the members were presented Quality Assurance data that included reports of 12 patient falls, three of the patients with falls were sent to the Emergency Department (ED) and one of the falls with an injury was admitted to the hospital. There were no Performance Improvement Projects (PIPs) for patient safety or falls reported or implemented. b. On 5/20/25, eight falls were reported. Three of the patients with falls were sent to the ED. One patient had suffered a hip fracture and was reported as a Sentinel Event (a patient safety event that results in death, permanent harm, or severe temporary harm). There were no PIPs for patient safety or falls reported or implemented. c. On 7/1/25, 13 falls were reported. Two of patients with falls were sent to the ED. One of the patients suffered a facial laceration and a broken wrist. There were no PIPs for falls reported by Quality, but documented “PIP is ongoing.” There was no documentation of a PIP for patient safety or falls provided to the surveyors. d. On 7/31/25, 10 patient falls were reported. Two of the fall patients were sent to the ED. There was no documentation of a PIP for patient safety or fall prevention and no documentation a PIP was to be implemented. e. On 8/25/25, 14 patient falls were reported. Three patients were sent to the ED. One of the patients suffered a Subdural Hematoma (a serious medical emergency where a blood clot forms between the brain and the outer layer, typically due to head trauma). A Sentinel Event was reported. There was no documentation of a PIP for patient safety or fall prevention and no documentation a PIP was to be implemented. f. On 9/26/25, 12 patient falls were reported. Three of the patients were sent to the ED. There was no documentation of a PIP for patient safety or fall prevention and no documentation a PIP was to be implemented. g. On 10/29/25, 12 patient falls were reported. Three of the patients were sent to the ED. There was no documentation of a PIP for patient safety or fall prevention and no documentation a PIP was to be implemented. The Governing Body failed utilize the Quality data presented in the meetings and failed to implement PIPs to ensure the patients were cared for in a safe environment.”

“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: 41624 Based on observations, medical record (MR) review, facility policies and procedure, video surveillance review, Emergency Medical Services (EMS) Incident Report, Hospital B Emergency Department (ED) record, and interviews, it was determined the psychiatric facility failed to ensure: 1. Fifteen minute (Q 15) observation checks were performed and documented by facility staff on all patients per policy. 2. The Community Action Plan was updated or had Interventions added per policy to decrease the risk of a repeated fall after patient falls occurred. 3. A safe and ligature risk free environment was maintained for all patients. This deficient practice affected seven of eight MRs reviewed including Patient Identifier (PI) # 2, PI # 7, PI # 8, PI # 5, PI # 4, PI # 1, and PI # 3, and had the potential to affect all patients admitted to this facility. Findings include: Facility Policy: Observation Levels Policy Number: None Revision Date: 3/2025 Policy: All patients, when admitted to Unity Psychiatric Care, will be automatically placed on fifteen (15) minute observation checks ...by a staff member. This will be considered routine observation and will continue until discharge regardless of changes in observation levels. Facility Policy: Fall Prevention Program Policy Number: None Original Date: 9/2015 Revision Date: 11/12/2025 Policy: The intent of Unity Psychiatric Care (UPC) fall prevention program is to increase patient safety and to provide a coordinated system to identify patients at risk for falls and develop an individualized interdisciplinary plan of care to minimize the incidence of falls and subsequent injury. Procedure: The fall prevention program is intended to: ...Direct the creation of an individualized treatment plan to reduce fall risk Team Members/Roles and Responsibilities: Director of Nursing (DON)/Assistant DON ...Completes post occurrence analysis report of all fall related occurrences. ...Ensures treatment plan reflects individual goal and interventions. Nursing (RN/LPN) (Registered Nurse/Licensed Practical Nurse) ...Implements safety interventions based on fall scale score. ...Ensures procedures for high-risk patients are in use. ...Assists patients as needed with transfers and ambulation. Risk Manager ...Helps identify and implement appropriate interventions. MHT (Mental Health Technician) Follows safety interventions for at risk patients. Assists patients as needed with transfers and ambulation... Providers ...Assesses mobility and orders interventions such as physical therapy consultation.. All Unity Staff ...Assists in assuring safety interventions are followed. Procedure: A. Fall Risk Assessment 1. The RN/LPN will complete Morse Fall Scale (MFS) Risk Assessment within 24 hours of admission. 2. Initiate interventions based on MFS score. (Low risk, moderate risk, high risk)... B. Interventions - Fall Risk Score determines level of fall prevention interventions warranted. C. Post Fall Evaluation ...4. Add interventions to help reduce risk of re-occurrence. ...6. Refer patients with falls to the therapy department for assessment as indicated... D. Monitoring Plan ...4. Patients with multiple falls should be identified and communicated to treatment team members. 5. Quality/PI (Performance Improvement) Committee will review all inpatient fall reports daily for trends and patterns and develop corrective action plans as needed for identified trend(s) that may require further monitoring to achieve the optimum goal for fall reductions within the hospital. 6. Implement/modify the patient’s current plan of care with intervention(s) associated with the cause of the fall. Medbridge Morse Fall Scale Adapted from JM Morse Cambridge University Press Background: This tool can be used to identify risk factors for falls in hospitalized patients. While the total score can be used to predict future falls, it is most useful for identifying risk factors in order to form a care plan to address them. ...Total Score: < (Less than) 25: Low risk 25-45: Moderate Risk > (Greater than) 45: High Risk Facility Policy: Assessment for Suicidal Ideation and Implementing Safety Planning Policy Number: Not Listed Revised: 7/2025 ...Perform a risk assessment of the environment. Ensure objects that pose a risk for self-harm are removed from the patient’s location. Keep patient away from anchor points for hanging and material that can be used for self-injury/ligature... 1. PI # 2 was admitted to the facility on 10/27/25 with a principal diagnosis of Dementia In Other Diseases Classified Elsewhere, Moderate, With Other Behavioral Disturbances. Review of the Client Profile-Order Details dated 10/27/25 at 7:09 PM revealed the following physician orders: - Fall precautions, continuous. - Other checks every 12 hours, ensure bed alarm is in place and functioning properly Q (every) shift. Replace as indicated. - ADL (Activities of Daily Living) precautions, continuous. Review of the UPC Nursing Assessment dated 10/27/25 at 8:59 PM revealed the RN documented PI # 2 was able to ambulate “ad lib” (as much as he/she desired) and required assistance with dressing, feeding/meals, hygiene/bathing, medications and toileting. Review of the MFS risk score for PI # 2 dated 10/27/25 revealed a score of 15, indicating low risk for falls. Review of the UPC Individual Progress Notes documented by the RN revealed PI # 2 had falls the following dates and times: On 10/29/25 8:57 AM, the RN “documented MHT was present, (PI # 2) resisted redirection by MHT and fell to the floor.” No injuries were sustained. Review of the IDT Occurrence Investigation Worksheet dated 10/29/25 revealed it was determined PI # 2 was not wearing anti-skid socks, and the Community Action Plan was for PI # 2 to have no-skid footwear to feet. Review of the Treatment Plan Interventions dated 10/29/25 at 10:22 AM revealed the licensed baccalaureate social worker (LBSW) assigned the intervention staff would complete Q 15 minute checks. On 10/31/25 10:05 AM the RN documented “while ambulating in the hallway, PI # 2 fell and sustained no injuries.” There was no IDT Occurrence Investigation Worksheet completed, nor additional fall interventions added. Review of the video dated 10/31/25 of camera two at the nurse’s station, was conducted with Employee Identifier (EI) # 10, Business Office Manager, and revealed the following safety concerns: On 10/31/25 at 10:03 AM, PI # 2, identified by staff present, was in the hallway in front of the day room/dining room, bent over and fell straight back. EI # 14, MHT, came out of the day room/dining room at 10:08 AM to assist PI # 2. EI # 10 confirmed at the time of video review, PI # 2’s fall at 10:03 AM. On 10/31/25 6:20 PM the RN documented PI # 2 fell while ambulating in the hallway and hit his/her head. PI # 2 was sent to Hospital B ED for evaluation via Emergency Medical Services (EMS) transport. Per video review dated 10/31/25 at 6:04 PM, PI # 2, identified by staff present, PI # 2 was at the nurse’s station, bent down and fell straight back. EI # 23, Housekeeper, EI # 12, LPN, and EI # 2, DON entered the hall. EI # 2 bent over to PI # 2 and at 6:05 PM returned to the nurse’s station office. EI # 14 checked PI # 2’s vitals at 6:18 PM. EI # 26, LPN, entered the nurses station swinging door, hitting PI # 2’s legs/knees with the swinging door, while lying in the floor next to the nurse’s station at 6: 38 PM. PI # 2 remained on the floor until the Emergency Medical Technicians (EMT)’s arrived at 6:48 PM. EI # 10 confirmed PI # 2’s fall at the time of the review, PI # 2’s legs/knees hit by EI # 26 swinging the nurses station door open to enter the nurse’s station and PI # 2 remaining on the floor for 44 minutes, from 6:04 PM until EMS arrived at 6:48 PM. Review of the Hospital B ED MR revealed PI # 2 was evaluated and discharged back to UPC via EMS on 11/1/25 at 1:00 PM with a discharge diagnosis of Dementia and Fall. There was no IDT Occurrence Investigation Worksheet completed and no facility investigation for the fall dated 10/31/25 at 6:20 PM, nor were additional fall interventions added. On 11/01/25 6:50 PM the RN documented PI # 2 was lying on a mattress on the dayroom floor, attempted to stand by pulling himself/herself up with the aid of a trash can, fell and hit his/her head on a chair. PI # 2 complained of head pain, and was sent to Hospital B ED via EMS for evaluation. Review of the video dated 11/1/25 of camera 14 in the Day Room/Dining Room, was conducted with EI # 10, and revealed the following safety concerns: On 11/1/25 at 4:20 PM, PI # 2, identified by staff present, was in the day room/dining room trying to stand up and fell. EI # 21, MHT, tried to catch PI # 2 and PI # 2 went to the ground. EI # 12, LPN, entered and left the room. EI # 22, RN, entered day room/dining room at approximately 4:32 PM. EMTs arrived for PI # 2 at 5:51 PM. EI # 10 confirmed at the time of video review, PI # 2’s fall and was on the floor from 4:20 PM until 5:51 PM, one hour and thirty-one minutes until EMTs arrived. Review of the Hospital B ED MR revealed PI # 2 was evaluated and discharged back to UPC via EMS on 11/2/25 at 12:30 AM with a discharge diagnosis of Dementia and Fall. Review of the IDT Occurrence Investigation Worksheet dated 11/2/25 at 1:00 PM, “Comments and Community Action Plan,” revealed EI # 5 documented PI # 2 fell ambulating in the hallway with unsteady gait, and had bare feet. Intervention added per worksheet was for PI # 2 to have a chair alarm while sitting. There were no signatures on the worksheet to indicate a post occurrence investigation was completed by the IDT. On 11/2/25 5:06 PM the RN documented PI # 2 was sitting in the chair and fell before his/her visit time. The RN documented there were no injuries noted and PI # 2 was on 72 hour fall precautions. Review of the Event Note dated 11/2/25 revealed the RN documented PI # 2 fell ambulating in the hallway, and the fall was witness by the “tech,” (mental health technician). Review of the video dated 11/2/25 of camera three, hallway, was conducted with EI # 10, and revealed the following safety concerns: On 11/2/25 at 3:41 PM, PI # 2 tried to sit in a chair in the hallway, and missed the chair, falling to the floor. No staff were present at the time of the fall. EI # 12 finds PI # 2 in the floor at 4:18 PM. EI # 12 entered a patient room, while PI # 2 is using his/her hands and feet to scoot on the floor. EI # 12 checked PI # 2’s vitals at 4:54 PM. EI 12, and EI 19, LPN, assisted PI #2 up to a wheelchair at 5:36 PM. EI # 10 confirmed at the time of the video review no 15-minute observation checks were completed for PI # 4 from 3:41 PM until 4:18 PM. Further review confirmed PI # 2 fell and was in the floor from 3:41 PM until 5:36 PM. There was no IDT Occurrence Investigation Worksheet completed, nor additional fall interventions added. Review of the 11/2/25 MFS revealed the RN documented a score of 50, indicating PI # 2 was a high risk for falls. There was no documentation safety interventions were added based on the fall scale score. Review of the 11/4/25 MFS revealed the RN documented a score of 75, indicating PI # 2 remained at a high risk for falls. There was no documentation safety interventions were added based on the fall scale score. On 11/5/25 8:30 AM the RN documented PI # 2 had a fall when trying to sit on a chair and missed the seat. The RN also documented PI # 2 sustained no injury. There was no IDT Occurrence Investigation Worksheet completed, nor additional fall interventions added. Review of the 11/6/25 MFS revealed the RN documented a score of 55, indicating PI # 2 remained at a high risk for falls. There was no documentation safety interventions were added based on the fall scale score. On 11/8/25 3:16 AM the RN documented PI # 2 was sitting in a wheelchair at the nursing station, “a loud thump noted, patient fell and hit his/her head to left temporal with skin tear noted and swelling.” PI # 2 was transported via EMS to Hospital B for evaluation. At 4:53 PM the RN documented PI # 2 returned from Hospital B, and was placed in room 107-A with a bed alarm in place. The RN further documented per report from Hospital B, PI # 2 had a small fracture to his/her right elbow and needed follow up with an orthopedic physician. Review of the video dated 11/8/25 camera two, nurse’s station, was conducted with EI # 10, and revealed the following safety concerns: On 11/8/25 at 3:17 AM, PI # 2, identified by staff present, tried to stand up from a wheelchair, fell over forward, hitting his/her head on the nurse’s station desk. EI # 15, RN, EI # 16, RN, EI # 17, MHT, EI # 18, MHT, assisted PI # 2 checking vitals, wiping his/her face and head, and wiping up the floor at 3:21 AM. EMT’s arrived at 3:42 AM. EI # 10 confirmed at the time of video review, PI # 2’s fall and was in the floor from 3:17 AM until 3:42 AM when the EMTs arrived. Review of the IDT Occurrence Investigation Worksheet dated 11/8/25 3:16 AM, “Comments and Community Action Plan,” revealed documentation PI # 2 fell from the wheelchair. Intervention added per worksheet was for PI # 2 to have a chair alarm while in chair, wheelchair and geri-chair. There was no signature on the worksheet to indicate who had documented the information and also no signatures on the worksheet to indicate a post occurrence investigation was completed by the IDT. Review of the Special Precautions Observation Sheets dated 10/27/25, 10/28/25, 10/30/25, 10/31/25, 11/2/25, 11/3/25, 11/5/25, and 11/10/25 revealed there were periods of time ranging from 30 minutes to one hour that Q 15 minute observations were not completed and documented per policy. Further review of the MR revealed there was no documentation the physician ordered every 12 hour checks were completed, nor the Q shift checks to ensure the bed alarm was in place and functioning properly. There was also no documentation the chair alarm, added as an intervention after the 11/1/25 fall, was in use and functioning properly. An interview was conducted on 11/14/25 at 3:57 PM with EI # 4, Regional Nurse Manager and EI # 5, who confirmed the facility failed to ensure the staff completed and documented patient observations per physician orders and facility policy, and failed to complete an IDT occurrence investigation after each fall per policy and implement/modify PI # 2’s current plan of care with intervention(s) associated with the cause of the fall. During the interview, the surveyor asked if a MFS of 75 indicated any specific fall interventions? EI # 3, another Regional Nurse Manager stated the score itself did not indicate a specific intervention, that interventions should have been put in after each fall, and were not. 2. PI # 7 was admitted to the facility on 10/18/25 with a principle diagnosis of Dementia In Other Diseases Classified Elsewhere, Mild, With Other Behavioral Disturbance. At time of admission, PI # 7 was able to ambulate with the aid of a walker. Review of the Client Profile-Order Details dated 10/18/25 at 6:12 AM revealed the following physician orders: - Fall precautions, continuous. - Other checks every 12 hours, ensure bed alarm is in place and functioning properly Q shift. Replace as indicated. - Other checks continuous, fall mat at bedside. Review of the UPC Individual Progress Notes documented by the RN revealed PI # 7 had falls the following dates and times: On 10/19/25, approximately 3:00 PM the RN documented PI # 7 had an unobserved fall in his/her room, and was found seated upright on the floor calling for help. PI # 7 stated to the RN he/she fell while walking to the bathroom, landed on his/her behind, and also hit his/her head with the fall. Due to PI # 7 being on Eliquis (blood thinner), he/she was sent to Hospital B ED via EMS for evaluation. The RN documented on 10/20/25 at 12:03 AM that PI # 7 returned to the faciity via EMS transport with a diagnosis of Concussion Status/Post Fall, and was assisted to a geri-chair. An IDT Occurrence Investigation Worksheet was completed, and the Community Action Plan was for PI # 7 to have a bed/chair alarm. On 10/24/25 at 4:54 PM the RN documented PI # 7 was in a wheelchair self propelling from the day room to the hall, “when this RN heard PI # 7 fall forward from wheelchair.” “Patient hit head, c/o (complains of) pain to top of the head.” The RN further documented PI # 7 was sent to Hospital B ED via EMS transport for evaluation. On 10/20/25, the RN documented PI # 7 returned to the facility at 2:08 AM via EMS with a diagnosis of UTI (Urinary Tract Infection). There was no IDT Occurrence Investigation Worksheet completed, nor additional fall interventions added. On 11/4/25 at 7:55 PM the RN documented the MHT came and reported PI # 7 was on the floor and upon arrival to PI # 7’s room, he/she was observed sitting on the floor near the bed, with legs stretched out in front of him/her. The RN further documented PI # 7 did not hit his/her head, denied pain, and a head to toe assessment for injury was completed. Review of the video dated 11/4/25 of camera three in the hallway outside PI # 7’s door was conducted with EI # 10, and revealed the following safety concerns: On date 11/1/25 EI # 24, MHT, identified by staff present, exited PI # 7’s room at 4:01 PM and re-entered at 5:51 PM with food tray and exits. EI # 24, EI # 25, MHT, and EI # 26, RN, enter PI # 7’s room at 5:53 PM. EI # 10 confirmed at the time of the video review no 15-minute observation checks were completed for PI # 7 from 4:01 PM until 5:51 PM. An IDT Occurrence Investigation Worksheet was completed, and the Community Action Plan was for PI # 7 to have “alarm,” and no-skid socks. Review of the Special Precautions Observation Sheets dated 10/22/25, 10/23/25, 10/24/25, and 11/1/25 revealed there were periods of time ranging from 15 minutes to 30 minutes that Q 15 minute observations were not completed and documented per policy. Further review of the MR revealed there was no documentation the physician ordered every 12 hour checks were completed, the Q shift checks to ensure the bed alarm was in place and functioning properly were completed, nor the continuous checks that the fall mat was in place. There was also no documentation the chair alarm, added as an intervention after the 10/19/25 fall, was in use and functioning properly. An interview was conducted on 11/14/25 at 3:22 PM with EI # 3 and EI # 4, Regional Nurse Managers, who confirmed the facility failed to ensure the staff completed and documented patient observations per physician orders and facility policy, and failed to complete an IDT occurrence investigation after each fall per policy and implement/modify PI # 7’s current plan of care with intervention(s) associated with the cause of the fall. 3. PI # 8 was admitted to the facility on 10/6/25 with a principle diagnosis of Alzheimer’s Disease With Behavioral Disturbance. Review of the Client Profile-Order Details dated 10/6/25 at 6:29 PM revealed the following physician orders: - Fall precautions, continuous. - Other checks every 12 hours, ensure bed alarm is in place and functioning properly Q shift. Replace as indicated. Review of the Admission Nursing Assessment dated 10/6/25 at 7:26 PM revealed the RN documented PI # 8 was ambulatory. Review of the UPC Individual Progress Notes documented by the RN revealed PI # 8 had falls the following dates and times: On 10/7/25 10:02 PM the RN documented PI # 8 was coming out of another patient’s room, slipped and fell, hitting his/her front right side of the head breaking his/her glasses. PI # 8 was sent to Hospital B ED via EMS transport for evaluation and returned to the facility 10/8/25 at 11:50 AM. An IDT Occurrence Investigation Worksheet was completed, and the Community Action Plan was for PI # 8 to wear no-skid socks. On 10/21/25 at 8:20 PM the RN documented PI # 8 had an unwitnessed fall in the hallway, and appeared to have no injury. PI # 8 was sent to Hospital B ED via EMS for evaluation and returned to the facility 10/22/25 at 9:35 AM with a diagnosis of UTI. An IDT Occurrence Investigation Worksheet was completed on 10/21/25, including an Occurrence Investigation Interview by the DON. Review of the interview revealed PI # 8 was not wearing “appropriate footwear” at the time of the fall, and the Community Action Plan was for PI # 8 to wear no skid-socks. On 10/22/25 at 3:05 PM the RN documented PI # 8 slid from the wheelchair to the floor, and the bed alarm was on but did not go off due to PI # 8 sliding and not falling. Initially his/her BP (blood pressure) was 70/35, heart rate 118. Repeat BP was 96/48. PI # 8 was sent to Hospital B ED for evaluation and returned to the facility 10/23/25 at 12:26 PM after being started on Bactrim for UTI. An IDT Occurrence Investigation Worksheet was completed, and the Community Action Plan was for PI # 8 to have Dyson (anti-slip silicone rubber pads) applied to the seat of the wheelchair, and also careplanned for a mattress on the floor. On 10/23/25 at 3:13 PM the RN documented PI # 8 was found lying on the floor and had a quarter sized hematoma to the front and back of his/her head, as well as a skin tear to the left elbow. The RN also documented he/she contacted EMS at 3:13 PM for transport to the ED, but after notifying EI # 13, NP (Nurse Practitioner), at 3:23 PM of the patient’s fall, EI # 13 ordered/advised not to transport PI # 8 to the ED at the time. The RN further documented PI # 8 was placed in a geri chair, vital signs with neurological checks were implemented, and ice packs were applied to the hematomas. An IDT Occurrence Investigation Worksheet was completed, which documented the fall was unwitnessed and occurred in PI # 8’s room. Review of the Occurrence Investigation Interview revealed PI # 8 was not wearing “appropriate footwear” at the time of the fall. The Community Action Plan intervention was for PI # 8 to wear no-skid socks. Continued review of PI # 8’s MR revealed he/she began complaining of severe left hip pain on 10/26/25 at 9:00 PM. EI # 13 was notified, and an order was received to perform x-ray of the left hip. The RN documented on 10/27/25 at 4:46 PM that PI # 8 had the x-ray at 2:00 PM which showed PI # 8 had a hip fracture, and PI # 8’s Power of Attorney chose to not pursue surgical repair and discharge PI # 8 home on hospice. PI # 8 was discharged 10/27/25 at 2:40 PM. Review of the Special Precautions Observation Sheets dated 10/6/25, 10/9/25, 10/12/25, 10/14/25, 10/17/25, 10/20/25, 10/24/25, and 10/27/25 revealed there were periods of time ranging from 15 minutes to 10 hours and 45 minutes that Q 15 minute observations were not completed and documented per policy. Further review of the MR revealed there was no documentation the physician ordered every 12 hour checks were completed, the Q shift checks were completed to ensure the bed alarm was in place and functioning properly, nor that PI # 8 wore non skid socks per the interventions after three falls. An interview was conducted on 11/14/25 at 4:39 PM with EI # 4 who confirmed the facility failed to ensure the staff completed and documented patient observations per physician orders and facility policy, and also confirmed the intervention after the three falls to have PI # 8 wear non skid socks was not effective. 4. PI # 5 was admitted to the facility on 11/5/25 at 8:17 PM with a principle diagnosis of Dementia In Other Diseases Classified Elsewhere, Moderate, With Other Behavioral Disturbances. Review of the Special Precautions Observation Sheets dated 11/10/25 and 11/11/25 revealed each day had 30 minutes that Q 15 minute observations were not completed and documented per policy. An interview was conducted on 11/14/25 at 3:40 PM with EI # 3 and EI # 4, who confirmed the facility failed to ensure the staff completed and documented patient observations per facility policy, Review of video surveillance conducted on 11/14/25 at 1:10 PM with EI # 1, of the hallway outside of PI # 5’s room revealed no Q 15-minute checks from 1:00 AM until 1:30 AM. An interview was conducted on 11/14/25 at 1:30 PM with EI # 1, who confirmed the Q 15 minute checks were not completed. 41623 5. PI # 4 was admitted on 10/31/25 with a principal diagnosis of Dementia In Other Diseases Classified Elsewhere, Moderate, with Other Behavioral Disturbance. Review of the Client Profile-Order details dated 10/31/25 revealed PI # 4 was at a high risk for falls with physician orders for fall precautions including fall mat at bedside, bed in lowest position, no-skid footwear, and use of chair/bed alarms. Review of the Interdisciplinary Team Occurrence Investigation Worksheet dated 11/1/25 revealed PI # 4 was found on the floor at 8:00 AM after an unwitnessed fall. The staff documented PI # 4 was transported to the hospital at 8:35 AM. There was no documentation the bed alarms were in place and working properly, no documentation the fall mat was in place, and no documentation the no-skid footwear were being worn. Further review of the Interdisciplinary Team Occurrence Investigation Worksheet dated 11/1/25 revealed the Conclusion and Action Plan was to apply alarms. Review of the Special Precautions observation sheet revealed the staff documented every 15 minutes PI # 4 was in his/her room, sleeping. Review of the recorded video was conducted on 11/13/25 with EI # 10 revealed on 11/1/25, EI # 17 exited PI # 4’s room at 5:50 AM. At 7:40 AM, EI # 21, MHT, entered PI # 4’s room. There was no video evidence of a staff member entering PI # 4’s room between 5:50 AM and 7:40 AM, which was one hour and 50 minutes in which there was no observation of PI # 4. EI # 10 confirmed at the time of the video review no 15-minute observation checks were completed for PI # 4 from 5:50 AM until 7:40 AM. . An interview was conducted on 11/14/25 at 3:40 PM with EI # 3 who confirmed the facility failed to ensure the staff conducted and documented patient observations per physician orders and facility policy. 6. PI # 1 was admitted on 10/30/25 with a principal diagnosis of Schizoaffective Disorder, Depressive Type. Review of the Client Profile-Order Details dated 10/30/25 revealed physician orders for fall precautions and for a bed alarm with the staff to check functioning every shift. Review of the Interdisciplinary Team Occurrence Investigation Worksheet dated 11/1/25 revealed at 12:00 PM, PI # 1 was found on the floor on the bathroom floor complaining of a fall with hip pain. Further review of the of the Interdisciplinary Team Occurrence Investigation Worksheet dated 11/1/25, EI # 12, documented “The nurse last seen this patient during the morning medication administration.” Review of the Electronic Medication Administration Record (eMAR) revealed the last medication given to PI # 1 was at 8:44 AM, which was three hours and 16 minutes prior to the staff finding PI # 1 on the bathroom floor. Review of the Special Precautions, Observation Sheet, dated 11/1/25 revealed from 7:00 AM through 5:45 PM the MHT had written across the observation sheet “Patient in room/Group Room”. There was no documentation of the observation of the patient every 15 minutes to include the patient’s location or behavior. There was no documentation the bed alarm was in place or functioning properly. Review of the Emergency Medical Services Incident Report form dated 11/1/25 revealed PI # 1 was transported from Unity Psychiatric Care to Hospital B at 12:29 PM with complaints of a fall with bilateral hip pain. Review of the video dated 11/1/25 of camera four, hallway outside PI # 1’s door was conducted with EI # 10, and revealed the following safety concerns: On 11/1/25 EI # 22, identified by staff present, entered PI # 1’s room holding linens and shut the door at 11:33 AM. EI # 22 exited the room at 11:39 AM. EI # 20, MHT, left the room with PI # 1 in a wheelchair at 11:41 AM. EI # 22 took PI # 1 to the nurse’s station where EI # 22 checked his/her vitals at 11:44 AM. PI # 1 was observed sitting in his/her wheelchair with a tray eating at 11:51 AM. EMS arrived at 12:10 PM and exited with PI # 1 at 12:23 PM. EI # 10 confirmed at the time of the video review, PI # 1 did not return to the facility after leaving with EMT’s. Review of Hospital B Emergency Department medical record revealed PI # 1 was treated for head pain from fall and discharged to home with family on 11/1/25 at 5:06 PM. PI # 1 did not return to Unity Psychiatric Care. Further review of the Special Precautions, Observation Sheet, dated 11/1/25 revealed the staff documented PI # 1 was in the dining room from 6:00 PM to 6:30 PM and in the group room from 6:30 PM to 6:45 PM. There was no documentation on the Observation Sheet the patient was not in the facility from 12:30 PM to 6:45 PM. An interview was conducted on 11/14/25 at 3:40 PM with EI # 3 who confirmed the facility failed to ensure the staff conducted and documented patient observations per physician orders and facility policy. 49603 7. PI # 3 was admitted to the facility on 10/25/25 at 3:15 PM with a principal diagnosis of Brief Psychiatric Disorder. Review of the Special Precautions Observation Sheets dated 10/27/25, 11/1/25, 11/2/25, 11/5/25, 11/6/25, 11/10/25, and 11/11/25 revealed that Q 15-minute observations were not completed and documented per policy. An interview was conducted on 11/14/25 at 3:53 PM with EI # 4 and EI # 5, Quality, Risk Manager, who confirmed the facility failed to ensure the staff completed and documented patient observations per physician orders and facility policy. 8. A tour of the facility was conducted on 11/14/25 at 1:45 PM, including observation of patient rooms 106 A and B, 107 A and B, 109 A and B, and 110 A and B. EI # 11, Activity Therapist and Licensed Medical Social Worker (LMSW) was also present. The following ligature risks were observed: Room 106 B - an oxygen concentrator not in use was against the wall across from the foot of the bed with the nasal cannula tubing coiled on top with an approximate length of seven feet. Rooms 107 A, 109 A and B, 110 A and B each had a bed alarm pad laying on top of the bed with an approximately six foot length cable secured only to the small alarm box underneath the bed. EI # 11 confirmed the ligature risks during the tour. 9. A tour of the facility’s 12 patient rooms was conducted on 11/14/25 at 2:15 PM, the following patient safety concerns were identified: a. Twenty beds had a bed alarm with a connection cord greater than 18 inches in length and were not secured to the bed. b. Room 102 had a bedside table with broken pieces on the top of the table and sharp edges. An interview was conducted on 11/14/25 at 2:28 PM with EI # 9, Maintenance Supervisor, who confirmed the ligature risks and patient safety concerns.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 41624 Based on medical record (MR) review, facility policy and procedure, and interview, it was determined the psychiatric hospital failed to ensure: 1. An occurrence investigation was completed for all patient falls that occurred during their inpatient stay. 2. Members of the Interdisciplinary Team (IDT) developed an individualized interdisciplinary plan of care to minimize the incidence of falls and subsequent injury. 3. The risk manager tracked all adverse fall events, then identified and implemented appropriate interventions for fall safety. This deficient practice affected Patient Identifier (PI) # 2, and PI # 7, two of eight MRs reviewed, and had the potential to affect all patients admitted to this facility. Facility Policy: Fall Prevention Program Policy Number: None Original Date: 9/2015 Revision Date: 11/12/2025 Policy: The intent of Unity Psychiatric Care (UPC) fall prevention program is to increase patient safety and to provide a coordinated system to identify patients at risk for falls and develop an individualized interdisciplinary plan of care to minimize the incidence of falls and subsequent injury. Procedure: The fall prevention program is intended to: ...Direct the creation of an individualized treatment plan to reduce fall risk Team Members/Roles and Responsibilities: Director of Nursing (DON)/Assistant DON ...Completes post occurrence analysis report of all fall related occurrences. ...Risk Manager ...Helps identify and implement appropriate interventions. ...All Unity Staff ...Assists in assuring safety interventions are followed. Procedure: ...C. Post Fall Evaluation ...3. Complete Nurse Event Note 4. Add interventions to help reduce risk of re-occurrence. ...7. Attempt to determine the root cause of the event, gather statements from staff members... D. Monitoring Plan ...3. Risk Manager will review all occurrences. 4. Patients with multiple falls should be identified and communicated to treatment team members. 5. Quality/PI (Performance Improvement) Committee will review all inpatient fall reports daily for trends and patterns and develop corrective action plans as needed for identified trend(s) that may require further monitoring to achieve the optimum goal for fall reductions within the hospital. 6. Implement/modify the patient’s current plan of care with intervention(s) associated with the cause of the fall. 1. PI # 2 was admitted to the facility on 10/27/25 at 7:09 PM with a principal diagnosis of Dementia In Other Diseases Classified Elsewhere, Moderate, With Other Behavioral Disturbances. Review of the MR revealed PI # 2 had seven falls from 10/29/25 to 11/8/25. The surveyor requested the occurence documentation and investigation for the seven individual falls, including any identified trends and patterns identified to develop the individualized treatment plan/interventions to increase fall safety. The facility provided an Interdisciplinary Team (IDT) Occurence Investigation Worksheet for falls that occurred on 10/29/25, 11/2/25 and 11/8/25. There was no documentation provided for two falls that occurred on 10/31/25, one on 11/1/25, nor one on 11/5/25. The facility failed to analyze and track each adverse event for PI # 2. An interview was conducted on 11/14/25 at 3:57 PM with Employee Identifier (EI) # 4, Regional Nurse Manager, and EI # 5, Quality and Risk Management, who confirmed an occurrence investigation was not completed for four fall events for PI # 2 to analyze their causes, and implement preventive actions. 2. PI # 7 was admitted to the facility on 10/18/25 at 4:20 AM with a principle diagnosis of Dementia In Other Diseases Classified Elsewhere, Mild, With Other Behavioral Disturbance. Review of the MR revealed PI # 7 had three falls from 10/19/25 to 11/4/25. The surveyor requested the occurence documentation and investigation for the individual falls, including any identified trends and patterns identified to develop the individualized treatment plan/interventions to increase fall safety. The facility provided an Interdisciplinary Team (IDT) Occurence Investigation Worksheet for falls that occurred on 10/19/25 and 11/4/25. There was no documentation provided for the fall that occurred on 10/24/25. The facility failed to analyze and track each adverse event for PI # 7. An interview was conducted on 11/14/25 at 3:22 PM with EI # 4 and EI # 5, who confirmed an occurrence investigation was not completed for the 10/24/25 adverse fall event for PI # 7 to analyze its cause, and implement preventive actions.”

“QAPI PERFORMANCE IMPROVEMENT PROJECTS CFR(s): 482.21(d) As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must be proportional to the scope and complexity of the hospital’s services and operations. (2) A hospital may, as one of its projects, develop and implement an information technology system explicitly designed to improve patient safety and quality of care. This project, in its initial stage of development, does not need to demonstrate measurable improvement in indicators related to health outcomes. (3) The hospital must document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. (4) A hospital is not required to participate in a QIO cooperative project, but its own projects are required to be of comparable effort. This Standard is not met as evidenced by: 41623 Based on facility policy, Quality Assurance documentation review, and interview, it was determined the facility failed implement preventive actions and mechanisms, including implementing Performance Improvement Projects (PIPs), to ensure patient safety and prevention of falls. This deficient practice had the potential to affect all patients admitted to this facility. Findings include: Facility Policy: Quality Assurance Performance Improvement Policy Number: Not Listed Revised: 7/2025 Policy: Unity Psychiatric Care has systems and procedures that provide for the continual monitoring of the quality, appropriateness, and utilization of services provided. Performance is monitored to ensure that the improvements are sustained. This is accomplished through a systematic review of records of the persons served utilizing the appropriate documentation review forms. Procedure: ...2. Quality Assurance (QA) Summary Report: ...this form is used to summarize all QA materials. The Risk Manager completes these forms and submits copies to the Administrators and the Board of Directors for review by the Quality Assurance Team... 1. Review of the QA data presented to the Governing Body Meeting minutes between 4/24/25 and 10/29/25 revealed a total of 81 falls were reported. 13 of the patients with falls were sent to an Emergency Department for evaluation of suspected injuries. One of the fall victims suffered a Subdural Hematoma (a serious medical emergency where a blood clot forms between the brain and its protective outer layer, typically due to head trauma) and one fall victim suffered a hip fracture. Both incidents were reported as Sentinel Events (a patient safety event that results in death, permanent harm, or severe temporary harm). There was no documentation the facility implemented PIPs to monitor and reduce the incidence of patient falls.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 41623 Based on observations, facility policy and procedure, and interviews it was determined the facility failed to ensure medications were stored properly and discontinued medications were disposed of per facility policy. This had the potential to affect all patients admitted to this facility. Findings include: Facility Policy: Disposal of Medications and Medication Related Supplies Policy Number: Note Listed Effective Date: 1/1/25 Policy: Discontinued medications and medications left in the facility after a resident’s discharge, which do not qualify for return to the pharmacy for credit, or are donated are destroyed... Procedures: A. Unused, unwanted and not returnable medications should be removed from their storage area and secured until destroyed... 3... the facility may engage a reverse distributor to pick up the unwanted, unused NON-CONTROLLED medications... 1. A observation of the Medication Cart and Medication Room was conducted on 11/13/25 at 12:45 PM with Employee Identifier (EI) # 8, Registered Nurse. Located in the bottom drawer of the medication cart, the surveyor observed the following medications of discharged patients: a. Albuterol 0.63 milligrams (mg)/3 milliters (ml), five doses) prescribed for UP # 2 who was discharged was four days earlier on 11/10/25. b. Ipratropium Bromide/Albuterol 0.5 mg/3 mg, 22 doses, prescribed for UP # 3, who was discharged four days earlier on 11/10/25. c. Olanzepine 10 milligrams (mg) vials, four vials, prescribed for an Unsampled Patient (UP) # 1 who was discharged eight days earlier on 11/6/25. Located in the top drawer of the medication cart, the surveyor observed 15 vials of Olanzepine 10 mg vials. There were no names of patients on any of the vials. EI # 8 stated some of the Olanzepine vials from discharged patients are kept on the cart to give to patients on a physician’s order. EI # 8 further stated the non-narcotic medications of discharged patients are normally placed in the the destruction bin in the medication room. An observation of the Medication Room conducted with EI # 8 revealed an approximately 30 gallon medication destruction bin with a small slit on top for inserting medications. The bin was completely full. EI # 8 was asked what happens when the bin is full. EI # 8 stated they had been placing the medication in a bag on top of the bin, but he/she did not know where the bag was now. An interview was conducted on 11/14/25 at 2:00 PM with EI # 3, Regional Nurse Manager, who stated they had moved the medication bag to another room until the medications could be picked up for destruction. Located in the locked Maintenance Office the surveyor observed a clear plastic bag with the following medications of recently discharged patients, still in original packaging: 1. Haloperidol 5 mg, 30 tablets. 2. Olanzapine 5 mg, 30 tablets. 3. Ibuprofen 400 mg, 29 tablets. 4. Hydroxyzine Pamoate 25 mg, 21 tablets. 5. Divalproex 250 mg, nine tablets. 6. Mirtazapine 15 mg, 12 tablets. 7. Sertraline 100 mg, 16 tablets. 8. Sertraline 100 mg, 16 tablets. 9. Trazadone 50 mg, 11 tablets. 10. Lisinopril 10 mg, 17 tablets. 11. Trazadone 50 mg, 27 tablets. 12. Olanzapine 2.5 mg, 6 tablets. 13. Quetiapine 25 mg, 14 tablets. 14. Haloperidol 5 mg, 13 tablets. 15. Trazodone 50 mg, one tablet. 16. Bumetanide 1 mg, 14 tablets. 17. Prednisone 20 mg, two tablets. 18. Eliquis 2.5 mg, 30 tablets. 19. Amiodarone 200 mg, 18 tablets. 20. Linzess 145 mg, 16 tablets. 21. Atorvastin 20 mg, 68 tablets. 22. Pantoprazole 40 mg, 22 tablets. 23. Pantoprazole 40 mg, three tablets. 24. Clanzapine 2.5 mg, 14 tablets. 25. Haloperidol 5 mg, 28 tablets. 26. trazodone 50 mg, seven tablets. 27. SMZ/TMP (sulfamethoxazole/trimethoprim) 800/160 mg, six tablets. 28. Quetiapine 25 mg, three tablets. 29. Trazodone 50 mg, 16 tablets. 30. Olanzapine 2.5 mg, 12 tablets. 31. Haloperidol 5mg, 14 tablets. 32. Olanzapine 5 mg, 13 tablets. 33. Pantoprazole 40 mg, 13 tablets. 34. Sertraline 50 mg, 14 tablets. 35. Pantoprazole 40 mg, 11 tablets. 36. Divalproex 250 mg, 21 tablets. 37. Levetiracetam 500 mg, 12 tablets. 38. Furosemide 20 mg, five tablets. 39. Trazodone 50 mg, three tablets. 40. Spironolactone 25 mg, 11 tablets. 41. Loperamide 2 mg, 30 tablets. 42. Olanzapine 10 mg, 11 tablets. 43. Trazodone 50 mg, 28 tablets. 44. Trazodone 5o mg, one tablet. 45. Olanzipine 5 mg, five tablets. 46. Haloperidol 5 mg, 14 tablets. 47. Trazodone 50 mg, 14 tablets. 48. Trazodone 50 mg, 14 tablets. 49. Trazodone 50 mg, six tablets. 50. Olanzipine 2.5 mg, seven tablets. 51. SMZ/TMP 800/160 mg, 12 tablets. 52. Trazodone 50 mg, three tablets. 53. Trazodone 50 mg, six tablets. 54. Trazodone 50 mg, 14 tablets. 55. Haloperidol 0.5 mg, 14 tablets. 56. Trazodone 50 mg, six tablets. 57. Baclofen 10 mg, 14 tablets. 58. Olanzapine 2.5 mg, 14 tablets. 59. Prednisone 20 mg, one tablet. 60. Prednisone 20 mg, one tablet. 61. Haloperidol 5 mg, 10 tablets. 62. Trazodone 50 mg, 28 tablets. 63. Haloperidol 5 mg, 14 tablets. 64. Trazodone 50 mg, three tablets. 65. Azithromycin 250 mg, two tablets. 66. Cefpodoxime 200 mg, 15 tablets. 67. Cefuroxime 500 mg, five tablets. 68. Trazodone 50 mg, 30 tablets. 69. Trazodone 50 mg, 25 tablets. 70. SMZ/TMP 800/160 mg, 11 tablets. 71. Trazodone 50 mg, two tablets. 72. Olanzepine 2.5 mg, 14 tablets. 73. Olanzepine 2.5 mg, 14 tablets. 74. Trazodone 50 mg, 10 tablets. 75. Methocarbam 500 mg, 30 tablets. 76. Spironolactone 25 mg, seven tablets. 77. Furosemide 20 mg, 10 tablets. 78. Trazodone 100 mg, nine tablets. 79. Levetiracetam 500 mg, 13 tablets. 80. Olanzapine 10 mg, four vials. 81. Olanzapine 10 mg, four vials. 82. Ipratropium/Albuterol Inhalation, 28 packs. 83. Trazodone 50 mg, five tablets. 84. Olanzapine 2.5 mg, five tablets. 85. Potassium Chloride Micro 20 milliequivalents (meq), five tablets. 86. Nitrofurantoin 100 mg, one tablet. 87. Olanzepine 2.5 mg, 13 tablets. 88. Trazodone 50 mg, six tablets. 89. Trazodone 50 mg, 14 tablets. 90. Olanzepine 2.5 mg, 10 tablets. 91. Insulin Lispor 100 unit/milliliter (ml), one vial. 92. Insulin Aspart Protamine 70/30 mix, one vial. 93. Cefpodoxime 200 mg, nine tablets. 94. Trazodone 50 mg, seven tablets. 95. Haloperidol 5 mg, 28 tablets. 96. Trazodone 50 mg, seven tablets. 97. Amoxicillin/Clavulanate 875/125 mg, two tablets. 98. Divalproex 250 mg, 30 tablets. 99. Trospium Chloride 60 mg, two tablets. 100. Haloperidol 5 mg, 28 tablets. 101. Olanzapine 2.5 mg, 14 tablets. 102. Trazodone 50 mg, 14 tablets. 103. Trazodone 50 mg, 14 tablets. 104. Fluconazole 150 mg, two tablets. 105. Trazodone 50 mg, 28 tablets. 106. Cephalexin 500 mg, 12 capsules. 107. Quetiapine 25 mg, one tablet. 108. Hydoxyzine 25 mg, 14 tablets. 109. Liothyronine Sodium 5 mg, one tablet. 110. Oxcarbazepine 300 mg, one tablet. 111. Atorvastatin 40 mg, one tablet. 112. Eliquis 5 mg, one tablet. 113. Levothyroxine 200 mg, one tablet. 114. Liothyronine Sodium 5 mg, one tablet. 115. Atorvastatin 10 mg, one tablet. 116. Isosorbide 30 mg, one tablet. 117. Eliquis 5 mg, one tablet. 118. Carvedilol 12.5 mg, one tablet. 119. Amiodarone 200 mg, one tablet. 120. Clopidogrel 75 mg, one tablet. 121. Donepezil 10 mg, one tablet. 122. Quetiapine 100 mg, one tablet. 123. Eliquies 5 mg, one tablet. 124. Metoprolol 25 mg, one tablet . 125. Memantine 10 mg, one tablet. 126. Armour Thyroid 90 mg, one tablet. 127. Fluticason 50 micrograms (mcg), one spray container. 128. Rivastigmine 13.3/24 mg, one patch. 129. Cyanocobalamine injection 1000 mg, one vial. 130. Atorvastatin 10 mg, two tablets. 131. Pravastatin 10 mg, 12 tablets. 132. Eliquis 2.5 mg, two tablets. 133. Quetiapine 100 mg, five tablets. 134. Divalproex 250 mg, four tablets. 135. Paroxetine 20 mg, three tablets. An interview was conducted on 11/14/25 at 2:00 PM with EI # 3, who confirmed the medications from discharged patients had not been removed from the medication cart and disposed of by destruction per facility policy.”

“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: 49603 Based on observations, and staff interview, the facility failed ensure supplies and equipment were maintained at an acceptable level of safety and quality. This affected 12 of 12 patient rooms. Findings Include: A tour of the facility was conducted on 11/14/25 at 2:15 PM of 12 patient rooms. All rooms had a single bathroom with a sink and toilet, the surveyor observed: a. Rooms 101, 103, 105, 111, and 112 were without running water in the sinks. Room 109 had water running constantly with an out of order sign on the door. b. There was no soap available for patient use at the sinks in any of the 12 rooms observed. An interview was conducted on 11/14/25 at 2:28 PM with Employee Identifier # 9, Maintenance Supervisor, who confirmed the rooms did not have running water. He stated, “Roto Rooter Plumbing had been approved today and would be here tomorrow to change out the sensors in the sinks”. EI # 9 also confirmed there was no soap at the sinks available for patient use.”