Avenir Behavioral Health Center

“HOSPITAL MUST MAINTAIN RECORDS CFR(s): 489.20(r)(1) [The provider agrees,] in the case of a hospital as defined in §489.24(b), (including both the transferring and receiving hospitals), to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer. This Standard is not met as evidenced by: 49638 Based on Hospital policies and procedures, Hospital document, medical records request, and employee interview, it was determined that the Hospital failed to ensure a patient medical record was maintained with all required documentation for at least 5 years. This deficient practice can result in a patient not getting appropriate psychiatric and medical care if they need further treatment. Findings Include: Hospital policy titled “Medical Staff Bylaws, Rules and Regulations,” Policy #19847425, Effective 02/2026, revealed “...The attending Practitioner shall be responsible for the preparation of a complete and legible medical record for each patient... Medical Staff Rules and Regulation Admission and Discharge of Patients ...12. Nurses completing Medical Screening Exams (MSE) must be a Qualified Medical Professional (QMP). For MSEs, RNs are considered QMPs and will be completing these exams ....” Hospital document titled “2.26 EMTALA” revealed : Patient #6 arrival date 2/9/2026, “ ...Arrival Time ...1010 ...Arrival Mode ...Car ...Emergency Medical/Psych Condition (Yes or No) ...No ...Disposition ...Transferred to ED Emergent ....” Request was made for the medical records for Patient #6, including medical screening examination and determination of an emergency medical condition. None was provided. Employees #1 and #3 confirmed, during interviews conducted March 17, 2026 through March 20, 2026, that no medical record for Patient #6, including medical screening examination and determination of an emergency medical condition, was available for review at the time of the survey.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 52829 Based on hospital policy and procedure review, hospital documentation review and request, and employee interview, it was determined that the hospital failed to comply with protecting and promoting patient’s rights as evidenced by: Cross reference A-0144: The hospital failed to ensure patients received care in a safe setting. Cross reference A-0160: The hospital failed to ensure an order was given for a chemical restraint. Cross reference A-0166: The hospital failed to ensure a modification was written in the patients care plan after a restraint. Cross reference A-0167: The hospital failed to ensure proper restraint technique was applied to a patient. Cross reference A-0168: The hospital failed to ensure an order was given for a physical restraint. Cross reference A-0169: The hospital failed to ensure restraint orders were not written as “as needed” (PRN). Cross reference A-0178: The hospital failed to ensure a face-to-face assessment was completed within an hour of a restraint initiation. Cross reference A-0194:The hospital failed to ensure registry staff received orientation and verified skills before providing services. Cross reference A-0208: The hospital failed to ensure a registry staff obtained seclusion/restraint training in accordance to policy. The cumulative and egregious effect of these systemic deficient practices resulted in the Hospital’s failure to meet the requirement for Condition of Participation for Patient Rights.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 52829 Based on hospital policy and procedure review, hospital documentation review, employee file review, and employee interview, it was determined that the hospital failed to meet the requirement of the Conditions of Participation for Nursing Services as evidenced by the following reference to standard-level deficiencies: Cross reference A-0392: The Nurse Executive failed to ensure staff are meeting the needs of patients on the floor. Cross reference A-0395: The Nurse Executive failed to ensure nursing services were provided to patients as ordered by a physician. Cross reference A-0396: The Nurse Executive failed to ensure staff were responding in accordance to patient interventions and care plans. Cross reference A-0398 : The Nurse Executive failed to ensure proper oversight of unlicensed contract staff. Cross reference A-0405: The Nurse Executive failed to ensure medication was administered in accordance with the order. The cumulative and egregious nature of these deficient practices resulted in the facility’s failure to meet the requirement for the Condition of Participation for Nursing Services.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 52829 Based on review of hospital records and staff interviews, it was determined the hospital failed to meet the emergency needs of patients within acceptable standards of practice as evidenced by: Cross reference A-1104: The hospital failed to ensure staff responded to an emergency situation in accordance to policy. The egregious nature of this deficient practice resulted in the hospital failing to meet the condition of participation for emergency services.”

“Special Staff Requirements CFR(s): Condition of Participation: Special Staff Requirements for Psychiatric Hospitals The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning. This Condition is not met as evidenced by: 52829 Based on record reviews and staff interviews, it was determined the hospital failed to adequately staff to meet the needs of patients within acceptable standards of practice as evidenced by: Cross reference A-1687: The hospital failed to ensure qualified staff provided services to patients. Cross reference A-1700: The hospital failed to ensure the necessary nursing care was provided to patients. Cross reference: A-1717: The hospital failed to ensure their staff met the qualifications in the job description. The cumulative and egregious nature of this deficient practice resulted in the facility’s potential inability to provide necessary medical care and treatment to patients.”

“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: 52829 Based on policies and procedures, hospital documentation review, medical record review, and employee interview, it was determined the hospital failed to ensure Patient #1 and Patient #5 received care in a safe setting. An immediate jeopardy was called in regards to: Patient #1 ’ s delay in life-saving care that resulted in patient expiration and; Patient #5 ’ s restraint by unqualified personnel and unapproved technique. Findings Include: 1. Policy #1875450, titled “Withdrawal from Alcohol/Benzodiazepine,” last effective 09/2025, revealed: “ ...Purpose: ...Instruments like the CIWA can help clinical personnel recognize the process of withdrawal before it progresses to more advanced stages, such as delirium tremens ...3. CIWA to be completed on admission and detox orders to be followed ....” Patient #1 ’ s medical record revealed the following: A document titled, “Patient Orders,” which revealed: “ ...Obtain vital signs and CIWA score every four (4) hours routine for 4 days (CIWA at 0000, 0400, 0800, 1200, 1600, 2000), then three times a day while awake until discontinued by provider (0900, 1500, 2100)., for 7 days ...Duration: 7 day taper, start date: 09/25/2025 11:15, end date: 10/02/2025 11:14 ....” A document titled, “CIWA-Ar History-(Patient #1),” which revealed: “ ...09/25/25 15:59 ...Score ...4 ...09/25/25 23:29 ...Score ...8 ...09/26/25 08:00 ...Score ...7 ...” Employee #2 confirmed during interview conducted on January 5, 2025, through January 14, 2025, that the aforementioned CIWA assessments for Patient #1 on 09/25/2025, through 09/26/2025, occurred past the four (4) hour timeframe that was provider ordered. Policy #18754579, titled “Code Blue,” last effective 09/2025, revealed: “...At Avenir Behavioral Health Center, a Code Blue is defined as ANY medical emergency that would require the use of additional medical personnel not currently available to the nurse. This may include, but is not limited to:...Major fall ...Upon discovering that a patient has experienced one of the above signs or symptoms, or any other sign or symptom of immediate medical concern, the staff member shall call a Code Blue by paging overheard ....” Policy #18754609, titled “Falls Assessment and Prevention,” last effective 09/2025, revealed: “...Post Falls Procedure ...attend to the immediate medical needs of the patient ....” Job Description titled “Registered Nurse,” revealed: “...Initiate emergency medical care when indicated ...Documentation meets current standards and policies ...Performs all aspects of patient care in an environment that optimizes patient safety ....” Patient #1 ’ s medical record revealed the following: A document titled “Daily Nursing Assessment 09/26/2025 18:03,” which revealed: “...At ~1500,...Gait unsteady; patient encouraged to sit for safety ...Shortly after, patient stood and fell to the floor ...did not respond to requests to sit up ...Pulse ox applied; radial pulse palpable ...Pulse ox would not adhere; patient became unresponsive. Alarm/code called;...Times are approximate, as this RN was actively intervening during the event. Please refer to video footage for exact sequence and timing ...Employee #8 ....” Video footage from 09/26/2025 revealed the following: 15:31:46- Patient #1 sitting in chair in dayroom. 15:31:50- Patient #1 stands up from chair. 15:31:52- Patient #1 stumbles into wall. 15:31:54- Patient #1 out of view of camera. 15:32:00- Patient #1 falls on floor in front of nursing station. Employee #8 and Employee #20 are facing Patient #1 as they fall. 15:32:05- Patient #1 still on floor. Employee #8 and #20 and using hand gestures to each and to Patient #1. Employee #9 is observed to be sitting in the nurses station. 15:32:23- Employee #20 walks past Patient #1 on floor. 15:32:45- Employee #8 walks up to Patient #1 on floor. Squats down and puts hand near Patient #1 ’ s left wrist. 15:32:52- Employee #20 stands up with hands in pockets next to Patient #1. 15:33:01- Employee #8 squats down and puts hand near Patient #1 ’ s left wrist. 15:33:20- Employee #8 puts hand near Patient #1 ’ s neck. 15:33:35- Employee #8 walks to nursing station from Patient #1 that is still on the floor and has not been observed to move. 15:33:41- Employee #20 steps back into view next to Patient #1. 15:34:24- Employee #8 squats down and puts hand near Patient #1 ’ s left wrist. 15:36:10- Employee #8 walks to nursing station from Patient #1 that is still on the floor and has not been observed to move. 15:37:28- Employee #20 walks up with a wheelchair to Patient #1, who is still on the floor and has not been observed to move. 15:39:36- Staff attempt to lift Patient #1 off ground onto wheelchair. 15:40:06- Staff fail to lift Patient #1. 15:40:08- Code Blue appears to be called. 15:40:43- Crash chart is brought out. Employee #1 and #2 confirmed in an interview conducted on January 8, 2026, through January 14, 2026, that Employee #8 documented inaccurate information in Patient #1 ’ s chart. It was revealed that Employee #8 never felt a pulse and was actively assuring staff Patient #1 ’ s was “behavioral” and directed staff not to call a code. Employee #1 and #2 further confirmed in an interview conducted on January 8, 2026, through January 14, 2026, that Employee #8 failed to implement hospital policies and procedure relating to Patient #1 that delayed their ability to receive life-saving care. 2. A review of Hospital policy titled “Seclusion and Restraint, Policy # 18754616,” with an effective date of 09/2025, revealed “...It is the intent of Avenir Behavioral Health Center (ABHC) to provide a safe environment for patients and staff, utilizing the least restrictive environment needed to achieve the best outcomes. This includes the following points:...Restraint or seclusion is used only as an emergency measure to manage a patient’s unanticipated, severely aggressive or destructive behavior that places the patient or others in imminent danger and all less restrictive measures have been determined to be ineffective ...The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member or others from harm ...Only approved CPI Team Control methods are to be used during a seclusion or restraint event ... A review of a document titled, “Risk Incident Report” dated 12/28/25, revealed Patient #5 was administered three types of restraints, including physical, mechanical & chemical, on December 28, 2025. A review of video surveillance of the corresponding incident on December 28, 2025 for Patient #5 revealed the following: 12:33 PM- Employee #11, Employee # 14 & Employee #17 are observed attempting to place Patient #5 in a three-person hold. Patient #5 is observed falling to his/her knee while Employee #17 has hand on the back of Patient #5 ’ s neck. 12:36 PM - Employee #14 & Employee #17 were observed with their hands wrapped around Patient #5 ’ s neck along with two other employees pressing Patient #5 ’ s body into a closed door. A review of a Hospital restraint training document titled “Physical Interventions-Holding Skills,” Information Source, CPI Training Manual, revealed a demonstration of Principles of Holding in a Standing Position & Higher-Level Holding-Standing Position Team Control Position, that demonstrates a 2-person restraint holding the person ’ s lower arms with a third person monitoring. The training document does not demonstrate hands being placed on the person ’ s neck. Employee #2 confirmed in interviews conducted on January 8, 2026 through January 14, 2026, that the holds observed during the review of the video surveillance of Patient #5 was not performed using an approved technique that is trained to Hospital employees.”

“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: 52829 Based on a review of policies and procedures, facility documentation, medical record, and staff interviews, it was determined the Hospital failed to ensure patients receiving a chemical restraint were recognized as restraints, and documented as being under restraint. This deficient practice poses a risk to the health and safety of patients if they are not monitored, assessed, and evaluated when under chemical restraint and could result in patient harm including death. Findings include: A.A.C. Title 9 Chapter 10 Article 1 states 203. “Restraint” means any physical or chemical method of restricting patient ’ s freedom of movement, physical activity, or access to the patient ’ s own body. Policy titled “Seclusion and Restraint,” policy #18754616, last effective 09_2025 revealed, “ ... Restraint or seclusion is used only as an emergency measure to manage a patient’s unanticipated, severely aggressive or destructive behavior ...B. As soon as possible, but no longer than one hour after the initiation of restraint or seclusion, qualified staff shall: Notify and obtain an order (verbal or written) from the licensed independent Contractor ... The order shall indicate the reason and maximum duration of restraint ....” Review of patient #5 medical record document titled “Progress Note” revealed, “ ... Date of Service 12/28/2025 13:23 ...Patient was outside with BHT and stated that he burned his finger with a cigarette ... Patient then started running toward door and broke threw unit doors. RN ran after patient into the intake area. Patient then attempted to break out of intake door to outside. RN and receptionist ... attempted to deescalate the situation with verbal communication ... staff arrived with restraint chair. Patient was placed in restraint chair ... RN obtained order for chemical restraint ... RN administered chemical restraint to patient ....” Review of patient #5 medical record document titled “medications” revealed, dated and time stamped entry “ ... 12/28/2025 01:19 PM ... haloperidol lactate, 5 mg/ml x 1 ml ... Given at 1320 ...given as a restraint ... lorazepam, 2 mg/ml x 1 ml , injection, solution ... given at 1320 ... diphenhydramine HCl, 50 mg/ml x 1 ml , injection, solution ... given at 1320 ....” Dated and time stamped entry “ ... 12/29/2025 03:00 PM ... haloperidol lactate, 5 mg/ml x 1 ml ... Given at approximately 1445 ... lorazepam, 2 mg/ml x 1 ml , injection, solution ... at approximately 1445 diphenhydramine HCl, 50 mg/ml x 1 ml , injection, solution ... at approximately 1445 ....”. Order for chemical restraint on 12/28/2025 was requested on survey conducted 1/8/2026 through 1/14/2026, none available for review. Order for chemical restraint on 12/29/2025 was requested on survey conducted 1/8/2026 through 1/14/2026, none available for review. Review of patient #20 medical record document titled “Documentation Supporting BIRP note B: (Behavior) I: (Intervention) R: (Response) P: (Plan)” signed by employee 31 time stamped 01/01/2026 15:40 revealed, “ ... Patient was extremely agitated and upset that the nurse would not go to his room to sleep with him ... Patient was being confrontational so much so that he spit on a BHT. In addition, patient was verbally aggressive towards staff ... Patient was seen aggressively charging towards staff and unit doors. The on-call provider ... was called and ordered a B 52 treatment ... Patient took a oral 5 mg Haldol and had a 50 mg of Benadryl IM ... Ativan was held for further assessment ....” Order for chemical restraint on 01/01/2026 was requested on survey conducted 1/8/2026 through 1/14/2026, none available for review. In joint interview conducted while on survey 1/14/2026 employee #1, #2, and #3 confirmed that patient #5 and patient #20 had received chemical restraints without an order from a provider per policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 52829 Based on a review of facility policy & procedure, facility documentation, medical records & staff interview, it was determined the Hospital failed to ensure patient treatment plans were reviewed & revised following the first episode of restraint per policy. This deficient practice poses the increased risk of future incidents requiring additional restraints and that treatment goals are delayed or not met. Findings include: A review of policy entitled, “Seclusion and Restraint, Policy # 18754616,” with an effective date of 09/2025, revealed “...The treatment plan shall be reviewed and revised following the first episode of restraint to include measures to prevent recurrence. Additional review of the treatment plan, with revisions as indicated, will occur if the patient is restrained on more than one occasion ....” A review of a document titled, “Risk Incident Report” dated 3/17/25, revealed Patient #3 was administered a chemical restraint. A review of a document titled, “Restraint/Seclusion Packet” dated 3/17/25 for Patient #3 revealed no selection made to the prompt of an update to the treatment plan as it was left blank, “...Restraint PI Tool ...Required Elements ...16. Treatment Plan reviewed/revised or appropriate reason to not revise is documented ....” A review of the medical record for Patient #3 revealed no documentation of a review & revision to Patient #3 ’ s treatment plan. A review of a document titled, “Risk Incident Report” dated 3/22/25, revealed Patient #4 was administered a chemical restraint. A review of a document titled, “Restraint/Seclusion Packet” dated 3/23/25 for Patient #4 revealed selection made to the prompt of an update to the treatment plan was marked under “...N/A ...”, “...Restraint PI Tool ...Required Elements ...16. Treatment Plan reviewed/revised or appropriate reason to not revise is documented ....” A review of the medical record for Patient #4 revealed no documentation of a review & revision to Patient #4 ’ s treatment plan. A review of a document titled, “Risk Incident Report” dated 12/28/25, revealed Patient #5 was administered three types of restraints, including physical, mechanical & chemical, on December 28, 2025. A review of a document titled, “Restraint/Seclusion Packet” dated 12/28/25 for Patient #5 revealed no selection made to the prompt of an update to the treatment plan as it was left blank, “...Restraint PI Tool ...Required Elements ...16. Treatment Plan reviewed/revised or appropriate reason to not revise is documented ....” A review of the medical record for Patient #5 revealed no documentation of a review & revision to Patient #5 ’ s treatment plan. A review of a document titled, “Risk Incident Report” dated 8/19/25, revealed Patient #19 was administered a mechanical restraint. A review of a document titled, “Restraint/Seclusion Packet” dated 8/19/25 for Patient #19 revealed no selection made to the prompt of an update to the treatment plan as it was left blank, “...Restraint PI Tool ...Required Elements ...16. Treatment Plan reviewed/revised or appropriate reason to not revise is documented ....” A review of the medical record for Patient #19 revealed no documentation of a review & revision to Patient #19 ’ s treatment plan. Employee #1 & Employee #2 confirmed in interviews conducted on January 8, 2026 through January 14, 2026, that no documentation of a review & revision of Patient #3, Patient #4, Patient #5, and Patient #19 ’ s treatment after the first episode of restraint was not available for review.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 50979 Based on Hospital policy and procedure, Hospital video monitoring footage, restraint training documentation, and employee interview, it was determined the Hospital failed to ensure the application of a patient restraint occurred pursuant to employee training. This deficient practice poses the potential risk of patient injury if restraint is applied without following approved technique. Findings include: A review of Hospital policy titled “Seclusion and Restraint, Policy # 18754616,” with an effective date of 09/2025, revealed “...It is the intent of Avenir Behavioral Health Center (ABHC) to provide a safe environment for patients and staff, utilizing the least restrictive environment needed to achieve the best outcomes. This includes the following points:...Restraint or seclusion is used only as an emergency measure to manage a patient’s unanticipated, severely aggressive or destructive behavior that places the patient or others in imminent danger and all less restrictive measures have been determined to be ineffective ...The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member or others from harm ...Only approved CPI Team Control methods are to be used during a seclusion or restraint event ... A review of a document titled, “Risk Incident Report” dated 12/28/25, revealed Patient #5 was administered three types of restraints, including physical, mechanical & chemical, on December 28, 2025. A review of video surveillance of the corresponding incident on December 28, 2025 for Patient #5 revealed the following: 12:33 PM- Employee #11, Employee # 14 & Employee #17 are observed attempting to place Patient #5 in a three-person hold. Patient #5 is observed falling to his/her knee while Employee #17 has hand on the back of Patient #5 ’ s neck. 12:36 PM - Employee #14 & Employee #17 were observed with their hands wrapped around Patient #5 ’ s neck along with two other employees pressing Patient #5 ’ s body into a closed door. A review of a Hospital restraint training document titled “Physical Interventions-Holding Skills,” Information Source, CPI Training Manual, revealed a demonstration of Principles of Holding in a Standing Position & Higher-Level Holding-Standing Position Team Control Position, that demonstrates a 2-person restraint holding the person ’ s lower arms with a third person monitoring. The training document does not demonstrate hands being placed on the person ’ s neck. Employee #2 confirmed in interviews conducted on January 8, 2026 through January 14, 2026, that the holds observed during the review of the video surveillance of Patient #5 was not performed using an approved technique that is trained to Hospital employees.”

“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: 52829 Based on a review of facility policy & procedure, facility documentation, medical records & staff interview, it was determined the hopsital failed to ensure an order from a physician or other licensed practitioner for each application of physical restraint for a patient is documented. This deficient practice poses a potential risk of patients not receiving care as ordered by a provider, which poses a potential risk of harm to the health and safety of patients. Findings include: A review of policy entitled, “Provider Orders, Policy # 18754292,” with an effective date of 08/2025, revealed “...Policy: It is the policy of the facility that all care, treatment, and services provided by the hospital are written directly or indirectly by a physician or licensed independent practitioner (LIP) credentialed by the hospital as outlined in the Medical Staff Bylaws; and that these orders are clear, concise, and in accordance with all other applicable policies. It is also the policy of the facility that all orders are authenticated/signed within 48 hours. Procedure: 1. All care, treatment, and services provided in the hospital is supported by a provider’s order. No care, treatment, or services may be provided prior to obtaining a provider’s order, except in the specific situations outlined in this policy. 2. The following types of orders are written by the medical staff for care, treatment, and services in the hospital:...i. Orders for seclusion and restraint ....” A review of a document titled, “Risk Incident Report” dated 12/28/25, revealed Patient #5 was administered three types of restraints, including physical, mechanical & chemical, on December 28, 2025. A review of video surveillance of the corresponding incident on December 28, 2025 for Patient #5 revealed two applications of physical holds or restraints, an administration of a chemical restraint and application of a mechanical restraint. A review of the medical record for Patient #5 revealed no documentation of orders by a physician or LIP for the two applications of physical restraint on December 28, 2025. A review of a document titled, “Risk Incident Report” dated 12/29/25, revealed Patient #5 was administered a chemical restraint on December 29, 2025. Further review of the document revealed, “...Pt held & Emergent IM given ....” A review of a document titled, “Restraint/Seclusion Packet” dated 12/29/25 for Patient #5 revealed, “...Intervention ...Other ...IM Injection w/hold ...Any recommendations to improve the process?...more coordinated hold ....” A review of the medical record for Patient #5 revealed no documentation of an order by a physician or LIP for the application of physical restraint on December 29, 2025. A review of a document titled, “Risk Incident Report” dated 12/30/25, revealed Patient #5 was administered two types of restraints, including physical & chemical, on December 30, 2025. Further review of the document revealed, “...Pt engaged in a physical altercation with a staff member, striking the staff multiple times ...The patient was physically restrained and placed on the ground ....” A review of a document titled, “Restraint/Seclusion Packet” dated 12/30/25 for Patient #5 revealed a checkmark selected for, “...Physical Restraint ...Time In/Out ...1100/1103 ....” A review of the medical record for Patient #5 revealed no documentation of an order by a physician or LIP for the application of physical restraint on December 30, 2025. Employee #1 & Employee #2 confirmed in interviews conducted on January 8, 2026 through January 14, 2026, that orders for physical restraints by a physician or LIP were not available for Patient #5 for the two applications on December 28, 2025, the one application on December 29, 2025 & the one application on December 30, 2025.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). This Standard is not met as evidenced by: 52829 Based on hospital policy and procedure, medical record review, and employee interview, it was determined the Hospital failed to ensure chemical restraint orders were written only when there was an immediate need for intervention, and not on an as needed basis. This deficient practice poses the risk of patients being restrained inappropriately, and a provider being unaware of the amount of seclusion and restraints a patient is receiving. Findings Include: Policy #18754616, titled “Seclusion and Restraint,” last effective 09/2025, revealed: “...Chemical Restraint-(42 CFR 482.13 (e)(1)(i)(B)) A drug or medication when used as a restriction to manage the patient ’ s behavior or restrict the patient ’ s freedom of movement and is not: A usual and customary part of a medical diagnostic or treatment procedure to which the individual or his/her legal representative has given consent ....” Policy #17861974, titled “Standing Orders, Procedures, Protocols,” last effective 03/2025, revealed: “...Restraint and Seclusion ...Standing orders may not be used for restraint or seclusion. ...” The National Institute of Health, National Library of Medicine, Journal of Education & Teaching in Emergency Medicine, October 15, 2020 article “Agitated Psychiatric Patient” revealed: “ ...The main classes of medications utilized for chemical restraint include first-generation antipsychotics (eg, haloperidol and droperidol), second-generation antipsychotics (olanzapine, quetiapine, risperidone, aripiprazole, and ziprasidone), benzodiazepines (eg, lorazepam and midazolam), and N-methyl-D-aspartic acid (NMDA) receptor antagonists (eg, ketamine) ....” The Journal of Clinical Psychiatry, May, 2021 article titled “Intramuscular B52” revealed “ ...a patient ’ s aggression is so severe that it necessitates use of an intramuscular agent ...intramuscular (IM) haloperidol with IM lorazepam with IM diphenhydramine. This recommendation is so common that it even has its own name: B52 or Benadryl (diphenhydramine), haloperidol 5 mg, and lorazepam 2 mg ....” Patient #8 ’ s medical record revealed a document titled “Patient Order ’ s,” which revealed: “...diphenhydramine HCl, 50 mg/ml x 1 ml , injection, solution, once, for 1 day, PRN Justification: extreme agitation PRN, Duration: One-Time, start date: 12/27/2025 18:00,...haloperidol lactate, 5 mg/ml x 1 ml , injection, solution, once, for 1 day, PRN Justification: extreme agitation PRN, Duration: One-Time, start date: 12/27/2025 18:00,...lorazepam, 2 mg/ml x 1 ml , injection, Syringe, once, for 1 day, PRN Justification: extreme agitation PRN, Duration: One-Time, start date: 12/27/2025 18:00,....” Patient #13 ’ s medical record revealed a document titled “Patient Order ’ s,” which revealed: “...Ativan (lorazepam), 2mg/ml x 0.5 MLs , injection, solution, once, for 1 day, PRN Justification: AGITATION PRN, Duration: 1 day, start date: 10/25/2025 17:00,...DIPHENYDRAMINE, 50mg/ml x 1 ML , IM, injection, once, for 1 day, PRN Justification: AGITATION PRN, Duration: 1 day, start date: 10/25/2025 17:00,...Haloperidol Lactate, 5mg/ml x 1 ML , injection, solution, once, for 1 day, PRN Justification: AGITATION PRN, Duration: 1 day, start date: 10/25/2025 17:00,....” Employee #2 confirmed in an interview conducted on January 14, 2026, that Patient #8 and Patient #13 ’ s medical record contained chemical restraint orders that were ordered as PRN (as needed).”

“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: 52829 Based on hospital policy and procedure, medical record review,hospital documentation, and employee interview, it was determined that the Hospital failed to ensure staff followed assessment processes when patients are placed in seclusion and/or restraint. This deficient practice poses a risk that patient needs are not consistently assessed, and met while in seclusion and/or restraint. Findings Include: Policy #18754616, titled “Seclusion and Restraint,” last effective 09/2025, revealed: “...A Practitioner or trained registered nurse shall conduct an in-patient evaluation of the patient within one hour initiation of restraint to assess physical and psychological status. The in-person evaluation includes the patient ’ s immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention ....” Patient #3 ’ s medical record revealed the following: A document titled “Progress Note 03/17/2025 01:19,” which revealed: “...Patient was displaying severe mania, pacing, excessive talking, very disruptive and not re-directable. Provider notified and orders received for Ativan 2mg, Benadryl 50mg and Haldol 5mg. Patient was compliant with taking and it took affect approximately l hour later. Patient then went to sleep. Will continue to monitor for safety ....” A document titled “Patient Order ’ s,” which revealed: “...Chemical Restraint, once, for 1 day Justification: DTO and/or DTS Duration: 1 day, start date: 03/17/2025 00:15 ....” Hospital documentation titled “RESTRAINT/SECLUSION PACKET,” dated 3/17/25, revealed: “...Verbal/Phone Order by:...Date: 3/17/25 Time: 0002 ...IN-PERSON EVALUATION BY PRACTICIONER/RN ...Nurse (RN)Signature:...Date: 3/17/25 Time: 0513 ....” Employee #2 confirmed in an interview conducted on January 8, 2026, through January 14, 2026, that the in-person evaluation was not conducted within one hour of initiation.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f) Restraint or Seclusion: Staff Training Requirements. The patient has the right to safe implementation of restraint or seclusion by trained staff. This Standard is not met as evidenced by: 52829 Based on review of facility documentation and staff interview, and document request it was determined that the Hospital failed to ensure that skills and knowledge are verified and documented for contracted staff prior to providing physical or behavioral services. Failure to verify the skills and knowledge of all personnel has the potential for patient harm due to unverified staff ’ s ability to provide necessary care. This is a repeat deficiency from complaint validation follow up survey #0051819, federal ID FIY912, with a plan of correction date of 12/2024, conducted on 1/6/2025. Findings include: Review of hospital document titled “New Employee Orientation & Ongoing Staff Training” policy #17237138, last revised 12_2024 revealed “Avenir provides general orientation to all newly hired employees. The orientation introduces the employee to the mission, vision and values of Avenir, provides employees with the key elements for effective job performance, and provides the tools to ensure a safe and healthy working environment ... Procedure: 1. All full-time, part-time and PRN employees, as well as any interns, must attend a New Employee Orientation session ... 2. The orientation will include the following: ...An overview of all departments at Avenir, their responsibilities, and how all disciplines are expected to work cohesively with one another. Information on health, safety, and environmental issues. Information related to the quality of care for all patients. Information/training on The Emergency Medical Treatment and Labor Act (EMTALA). Specific department-related overviews provided by Department Directors. Information on employment related services. Information on training and education programs available to employees. Payroll information. Information on employee benefits, including health insurance, PTO and Ell and other benefit offerings. Sexual Harassment and Diversity. Compliance and Ethics Program Training. HIPAA Compliance. Departmental position-specific training as outlined by Avenir’ s clinical and operations leadership ...All newly hired staff/interns are required to complete all aforementioned trainings before providing any services. The verification of completed trainings is to be kept in the staff /intern’s personnel file ....” Review of hospital document not titled but verified by employee #1 and #2 to be a list of contracted employees providing physical and behavioral services to patients revealed: Employee #27 had worked 12/16/25, 12/25/25, 12/27/25, 12/31/25, 1/2/2026, 1/3/2026, 1/4/2026, 1/9/2026, and 1/12/2026 Employee #28 had worked 12/31/2025 an 1/5/2026 Employee #29 had worked 1/1/2026 Employee #30 had worked 12/20/2025 and 1/1/2026 Documentation of skills verification for employees #27, #28, #20 and #30 was requested while on survey conducted 1/5/2026 through 1/14/2026, none was provided for review. Interview with employee #1, #2, and #3 conducted while on survey confirmed that employee #27, #28, #29 and #30 had provided physical and behavioral services to patients on the above listed dates.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 52829 Based on review of hospital policies and procedures, personnel records review, document review, and staff interviews, it was determined that the Hospital failed to require that ongoing training requirements for each type of restraint and seclusion used in the hospital were completed annually by staff. This deficient practice poses a risk to the health and safety of patients, when there is not an appropriately trained staff to ensure patient safety if a restraint or seclusion is required. Findings include: Review of hospital document titled “Seclusion and Restraint” policy #18754616, last effective 09_2025 revealed, “ ... Trained Personnel- is any employee or contracted staff who has completed the approved education and demonstrated competency in the application of restraint ....” Personnel record review revealed Employee #29 had no documentation of annual restraint application training. In joint interview conducted while on survey 1/14/2026 employee #1, #2, and #3 confirmed that employee #29 had no documentation of restraint and seclusion training.”

“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: 52829 Based on hospital policy and procedure, hospital documentation review, medical record review, video observation, and employee interviews, it was determined the hospital failed to implement the post-fall procedure as outlined in policy. This deficient practice resulted in a registered nurse not responding to a witnessed, patient fall and the patient expired. Findings Include: Policy #18754609, titled “Falls Assessment and Prevention,” last effective 09/2025, revealed: “...Post Falls Procedure ...attend to the immediate medical needs of the patient ....” Patient #1 ’ s medical record revealed the following: A document titled “Daily Nursing Assessment 09/26/2025 18:03,” which revealed: “...At ~1500,...Gait unsteady; patient encouraged to sit for safety ...Shortly after, patient stood and fell to the floor ...did not respond to requests to sit up ...Pulse ox applied; radial pulse palpable ...Pulse ox would not adhere; patient became unresponsive. Alarm/code called;...Times are approximate, as this RN was actively intervening during the event. Please refer to video footage for exact sequence and timing ...Employee #8 ....” Video footage from 09/26/2025 revealed the following: 15:31:46- Patient #1 sitting in chair in dayroom. 15:31:50- Patient #1 stands up from chair. 15:31:52- Patient #1 stumbles into wall. 15:31:54- Patient #1 out of view of camera. 15:32:00- Patient #1 falls on floor in front of nursing station. Employee #8 and Employee #20 are facing Patient #1 as they fall. 15:32:05- Patient #1 still on floor. Employee #8 and #20 and using hand gestures to each and to Patient #1. Employee #9 is observed to be sitting in the nurses station. 15:32:23- Employee #20 walks past Patient #1 on floor. 15:32:45- Employee #8 walks up to Patient #1 on floor. Squats down and puts hand near Patient #1 ’ s left wrist. 15:32:52- Employee #20 stands up with hands in pockets next to Patient #1. 15:33:01- Employee #8 squats down and puts hand near Patient #1 ’ s left wrist. 15:33:20- Employee #8 puts hand near Patient #1 ’ s neck. 15:33:35- Employee #8 walks to nursing station from Patient #1 that is still on the floor and has not been observed to move. 15:33:41- Employee #20 steps back into view next to Patient #1. 15:34:24- Employee #8 squats down and puts hand near Patient #1 ’ s left wrist. 15:36:10- Employee #8 walks to nursing station from Patient #1 that is still on the floor and has not been observed to move. 15:37:28- Employee #20 walks up with a wheelchair to Patient #1, who is still on the floor and has not been observed to move. 15:39:36- Staff attempt to lift Patient #1 off ground onto wheelchair. 15:40:06- Staff fail to lift Patient #1. 15:40:08- Code Blue appears to be called. 15:40:43- Crash chart is brought out. Employee #1 and #2 confirmed in an interview conducted on January 5, 2025, through January 14, 2025, that Employee #8, #9, and #20 did not implement post-fall procedure to Patient #1 after they fell.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 52829 Based on Hospital policy and procedure, medical records and employee interview, it was determined the Hospital failed to ensure measurement of patient alcohol withdrawal symptoms occurred per provider order. This deficient practice poses a potential risk of unmonitored escalation of withdrawal symptoms resulting in patient physical harm or death. Findings include: Policy #1875450, titled “Withdrawal from Alcohol/Benzodiazepine,” last effective 09/2025, revealed: “ ...Purpose: ...Instruments like the CIWA can help clinical personnel recognize the process of withdrawal before it progresses to more advanced stages, such as delirium tremens ...3. CIWA to be completed on admission and detox orders to be followed ....” Patient #1 ’ s medical record revealed the following: A document titled, “Patient Orders,” which revealed: “ ...Obtain vital signs and CIWA score every four (4) hours routine for 4 days (CIWA at 0000, 0400, 0800, 1200, 1600, 2000), then three times a day while awake until discontinued by provider (0900, 1500, 2100)., for 7 days ...Duration: 7 day taper, start date: 09/25/2025 11:15, end date: 10/02/2025 11:14 ....” A document titled, “CIWA-Ar History-(Patient #1),” which revealed: “ ...09/25/25 15:59 ...Score ...4 ...09/25/25 23:29 ...Score ...8 ...09/26/25 08:00 ...Score ...7 ...” Employee #2 confirmed during interview conducted on January 5, 2025, through January 14, 2025, that the aforementioned CIWA assessments for Patient #1 on 09/25/2025, through 09/26/2025, occurred past the four (4) hour timeframe that was provider ordered. Patient #11 ’ s medical record revealed the following: A document titled, “Patient Orders,” which revealed: “ ...Obtain vital signs and CIWA score every four (4) hours routine for 4 days (CIWA at 0000, 0400, 0800, 1200, 1600, 2000), then three times a day while awake until discontinued by provider (0900, 1500, 2100)., for 7 days ...Duration: 7 day taper, start date: 11/24/2025 13:00, end date: 12/01/2025 12:59 ....” A document titled, “CIWA-Ar History-(Patient #1),” which revealed: “ ...11/28/25 21:54 ...Score ...10 ...11/28/25 08:51 ...Score ...0 ....” A document titled “Med Log,” which revealed: “...Scheduled ...04:00 ...Action ...zero score/patient sleeping ...Scheduled ...16:00 ...Action ...pt asleep during this time ....” Employee #2 confirmed during interview conducted on January 8, 2026, through January 14, 2026, that the aforementioned CIWA assessments for Patient #11 on 11/28/25 through 11/29/25, occurred past the four (4) hour timeframe that was provider ordered and was supposed to be taken even if the patient is asleep.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 52829 Based on hospital policy and procedure, medical record review, and employee interview, it was determined the hospital has failed to ensure patients received a care plan post-fall. This deficient practice poses a potential danger to high fall-risk patients to fall again. Findings Include: Policy #18754609, titled “Falls Assessment and Prevention,” last effective 09/2025, revealed: “...Post Falls Procedure ...A Falls Treatment Plan is written and interventions on the treatment plan address the identified risk factors ....” Patient #7 ’ s medical record revealed the following: A document titled “Progress Note 09/14/2025 00:52,” which revealed: “...Patient with unwitnessed fall @ 2350 in patients’ room ....” A Falls Treatment Plan was requested after Patient #7 ’ s fall on 9/13/2025 2350. None was provided at the time of the survey. Employee #2 confirmed in an interview conducted on January 14, 2025, that there was no Falls Treatment Plan completed for Patient #7 after their fall on 9/17/2025 2350.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 52829 Based on a review of facility policy & procedure, personnel records, facility documentation & staff interview, it was determined the hospital failed to document that clinical oversight was provided to Behavioral Health Technicians (BHT) at least once each two-week period if the BHT provides services related to patient care at the health care institution during the two-week period for four (4) of four (4) BHT’s for a total of four (4) missing oversights. This deficient practice poses a potential risk that staff are not adequately supervised by Behavioral Health Professionals (BHP) to provide services to patients outside their scope and could result in patient harm. Findings include: A review of policy entitled, “Clinical Oversight, Policy # 19313084,” with an effective date of 11/2025, revealed “...Procedure ...A. Clinical oversight is provided to all paraprofessionals and behavioral health technicians providing behavioral health services. B. Clinical Oversight is provided by a staff member meeting the qualifications of a Behavioral Health Professional. C. Clinical oversight to behavioral health paraprofessionals and technicians is provided to ensure that the patients’ needs are met based on the scope and extent of the services provided, the acuity of the patients receiving services, the number of patients receiving services. D. Clinical oversight is provided at a minimum once every fifteen days if the behavioral health technician or paraprofessional provides services related to client care during that time-frame. E. For any staff who do not work during the two-week oversight period, clinical oversight will still be provided electronically as allowed by AAC R9-10-115(5) ....” A review of facility personnel files on January 12, 2026, revealed four (4) employees, Employee #27, Employee #28, Employee #29 and Employee #30 who require clinical oversight per facility policy & job description. A review of facility documentation on January 12, 2026, revealed the four employees, Employee #27, Employee #28, Employee #29 and Employee #30, provided behavioral health services on the following dates & prompting at least one clinical oversight to be provided: Employee #27: 12/16/2025, 12/25/2025, 12/27/2025, 12/31/2025, 1/2/2026, 1/3/2026, 1/4/2026, 1/9/2026 & 1/12/2026. Employee #28: 12/31/2025 & 1/5/2026 Employee #29: 1/1/2026 Employee #30: 12/20/2025 & 1/1/2026 A request was made on January 12, 2026 for documentation of clinical oversight that was conducted within the two-week timeframe that behavioral health services were provided in Dec 2025 & Jan 2026 for four employees, Employee #27, Employee #28, Employee #29 and Employee #30. None was available for review at the time of survey. Employee #3 confirmed in interviews conducted on January 12, 2026, that no documentation of clinical oversight conducted within the two-week timeframe that behavioral health services were provided in Dec 2025 & Jan 2026 for four employees, Employee #27, Employee #28, Employee #29 and Employee #30 was available for review.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 52829 Based on hospital policy and procedure, medical record review, hospital documentation and employee interview, it was determined that the Hospital failed to ensure that sedative medication was administered for the indication as prescribed by a physician. Failure to administer medication for the prescribed indication poses a potential risk for hypersedation and adverse patient outcomes. Findings include: Policy #17862027, titled “Medication Administration,” last revised 03/2025, revealed: “...A provider must be documented on the chart for all medications administered. The order may include:...An indication for medication must be documented in the medical record ....” Patient #14 ’ s medical record revealed the following: A document titled “Progress Note 10/14/2025 10:27,” which revealed: “...This nurse responded to an agitated patient in intake. Pt still on stretcher, but pt was threatening admission staff and spitting towards them. The rounding provider assessed pt and ordered STAT dose of haldol 5mg, ativan 2mg and Benadryl 50mg IM ....” A document titled “Patient Order ’ s,” which revealed: “...ATIVAN (lorazepam), 2mg/ml x 1 ML , injection, solution, once, for 1 day Justification: AGITATION / DTO Duration: 1 day, start date: 10/14/2025 10:00,...DIPHENYDRAMINE, 50mg/ml x 1 ML , IM, injection, once, for 1 day Justification: AGITATION / DTO Duration: 1 day, start date: 10/14/2025 10:00,...Haloperidol Lactate, 5mg/ml x 1 ML , injection, solution, once, for 1 day Justification: AGITATION / DTO Duration: 1 day, start date: 10/14/2025 10:00,....” A document titled “Medications,” which revealed: “...ATIVAN (lorazepam) 2mg/ml solution, injection 1 ML MED Left deltoid Administered by ...10/14/2025 10:14 ...Haloperidol Lactate 5mg/ml solution, injection 1 ML MED Left deltoid Administered by ...10/14/2025 10:14 ...DIPHENYDRAMINE 50mg/ml injection, IM 1 ML MED Administered by ...10/14/2025 11:57. ...” Documentation that included justification of agitation at 10/14 11:57 was requested. None was provided at the time of the survey. A document titled “Progress Note 10/15/2025 18:45,” which revealed: “...PT CAME TOWARDS ME AGGRESSIVE AND MAKING THREATS AFTER PUTTING ON CLOTHES, PT ALSO WAS THREATENING AND JUMPING AT OTHER STAFF, THEN THREW AN APPLE AT STAFFS HEAD WHILE STATING RACIAL SLURS AND MAKING PHYSICAL THREATS, THE BUTTON WAS THEN PRESSED. PT REMAINED AGGRESSIVE TOWARDS ME VERBALLY AND POTENTIANALLY PHYSICALLY ....” A document titled “Patient Order ’ s,” which revealed: “...ATIVAN (lorazepam), 2mg/ml x 1 ML , injection, solution, once, for 1 day Justification: AGITATION Duration: 1 day, start date: 10/15/2025 18:30,...DIPHENYDRAMINE, 50mg/ml x 1 ML , IM, injection, once, for 1 day Justification: AGITATION Duration: 1 day, start date: 10/15/2025 18:30,...Haloperidol Lactate, 5mg/ml x 1 ML , injection, solution, once, for 1 day Justification: AGITATION Duration: 1 day, start date: 10/15/2025 18:30,....” A document titled “Medications,” which revealed: “...Haloperidol Lactate 5mg/ml solution, injection 1 ML MED Administered by ...10/15/2025 18:52 ...DIPHENYDRAMINE 50mg/ml injection, IM 1 ML MED administered in right deltoid Administered by ...10/15/2025 21:28 ...ATIVAN (lorazepam) 2mg/ml solution, injection 1 ML MED Administered by ...10/15/2025 18:52 ....” Documentation that included justification of agitation at 10/15 21:28 was requested. None was provided at the time of the survey. Hospital documentation titled “RISK INCIDENT REPORT,” dated 10/15/2025, which revealed medication was ordered for Patient #14 for agitation. The documentation further revealed only “...have[sic]...” of the medication was administered at the time of event and the “...remainder ...” would be administered by a different staff. Employee #2 confirmed in an interview on January 14, 2026, that the medications administered at separate times did not contain an indication as to why the medication was given outside of the providers ordered date and time.”

“EMERGENCY SERVICES READINESS CFR(s): Effective July 1, 2025, in accordance with the complexity and scope of services offered, there must be adequate provisions and protocols to meet the emergency needs of patients. This Standard is not met as evidenced by: 52829 Based on hospital policy and procedure, hospital documentation review, medical record review, video observation, and employee interviews, it was determined the Hospital o ensure emergency medical services are provided to an inpatient.This deficient practice resulted in a delay in life-saving care when a patient was experiencing an emergency medical episode and the patient expired. Findings Include: Policy #18754579, titled “Code Blue,” last effective 09/2025, revealed: “...At Avenir Behavioral Health Center, a Code Blue is defined as ANY medical emergency that would require the use of additional medical personnel not currently available to the nurse. This may include, but is not limited to:...Major fall ...Upon discovering that a patient has experienced one of the above signs or symptoms, or any other sign or symptom of immediate medical concern, the staff member shall call a Code Blue by paging overheard ....” Patient #1 ’ s medical record revealed the following: A document titled “Daily Nursing Assessment 09/26/2025 18:03,” which revealed: “...At ~1500,...Gait unsteady; patient encouraged to sit for safety ...Shortly after, patient stood and fell to the floor ...did not respond to requests to sit up ...Pulse ox applied; radial pulse palpable ...Pulse ox would not adhere; patient became unresponsive. Alarm/code called;...Times are approximate, as this RN was actively intervening during the event. Please refer to video footage for exact sequence and timing ...Employee #8 ....” Video footage from 09/26/2025 revealed the following: 15:31:46- Patient #1 sitting in chair in dayroom. 15:31:50- Patient #1 stands up from chair. 15:31:52- Patient #1 stumbles into wall. 15:31:54- Patient #1 out of view of camera. 15:32:00- Patient #1 falls on floor in front of nursing station. Employee #8 and Employee #20 are facing Patient #1 as they fall. 15:32:05- Patient #1 still on floor. Employee #8 and #20 and using hand gestures to each and to Patient #1. Employee #9 is observed to be sitting in the nurses station. 15:32:23- Employee #20 walks past Patient #1 on floor. 15:32:45- Employee #8 walks up to Patient #1 on floor. Squats down and puts hand near Patient #1 ’ s left wrist. 15:32:52- Employee #20 stands up with hands in pockets next to Patient #1. 15:33:01- Employee #8 squats down and puts hand near Patient #1 ’ s left wrist. 15:33:20- Employee #8 puts hand near Patient #1 ’ s neck. 15:33:35- Employee #8 walks to nursing station from Patient #1 that is still on the floor and has not been observed to move. 15:33:41- Employee #20 steps back into view next to Patient #1. 15:34:24- Employee #8 squats down and puts hand near Patient #1 ’ s left wrist. 15:36:10- Employee #8 walks to nursing station from Patient #1 that is still on the floor and has not been observed to move. 15:37:28- Employee #20 walks up with a wheelchair to Patient #1, who is still on the floor and has not been observed to move. 15:39:36- Staff attempt to lift Patient #1 off ground onto wheelchair. 15:40:06- Staff fail to lift Patient #1. 15:40:08- Code Blue appears to be called. 15:40:43- Crash chart is brought out. Employee #1 and #2 confirmed in an interview conducted on January 8,2026 through January 14, 2026 that Employee #8, #9, and #20 did not implement life- saving emergency services to Patient #1 after they experienced an emergency medical crisis and became unresponsive.”

“Personnel - Active Treatment CFR(s): [The hospital must employ or undertake to provide adequate numbers of qualified professional, technical, and consultative personnel to:] Provide active treatment measures; This Standard is not met as evidenced by: 50979 Based on a review of facility policy and procedure, personnel files, , video review, and staff interviews, it was determined that the Hospital failed to ensure that personnel performed duties delineated in their specific job description and not provide physical or psychological services outside their scope of practice. This deficient practice poses the potential risk of harm to the patients when a personnel member is performing tasks outside their specific job description and skills needed to provide safe care. Findinsg Include: Review of hospital document titled “New Employee Orientation & Ongoing Staff Training” policy #17237138, last revised 12_2024 revealed, “ ... POLICY: Avenir provides general orientation to all newly hired employees ... PROCEDURE: 1. All full-time, part-time and PRN employees, as well as any interns, must attend a New Employee Orientation session ... 8. All Department Directors are expected to provide ongoing supervision and oversight of their assigned team members, and to provide education and training as necessary ....” Review of employee #18 employee file a hospital document titled “Housekeeping Job Description” revealed “ ... Position Summary ... Responsible for performing housekeeping sand laundry functions ... Essential job functions: ... Perform daily cleaning functions as directed ....” Video review conducted on 1/8/2026 with employee #2 revealed, employee #18 providing physical services to a patient. Request for Signed job description for employee #18 stating that the position was qualified to provide physical services to patients was requested on 1/8/2026, none provided while on survey conducted 1/5/2026 through 1/14/2026. Employee #3 confirmed in interview conducted while on survey conducted 1/5/2026 through 1/14/2026 that employee #18 is witnessed, on video that was reviewed 1/8/2026, providing physical services to a patient. Employee #3 also confirmed at the same time that employee #18 ’ s job description does not show that physical services to patients is an essential job function.”

“Director of Psychiatric Nursing CFR(s): The hospital or unit must have a qualified director of psychiatric nursing services. In addition to the director of nursing, there must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide nursing care necessary under each patient’s active treatment program and to maintain progress notes on each patient. This Standard is not met as evidenced by: 52829 Based on hospital policy and procedure, hospital documentation review, medical record review, video observation, and employee interviews, the Department determined the registered nurse failed to determine the clinical implications of client signs, symptoms, and changes, as either expected, unexpected, or emergent situations. This deficient practice resulted in a delay in life-saving care and the patient expired. Findings Include: Job Description titled “Registered Nurse,” revealed: “...Initiate emergency medical care whenindicated ...Documentation meets current standards and policies ...Performs all aspects of patient care in an environment that optimizes patient safety ....” Patient #1 ’ s medical record revealed the following: A document titled “Daily Nursing Assessment 09/26/2025 18:03,” which revealed: “...At ~1500,...Gait unsteady; patient encouraged to sit for safety ...Shortly after, patient stood and fell to the floor ...did not respond to requests to sit up ...Pulse ox applied; radial pulse palpable ...Pulse ox would not adhere; patient became unresponsive. Alarm/code called;...Times are approximate, as this RN was actively intervening during the event. Please refer to video footage for exact sequence and timing ...Employee #8 ....” Video footage from 09/26/2025 revealed the following: 15:31:46- Patient #1 sitting in chair in dayroom. 15:31:50- Patient #1 stands up from chair. 15:31:52- Patient #1 stumbles into wall. 15:31:54- Patient #1 out of view of camera. 15:32:00- Patient #1 falls on floor in front of nursing station. Employee #8 and Employee #20 are facing Patient #1 as they fall. 15:32:05- Patient #1 still on floor. Employee #8 and #20 and using hand gestures to each and to Patient #1. Employee #9 is observed to be sitting in the nurses station. 15:32:23- Employee #20 walks past Patient #1 on floor. 15:32:45- Employee #8 walks up to Patient #1 on floor. Squats down and puts hand near Patient #1 ’ s left wrist. 15:32:52- Employee #20 stands up with hands in pockets next to Patient #1. 15:33:01- Employee #8 squats down and puts hand near Patient #1 ’ s left wrist. 15:33:20- Employee #8 puts hand near Patient #1 ’ s neck. 15:33:35- Employee #8 walks to nursing station from Patient #1 that is still on the floor and has not been observed to move. 15:33:41- Employee #20 steps back into view next to Patient #1. 15:34:24- Employee #8 squats down and puts hand near Patient #1 ’ s left wrist. 15:36:10- Employee #8 walks to nursing station from Patient #1 that is still on the floor and has not been observed to move. 15:37:28- Employee #20 walks up with a wheelchair to Patient #1, who is still on the floor and has not been observed to move. 15:39:36- Staff attempt to lift Patient #1 off ground onto wheelchair. 15:40:06- Staff fail to lift Patient #1. 15:40:08- Code Blue appears to be called. 15:40:43- Crash chart is brought out. Employee #1 and #2 confirmed in an interview conducted on January 8, 2026, through January 14, 2026, that Employee #8 documented inaccurate information in Patient #1 ’ s chart. It was revealed that Employee #8 never felt a pulse and was actively assuring staff Patient #1 ’ s was “behavioral” and directed staff not to call a code. Employee #1 and #2 further confirmed in an interview conducted on January 8, 2026, through January 14, 2026, that Employee #8 failed to implement hospital policies and procedure relating to Patient #1 that delayed their ability to receive life-saving care.”

“Social Services Staff Responsibilities CFR(s): Social service staff responsibilities must include, but are not limited to, participating in discharge, planning, arranging for follow-up care, and developing mechanisms for exchange of appropriate information with sources outside the hospital. This Standard is not met as evidenced by: 50979 Based on hospital policy and procedure, personnel records, and employee interviews, it was determined the hospital failed to ensure personnel members have acquired the specific education to provide the expected physical health services or behavioral health services listed in the established job description. This deficient practice can result in patient harm if unqualified staff are providing patient care outside their scope of practice. Findings Include: Job Description titled “Social Worker,” revealed: “...EDUCATION (Required)... Bachelor ’ s Degree in Social Work (BSW) or Bachelor ’ s Degree in Counseling (BC) or Master ’ s Degree in Behavioral Health Field ....” Patient #2 ’ s medical record revealed a document titled “Group Sessions,” dated 7/26/2025, which revealed: “...Group Therapy (SW) 15:00 by Employee #13, Social Worker ....” Employee #13 ’ s personnel record revealed a document titled “Job Description” which revealed a signed “Social Worker” Job Description. Request for the required education for Employee #13 as listed in the Job Description. None was presented at the time of the survey. Employee #3 confirmed in an interview conducted on January 8, 2026, through January 14, 2026, that Employee #13 did not have the required education established in the job description and was performing group therapy sessions.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 49638 Based on Hospital policy review, Patients medical record review, document request, and employee interview, it was determined that the Hospital failed to implement and enforce Hospital policy for screening of patients to determine the presence of an Emergent Medical Condition. This failure poses the risk of a staff member working outside their scope of practice, an emergency medical and/or psychiatric condition going undiagnosed, and a patient having an unsafe disposition from the facility if deemed to not have an emergency medical condition by an unqualified staff member. Findings Include: Hospital document titled “EMTALA” Policy #19308786 last revised 11/2024 revealed: “... DEFINITIONS: H. “Qualified Medical Person” or “Qualified Medical Personnel” means an individual or individuals determined qualified by Hospital bylaws or rules and regulations (and consistent with state licensure) to perform a Medical Screening Examination. In the Hospital, qualified medical personnel are limited to physicians, physician assistants, nurse practitioners, social workers, and registered nurses who have been deemed qualified ... Procedure: A. The Hospital will provide an appropriate medical screening examination within the capability of the Hospital’s Dedicated Emergency Department ... Process: 1. Triage a. As soon as practical after arrival, individuals who come to the Emergency Department will be triaged in order to determine the order in which they will receive a medical screening examination ... B. Medical Screening Examination 2. The medical screening examination is the examination of the patient by the Qualified Medical Person required to determine within reasonable clinical confidence whether an emergency medical condition does or does not exist ... 3. Monitoring must continue until the individual is stabilized or appropriately admitted or transferred ....” Hospital policy titled, “Emergency Services” Policy #18754582 last approved 9/2025, revealed: “ ... General Guidelines 1. An RN is immediately available, as needed, to provide bedside care to any patient. 2. RN(s) at the hospital are qualified, through a combination of education, licensure, and training, to conduct an assessment that enables them to recognize the fact that a person has a need for emergency care ....” Hospital policy titled “Medical Staff Bylaws, Rules and Regulations” Policy #18016964 last approved 4/2025 revealed, Unable to locate the definition of qualified medical personnel. A review of 20 medical records revealed patients #1, #3, #5, #6, #7, #8, #9, #10, #12, #13, #16, #17, #18, #19, and #20 did not have documentation of a Medical Screening Exam performed by a Qualified Medical Professional as listed in hospital policy. Employee #1, #2, #3, and #4 confirmed in an interview on 11/25/2025, that the above listed patients did not receive a medical screening exam by a qualified medical professional while in intake.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 49638 Based on Hospital policy review, Patients medical record review, document request, and employee interview, it was determined that the Hospital failed to implement and enforce Hospital policy for screening of patients to determine the presence of an Emergent Medical Condition. 1. A medical screening exam by a qualified medical practitioner (QMP). 2. An assessment performed by an RN. This failure poses the risk of a licensed staff member working outside their scope of practice, an emergency medical and/or psychiatric condition going undiagnosed, and a patient having an unsafe disposition from the facility if deemed to not have an emergency medical condition by an unqualified staff member. Findings Include: Hospital document titled “EMTALA” Policy #19308786 last revised 11/2024 revealed: “... DEFINITIONS: H. “Qualified Medical Person” or “Qualified Medical Personnel” means an individual or individuals determined qualified by Hospital bylaws or rules and regulations (and consistent with state licensure) to perform a Medical Screening Examination. In the Hospital, qualified medical personnel are limited to physicians, physician assistants, nurse practitioners, social workers, and registered nurses who have been deemed qualified ... Procedure: A. The Hospital will provide an appropriate medical screening examination within the capability of the Hospital’s Dedicated Emergency Department ... Process: 1. Triage a. As soon as practical after arrival, individuals who come to the Emergency Department will be triaged in order to determine the order in which they will receive a medical screening examination ... B. Medical Screening Examination 2. The medical screening examination is the examination of the patient by the Qualified Medical Person required to determine within reasonable clinical confidence whether an emergency medical condition does or does not exist ... 3. Monitoring must continue until the individual is stabilized or appropriately admitted or transferred ....” Hospital policy titled, “Emergency Services” Policy #18754582 last approved 9/2025, revealed: “ ... General Guidelines 1. An RN is immediately available, as needed, to provide bedside care to any patient. 2. RN(s) at the hospital are qualified, through a combination of education, licensure, and training, to conduct an assessment that enables them to recognize the fact that a person has a need for emergency care ....” Hospital policy titled “Medical Staff Bylaws, Rules and Regulations” Policy #18016964 last approved 4/2025 revealed, Unable to locate the definition of qualified medical personnel. Hospital policy titled “Nursing Scope of Service” Policy #18754611 last approved 9/2025 revealed, “ ... Procedure: e. Assessment is a foundational element of nursing care. As such, RNs will be on duty for patient care delivery 24 hours a day, 7 days a week. RN assessment is ongoing and informs each subsequent step in the nursing process ....” Review of Arizona Revised Statute § 32-1601 revealed “ ... Definitions ... 19. “Practical nurse” means a person who holds a practical nurse license issued pursuant to this chapter or pursuant to a multistate compact privilege and who practices practical nursing as defined in this section ... 20. “Practical nursing” includes the following activities that are performed under the supervision of a physician or a registered nurse: (a) Contributing to the assessment of the health status of individuals and groups ....” Review of Arizona Administrative Code TITLE 4. PROFESSIONS AND OCCUPATIONS CHAPTER 19. BOARD OF NURSING revealed, “ ... R4-19-401. Standards Related to Licensed Practical Nurse Scope of Practice B. A LPN ’ s nursing practice is limited to those activities for which the LPN has been prepared through basic practical nursing education in accordance with A.R.S. § 32-1637(1) ....” A review of 20 medical records revealed patients #1, #3, #5, #6, #7, #9, #10, #12, #13, #16, #17, #18, #19, and #20 did not have documentation of a Medical Screening Exam performed by a Qualified Medical Professional as listed in hospital policy. A review of 20 medical records revealed patients #1, #3, #5, #6, #7, #9, #10, #12, #13, #16, #17, #18, #19, and #20 did not have documentation of a Registered Nurse assessment performed in the Intake Assessment, they confirmed that the assessments had been performed by Licensed Practical Nurses. Employee #1, #2, #3, and #4 confirmed in an interview on 11/25/2025, that the above listed patients did not receive an assessment by a Registered Nurse in the intake Assessment, they further confirmed that the above patients did not receive a medical screening exam by a qualified medical professional while in intake.”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 49638 Based on Hospital policy and procedure, Hospital document review, medical record review, and employee interview, it was determined the Hospital delayed treatment for 11 of 20 patients who presented to the Hospital seeking emergency treatment. Failure to provide timely treatment poses the potential risk that a patient, determined to have an emergency medical condition, will not receive necessary treatment. Findings include: Hospital policy titled “EMTALA,” Policy #19308786, Last Approved 11/2025, revealed “ ...B. The Hospital will: (a) provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to stabilize the emergency medical condition ...B. Medical Screening Examination ...3. Monitoring must continue until the individual is stabilized or appropriately admitted ...The medical screening examination, and ongoing patient assessment, must be documented in the medical record ...If, after a medical screening examination, it is determined that an individual has an emergency medical condition, the Hospital must: ...2. Admit the individual to the Hospital in order to stabilize the individual ....” Hospital policy titled “Intake Admission Process,” Policy #19356003, Last Approved 11/2025, revealed “ ...a. At the time of admission, the patient/guardian will also be asked to complete the following: ...iv. Admission Profile and Consent to Treatment ...b. Once the admission to the facility is completed, the patient will be escorted to the appropriate unit ....” Hospital policy titled “Levels of Observation,” Policy #18754615, Last Approved 09/2025, revealed “ ...a. Routine observations: minimum patient observation of at least fifteen (15) minutes. All patients will be monitored every 15 minutes unless a higher level of observation if ordered ...5. Upon admission, all patients are maintained in constant visual sight until the initial safety search and nursing assessment of self-harm, assault, and acting out risk is completed ....” A total of 20 patient medical records were randomly selected for review from the Hospital ’ s EMTALA Log. Eleven (11) out of 20 medical records and related Hospital documents revealed the following: Patient #2 Hospital document titled “EMTALA Log” revealed Patient #2 arrived at the Hospital on October 11, 2025, at 11:58 as a “AMBO,” “Emergency Medical/Psych Condition” was marked “YES,” with “Disposition” noted as “ADMITTED,” at 11:58 and “Time Arrived on Unit” documented as 1400. Medical record document titled “ABHC Nursing Assessment Ver 1.1 11/06/2025,” revealed “ ...Evaluation Date: 10/10/2025 ...Time of arrival on unit: 10/11/2025 14:30 ...completed by: (Employee #15) Signature time stamp at 10/10/2025 17:13 ....” Medical record document titled “Conditions of Admission” revealed “ ...1. Consent to Hospital Care ...,” displaying signature of Patient #2 dated and timed “ ...10/10/2025 12:13 ....” Patient #4 Hospital document titled “EMTALA Log” revealed Patient #4 arrived at the Hospital on October 31, 2025, at 22:48 as a “blank” “Emergency Medical/Psych Condition” was marked “YES,” with “Disposition” noted as “ADMITTED,” at 2248 and “Time Arrived on Unit” documented as 7:06am. Medical record document titled “ABHC Nursing Assessment Ver 1.1 10/31/2025,” revealed “ ...Evaluation Date: 10/31/2025 ...Time of arrival on unit: 11/06/2025 20:48 ...completed by: (Employee #9) Signature time stamp at 11/07/2025 04:45 ....” Document displayed signature of Employee #14 dated and timed “ ...11/01/2025 at 07:53 ....” Medical record document titled “Conditions of Admission” revealed “ ...1. Consent to Hospital Care ...,” displaying signature of Patient #4 dated and timed “ ...11/01/2025 06:16 ....” Medical record document titled “PATIENT OBSERVATION RECORD,” dated 11/01/2025, revealed “ ...Observation Level Q15 ...Precautions ...Suicide (box checked) ...,” with no documented patient monitoring from 22:48 (time of admission) until 07:00 (time of arrival on unit). Patient #6 Hospital document titled “EMTALA Log” revealed Patient #6 arrived at the Hospital on November 6, 2025, at 1900 as a “AMBO,” “Emergency Medical/Psych Condition” was marked “YES,” with “Disposition” noted as “ADMITTED,” at 1900 and “Time Arrived on Unit” documented as 2055. Medical record document titled “ABHC Nursing Assessment Ver 1.1 11/06/2025,” revealed “ ...Evaluation Date: 11/6/2025 ...Time of arrival on unit: 11/06/2025 20:48 ...completed by: (Employee #9) Signature time stamp at 11/07/2025 04:45 ....” Document displayed signature of Employee #14 dated and timed “ ...11/07/2025 at 07:07 ....” Medical record document titled “Conditions of Admission” revealed “ ...1. Consent to Hospital Care ...,” displaying signature of Patient #6 dated and timed “ ...11/06/2025 20:25 ....” Medical record document titled “PATIENT OBSERVATION RECORD,” dated 11/06/2025, revealed “ ...Observation Level Q15 ...Precautions ...Suicide (box checked) ...,” with no documented patient monitoring from 1900 (time of admission) until 20:45 (time of arrival on unit). Patient #7 Hospital document titled “EMTALA Log” revealed Patient #7 arrived at the Hospital on November 11, 2025, at 08:59 as a “AMBO,” “Emergency Medical/Psych Condition” was marked “YES,” with “Disposition” noted as “ADMITTED,” at 08:59 and “Time Arrived on Unit” documented as 09:55. Medical record document titled “ABHC Nursing Assessment Ver 1.1 11/11/2025,” revealed “ ...Evaluation Date:11/11/2025 ...Time of arrival on unit: 11/11/2025 11:41 ...completed by: (Employee #10) Signature time stamp at 11/11/2025 12:10 ....” Document displayed signature of Employee #16 dated and timed “ ...11/12/2025 at 08:29 ....” Medical record document titled “Conditions of Admission” revealed “ ...1. Consent to Hospital Care ...,” displaying signature of Patient #7 dated and timed “ ...11/11/2025 09:21 ....” Medical record document titled “PATIENT OBSERVATION RECORD,” dated 11/11/2025, revealed “ ...Observation Level ...blank ...Precautions ...blank ...,” with no documented patient monitoring from 08:59 (time of admission) until 09:55 (time of arrival on unit). Patient #10 Hospital document titled “EMTALA Log” revealed Patient #10 arrived at the Hospital on August 12, 2025, at 17:19 as a “WALK IN,” “Emergency Medical/Psych Condition” was marked “YES,” with “Disposition” noted as “ADMITTED,” at 17:19 and “Time Arrived on Unit” documented as 18:47. Medical record document titled “ABHC Nursing Assessment Ver 1.1 08/12/2025,” revealed “ ...Evaluation Date: 08/12/2025 ...Time of arrival on unit: 08/12/2025 18:20 ...completed by: (Employee #19) Signature time stamp at 08/13/2025 02:32 ....” Document displayed signature of Employee #16 dated and timed “ ...08/13/2025 at 07:53 ....” Medical record document titled “Conditions of Admission” revealed “ ...1. Consent to Hospital Care ...,” displaying signature of Patient #10 dated and timed “ ...08/12/2025 17:41 ....” Medical record document titled “PATIENT OBSERVATION RECORD,” dated 08/12/2025, revealed “ ...Observation Level ...Q 15 ...Precautions ...blank ...,” with no documented patient monitoring from 17:19 (time of admission) until 18:20 (time of arrival on unit). Patient #11 Hospital document titled “EMTALA Log” revealed Patient #11 arrived at the Hospital on August 29, 2025, at 20:40 as a “AMBO,” “Emergency Medical/Psych Condition” was marked “YES,” with “Disposition” noted as “ADMITTED,” at 20:40 and “Time Arrived on Unit” documented as 21:40. Medical record document titled “ABHC Nursing Assessment Ver 1.1 08/29/2025,” revealed “ ...Evaluation Date: 08/29/2025 ...Time of arrival on unit: blank ...completed by: (Employee #20) Signature time stamp at 08/30/2025 06:43 ....” Medical record document titled “Conditions of Admission” revealed “ ...1. Consent to Hospital Care ...,” displaying signature for Patient #11 ’ s representative, dated “ ...08/29/2025 ....” Medical record document titled “PATIENT OBSERVATION RECORD,” dated 08/29/2025, revealed “ ...Observation Level ...Q 15 ...Precautions ...blank ...,” with no documented patient monitoring from 20:40 (time of admission) until 21:30. Patient #14 Hospital document titled “EMTALA Log” revealed Patient #14 arrived at the Hospital on September 13, 2025, at 20:25 as a “AMBO,” “Emergency Medical/Psych Condition” was marked “YES,” with “Disposition” noted as “ADMITTED,” at 20:25 and “Time Arrived on Unit” documented as 21:35. Medical record document titled “ABHC Nursing Assessment Ver 1.1 09/13/2025,” revealed “ ...Evaluation Date: 09/13/2025 ...Time of arrival on unit: blank ...Comments ...refusing to complete assessment, 3 attempts ...completed by: (Employee #2) Signature time stamp at 09/15/2025 07:15 ....” Medical record document titled “Conditions of Admission” revealed “ ...1. Consent to Hospital Care ...,” displaying signature of Patient #14 dated and timed “ ...09/13/2025 20:54 ....” Medical record document titled “PATIENT OBSERVATION RECORD,” dated 09/13/2025, revealed “ ...Observation Level ...Q 15 ...Precautions ...blank ...,” with no documented patient monitoring from 20:25 (time of admission) until 21:45. Patient #15 Hospital document titled “9.25 EMTALA Log” revealed Patient #15 arrived at the Hospital on September 2, 2025, at 1830 as a “WALK ’ IN [sic],” “Emergency Medical/Psych Condition” was marked “YES,” with “Disposition” noted as “ADMITTED,” at 1830 and “Time Arrived on Unit” documented as 2111. Medical record document titled “ABHC Nursing Assessment Ver 1.1 09/02/2025,” revealed “ ...Evaluation Date: 09/02/2025 ...Time of arrival on unit: 09/02/2025 21:00 ...completed by: (Employee #9) (no completion date or time documented) ....” Document displayed signature of Employee #2 dated and timed “ ...09/03/2025 06:30 ....” Medical record document titled “Conditions of Admission” revealed “ ...1. Consent to Hospital Care ...,” displaying signature of Patient #15 dated and timed “ ...09/02/2025 19:05 ....” Medical record document titled “PATIENT OBSERVATION RECORD,” dated 9/2/25, revealed “ ...Observation Level Q15 ...Precautions ...Suicide (box checked) ...,” with no documented patient monitoring from 1830 (time of admission) until 21:00 (time of arrival on unit). Patient #17 Hospital document titled “November” (EMTALA Log) revealed Patient #17 arrived at the Hospital on November 1, 2025, at 1700 by “AMBO,” “Emergency Medical/Psych Condition” was marked “YES,” with “Disposition” noted as “ADMITTED,” at 1700 and “Time Arrived on Unit” documented as 1816. Medical record document titled “ABHC Nursing Assessment Ver 1.1 11/01/2025,” revealed “ ...Evaluation Date: 11/01/2025 ...Time of arrival on unit: 11/01/2025 18:00 ....” Document displayed signature of Employee #11 dated and timed “ ...11/02/2025 10:51 ...,” including “ ...RN reviewed ...Created By: (Employee #2) at 11/03/2025 08:51 ....” Medical record document titled “Conditions of Admission” revealed “ ...1. Consent to Hospital Care ...,” displaying signature of Patient #17 dated and timed “ ...11/01/2025 17:12 ....” Medical record document titled “PATIENT OBSERVATION RECORD,” dated 11/1/25, revealed “ ...Observation Level Q15 ...,” with no documented patient monitoring from 1700 (time of admission) until 18:15 (time of arrival on unit). Patient #20 Hospital document titled “9.25 EMTALA Log” revealed Patient #20 arrived at the Hospital on September 26, 2025, at “332 AM” by “AMBO,” “Emergency Medical/Psych Condition” was marked “YES,” with “Disposition” noted as “ADMITTED,” at “332 am” and “Time Arrived on Unit” documented as “405AM.” Medical record document titled “ABHC Nursing Assessment Ver 1.1 09/26/2025,” revealed “ ...Evaluation Date: 09/26/2025 ...Time of arrival on unit: (blank) ....” Document displayed signature of Employee #12 dated and timed “ ...09/26/2025 07:03 ....” Medical record document titled “Conditions of Admission” revealed “ ...1. Consent to Hospital Care ...,” displaying signature of Patient #20 dated and timed “ ...09/26/2025 04:37 ....” Medical record document titled “PATIENT OBSERVATION RECORD,” dated 9/26/25, revealed “ ...Observation Level Q15 ...Precautions ...FALL RISK ...,” with no documented patient monitoring from 3:32 (time of admission) until 4:45 (after time of arrival on unit). Employees #2 and #4 stated, during interviews conducted on November 25, 2025, that patients are monitored from time of admission to time of arrival on unit. Documentation of monitoring during these times for Patients #2, #4, #6, #7, #10, #11, #14 #15, #17, and #20 was requested, none was provided, and Employees #2 and #4 confirmed no monitoring documentation during these times was available for review at the time of the survey.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 49638 Based on a review of the Hospital’s policy and procedures, patient medical records, associated document requests, and employee interviews, it was determined that the Hospital failed to implement and enforce the Hospital policy that specifies the process by which the Hospital coordinates patient transfers. This deficient practice poses a potential risk of patient harm when the coordination of patient care activities for patient transfers is not executed pursuant to hospital policy. Findings include: Hospital Policy titled “EMTALA” (Number:19308786), last review/revision date of 11/2024, revealed “....Process ...1. Triage a. As soon as practical after arrival, individuals who come to the Emergency Department will be triaged in order to determine the order in which they will receive a medical screening examination ... B. Medical Screening Examination 2. The medical screening examination is the examination of the patient by the Qualified Medical Person required to determine within reasonable clinical confidence whether an emergency medical condition does or does not exist ... 3. Monitoring must continue until the individual is stabilized or appropriately admitted or transferred ...H. Transfer of Unstable Individuals ...2. When the Hospital transfers an individual with an unstabilized emergency medical condition to another facility, the transfer shall be carried out in accordance with the following procedures ...a. The Hospital shall, within its capability, provide medical treatment that minimizes the risks to the individual ’ s health ...b. A representative of the receiving facility must confirm that:...1. The receiving facility has available space and qualified personnel to treat the individual; and ...2. The receiving facility agrees to accept transfer of the individual and to provide appropriate medical treatment ...c. The Hospital must send to the receiving facility copies of all pertinent medical records available at the time of transfer, including: (1) history; (2) records related to the individual ’ s emergency medical condition; (3) observations of signs and symptoms; (4) preliminary diagnoses; (5) results of diagnostic studies or telephone reports of the studies; (6) treatment provided; (7) results of any tests; (8) the written patient consent or physician certification to transfer; and (9) the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. The Hospital must forward relevant records, pending lab work and test results to the receiving facility that was not available at the time of transfer....” Hospital Document titled “EMTALA Log” from August 2025 through November 2025 revealed: Patient #1 arrival date 10/08/2025, “...Arrival Time ...13:00 ...Arrival mode ...AMBO ...Emergency Medical/Psych Condition (YES or NO)...YES ...Disposition ...SENT TO ER ...Admit Time ...13:00...” Patient #13 arrival date 09/28/2025, “...Arrival Time ...1216 ...Arrival mode ...Walk-In ...Emergency Medical/Psych Condition (YES or NO)...YES ...Disposition ...REFERRED ...Admit Time ...1404....” Patient #1 ’ s medical record revealed the following: Hospital document titled “Medical Progress Note Medical” for Patient #1 dated 10/14/2025 16:05, revealed “...Interval History ...The patient present as pre-occupied as {he} feels {his} tongue was swelling in {his} mouth ...while at intake yesterday was complaining that {his} tongue was stuck and was having trouble swallowing because the tongue felt heavy ...Sent out for medical clearance. ...” A request for both Patient #1 ’ s Medical Screening Examination and confirmation from a representative of the receiving facility to accept transfer of the individual and to provide appropriate medical treatment for Patient #1 was made on November 25, 2025. None was provided at the time of survey Patient #13 ’ s medical record revealed the following: Hospital document titled “Intake Assessment” for Patient #13 dated 09/28/2025 12:19, revealed “...Reason for Admission or Chief Complaint...Patient ...brought into Avenir via walk in ...patient having an anxiety/panic attack crisis ...Patient made a comment to paramedics that they wanted to go to sleep and not wake up ... {Husband} stated that {she} was drinking last night and that {her} head is cloudy ...We are at full capacity, our provider ...said that it was ok to refer out ...I contacted Destiny Springs and they have availability ...{Husband} will drive {her} over there {he} does not want an ambulance to transport {her} because it will trigger {her}...VII. BASED ON THE ABOVE ASSESSMENT ...Does Meet Level One Criteria ...CLINICAL EXPLANATION ...Pt would benefit from inpatient admission for medication stabilization and symptom management ...” A request for both Patient #13 ’ s Medical Screening Examination and confirmation from a representative of the receiving facility to accept transfer of the individual and to provide appropriate medical treatment for Patient #13 was made on November 25, 2025. None was provided at the time of survey. Employee #2 confirmed in an interview conducted on November 25, 2025 that a transfer packet was not completed on Patient #1 or Patient #13 and could not be provided for review.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 49638 Based on review of Hospital policy and procedure, medical records, and employee interview, it was determined the Hospital failed to adhere to policy during intake and assessment for patients presenting from a referring facility, resulting in refusal to accept. This deficient practice poses the potential risk that patients will not receive timely care, causing possible patient harm. Findings include: Hospital Policy titled “Admission, Continued Stay, and Exclusionary Criteria” (Number:17905240), last review/revision date of 04/2025, revealed “...Procedure:...III. Criteria that identify patients for whom acute psychiatric care in the inpatient setting is not appropriate at the facility, otherwise known as exclusionary criteria:...a. Complex medical acuity that is potentially life threatening and cannot be safely managed in a freestanding psychiatric facility ...i. This includes, but is not limited to:...complicated intravenous medication including hyper-alimentation, blood and/or blood products, severe head trauma, onset of dysrhythmia which compromises medical stability, central line placement, diabetic ketoacidosis, renal failure, indwelling devices including wound drainage devices, Chest tubes, NG tubes, tracheostomy, telemetry, reverse isolation and the associated conditions, respiratory insufficiency with inability to maintain oxygen saturation >90% with oxygen, any Stage III+ decubitus ulcerations, and/or unresponsive/comatose patients ...b. Patients under the age of 18 ...c. Baseline cognitive impairment to such a degree that the patient would be unable to benefit from the behavioral health treatment intervention offered within either the hospital ’ s psychiatric units ...d. Patients for whom another, less restrictive level of care would be safe and effective in meeting their needs....” Hospital Document titled “EMTALA Log” from August 2025 through November 2025 revealed: Patient #12 arrival date 09/04/2025, “...Arrival Time ...923 ...Arrival mode ...Ambo ...Emergency Medical/Psych Condition (YES or NO)...YES ...Disposition ...PT SENT BACK TO REFERER CBI AS PT WAS DENIED ...Admit Time ...923...Time Arrived on Unit ...927....” Patient #12 ’ s medical record revealed the following: Hospital document titled “Nurse To Nurse” for Patient #12 dated 9/04/25, revealed “...Reason for Admission Per Packet ...Psychosis ...Comments ...Brought by police at CBI for aggression ...Time Referral Received ...119 ...Transport called ...Yes ...Estimated Pick up Time:...9 AM ...” Hospital communication documentation dated 9/4/2025, revealed, “...Patient #12 who was denied on the shift report but arrived this morning with Ambo ...Patient #12 was accepted and then nurses looked in packet and called and cancelled her ...Provider already approved ...” Documentation of an emergency medical screening exam, physician staffing, and stabilizing treatment provided was requested. None was provided at time of survey. Employee #2 and Employee #4 confirmed in an interview on November 24, 2025 through November 25, 2025 that Patient #12 was brought to the Hospital by ambulance from Community Bridges on 09/04/2025 after being accepted but was denied once the patient got to the Hospital due to receiving a restraint in the last twelve (12) hours though this is not mentioned in the exclusion criteria in Hospital policy.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45202 Based on review of hospital records and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient’s rights as evidenced by: Cross reference A0117: Failure to ensure ensure a patient or patient’s representative received a written copy of their patient rights for six (6) of 11 patients. Cross reference A0131: Failure to inform patients that there was not an MD/DO present at the hospital 24/7. Cross reference A-0144: Failure to ensure a patient bathroom was free from a condition or situation that may cause a patient or other individual to suffer physical injury by not ensuring that the area is free from ligature risk. Cross reference A-0160: Failure to record and monitor as a restraint, the use of 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, and therefore did not follow proper procedures and protocols for a chemical restraint. The cumulative effect of these systemic deficient practices resulted in the facility’s failure to meet the requirement for the Condition of Participation for Patient Rights and provide a safe environment for patients to protect them from harm.”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 45202 Based on the review of records and staff interviews, it was determined that the Medical Staff failed to provide quality patient care as stated in the by-laws as evidenced by: 0340: Failed to periodically conduct appraisals of its members. 0358: Failed to ensure a History and Physical examination was completed within the timeframe determined by medical staff rules and regulations. 0454: Failed to ensure practitioner orders were completed and signed as determined by medical staff rules and regulations. The cumulative effect of these systemic problems resulted in the medical staff’s inability to ensure the provision of quality patient care.”

“FOOD AND DIETETIC SERVICES CFR(s): 482.28 The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company may be found to meet this Condition of Participation if the company has a dietitian who serves the hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment. This Condition is not met as evidenced by: 45202 Based on policy and procedure, Arizona Administrative Code, United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, observation, and interview, the Department determined that the hospital failed to ensure: 1. The kitchen was maintained and cleaned without leading pipes 2. Food was not kept past it’s expiration 3. Food was not cross contaminated 4. Spills were cleaned 5. Food removed from its original container was dated and labeled 6. Temperatures logs were not being kept daily The cumulative effect of these deficient practices poses a high potential risk of harm to patients and other individuals who may consume food that was stored and prepared in the facility kitchen in unsanitary equipment and environment if the facility does not follow guidelines set forth in dietary guidelines. Findings include: The Arizona Administrative Code (9 A.A.C. 8, Article 1) requires: “...ARTICLE 1. FOOD ESTABLISHMENTS...R9-8-101. Purpose and Definitions...A. The Department incorporates by reference the United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration and shall comply with the 2017 Food Code (FC) as specified in this Article. This incorporation by reference contains no future editions or amendments. The incorporated material is on file with the Department and is available for order at: https://www.fda.gov/Food/ResourcesForYou/Consumers/ucm239035.htm, refer to publication number IFS17....” The United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration incorporated by reference in subsection (A) from R9-8-101 Food Establishments Purpose and Definition and R9-10-231 Dietary Services requires: “...6-5 MAINTENANCE AND OPERATION Subpart 6-501 Premises...PHYSICAL FACILITIES shall be maintained in good repair. 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. 4-6 CLEANING OF EQUIPMENT AND UTENSILS...4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch....(B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris....” Facility policy titled “Food and Nutrition Services” revealed “...Policy: ...It is the policy of the facility to ensure safe and sanitary food service operations, including storage, handling, preparation, and distribution of food...Procedure: ...4. All food preparation areas, equipment, dishes, and utensils are appropriately cleaned and sanitized after use in accordance with local health guidelines...5. All perishable food and drinks for patient use will be stored in kitchen or unit refrigerators and labeled with the date of delivery to the unit. Staff shall monitor the unit refrigerators and remove any item that is not dated, labeled with a patient name if open, or appearing unfit for patient consumption....” Observation of kitchen area during on-site tour conducted on August 27, 2024, revealed the following: General kitchen preparation area: Metal drainage pipe underneath sink with blue-green discoloration leaking at the L-joint, dripping water into a metal food service pan sitting on the floor. Dry food storage area containing: 1. One can of El Pato Salsa de Chile Fresco with a date stamp of “Best By 02/23/24.” 2. Three cans Embasa Chipotle Peppers with a date stamp of “Best By May 2022.” 3. A bin of Flour dated “10/03/23 3:36 PM” Employee #4 confirmed that the shelf life of Flour outside its original container is not more than 30 days. 4. A bin of Sugar dated “10/03/2023 3:36 PM” Employee #4 confirmed that the shelf life of Sugar outside its original container is not more than 30 days. Walk-in cooler revealed: 1. Multiple individually wrapped foods, removed from their original packaging, that did not have expiration dates and were without attached or posted dates when food items were removed from their original packaging. 2. A metal sheet pan with multiple food containers on it and an unidentified red-colored liquid pooled on the sheet pan surface. 3. Another sheet pan in the walk-in cooler had a partially used tube of hamburger meat wrapped in cellophane on it and a red-colored liquid coming from the wrapped meat and pooling in one corner of the pan. Temperatures: 1. Daily Kitchen Dishwasher Temperature Log was not completed since 8/22/2024. 2. Daily Holding Refrigerator Temperature Log was not completed since 8/25/2024. 3. Daily Freezer Temperature Log was not completed since 8/25/2024. Employee #4 confirmed in an interview conducted during the on-site tour conducted on August 27, 2024, that the metal drainage pipe was leaking and in need of repair, that the aforementioned food items were either expired or not stored according to policy, temperatures logs were not completed daily, and that sheet pans used for food storage had not been cleaned and that food for patient use was exposed to potentially contaminated liquid.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 45202 Based on facility policy and procedure, medical record review and employee interview, the Department determined the administrator failed to ensure a patient or patient’s representative received a written copy of their patient rights for six (6) of 11 patients. This deficient practice poses the potential risk that patients or patient representatives are not informed of their rights at the time of admission. Findings include: Facility policy titled “Patient Rights” revealed “...This facility informs each patient, patient’s guardian, and/or patient’s family when appropriate, of the patient’s rights, in advance of furnishing or discounting patient care whenever possible. The rights are discussed during admission, a copy is furnished in the patient handbook, and they are posted throughout the hospital units...” Facility policy titled “Intake Admission Process” revealed “...III. Protection of the Patient’s rights at admission: ...a. Upon admission, each patient, or when appropriate, the patient’s representative, is informed, [sic] of the patient’s rights, in advance of furnishing or discounting patient care whenever possible....” Medical records review conducted on August 28, 2024, revealed no evidence that patient rights were received by Patients #8. #18, #21, #22, #23, and #35. Employee #3 confirmed during an interview conducted on August 28, 2024, that there was no documentation present in medical records that Patients #8. #18, #21, #22, #23, and #35 received a copy of their patient rights.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 45202 Based on the review of documents, observations on tour, and interviews, the Department determined the hospital failed to inform patients that there was not an MD/DO present at the hospital 24/7. The deficient practice poses a potential risk to patients that may compromise the quality and safety of patient care. Findings include: Hospital documents included a Patient Packet that is provided to patients upon admission. Review of the packet did not include notification to patients that there was not an MD/DO on-site 24/7. Review of patient medical records revealed no documentation of notification of provider coverage. Observations on tour conducted on August 30, 2024 included the hospital lobby and intake area. Patient rights were posted in the hospital’s intake area. There was no notice informing patients that there was not an MD/DO on-site 24/7. Employee #2 and Employee #3 confirmed during an interview conducted on August 30, 2024, that the hospital does not have a hospital posting to notify patients that there is no MD/DO present on-site 24/7. The hospital does not provide patients with a written notification that there is no MD/DO present at the hospital 24/7.”

“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: 45202 Based on observation, review of documents and staff interviews, it was determined the Hospital failed to ensure a patient bedroom and bathroom was free from a condition or situation that may cause a patient or other individual to suffer physical injury by not ensuring that the area is free from ligature risk. This deficient practice provides opportunities for patients to utilize these as tie off points, thus presenting a health and safety risk for patients. Findings include: Observation on August 28, 2024, revealed the facility’s non-compliance with State licensing requirements for environmental standards and physical plant standards to protect the health and safety of patients receiving treatment at the facility. Ligature risks were identified during the facility tour that included; 1. Patient bedroom internal door knobs were not installed flush with the wall and did not have pick resistant caulk if not flush, creating a tie off point. 2. Six patient bathroom mirrors were not installed flush with the wall and did not have pick resistant caulk if not flush, creating a tie off point. 3. Three soap dishes in patient bathrooms were not installed flush with the wall and did not have pick resistant caulk if not flush, creating a tie off point. 4. All patient bathroom shower heads were not installed flush with the wall and did not have pick resistant caulk if not flush, creating a tie off point. 5. Patient bedroom and bathroom light switches (13) were not installed flush with the wall and did not have pick resistant caulk if not flush, creating a tie off point and possible access to electrical. Document titled “EOC Safety and infection Control Minutes” for April 2024 to June 2024, did not identify the issues. Interview with Employee #2, Employee #3 and Employee #4 confirmed in an interview on August 28, 2024, that the above identified ligaures were not addressed.”

“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: 45202 Based on facility policy and procedure, review of facility medical records, document request and employee interview, the Department determined the administrator failed to record and monitor as a restraint, the use of 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, and therefore did not follow proper procedures and protocols for a chemical restraint. This deficient practice poses a risk to patient health and safety including possible death if a patient is not properly monitored after a chemical restraint. Findings include: Facility policy titled “Seclusion and Restraint” revealed “...Procedure: ...E. The patient shall be monitored and reassessed through continuous in-person observation, documented on the restraint/seclusion checklist....” Facility medical record review revealed the following: Patient #23 - Document titled “RISK INCIDENT REPORT - CONFIDENTIAL REPORT OF OCCURRENCE” revealed “...Date of Occurrence: 3/1/2024...Patient was in therapy room with (unidentified employee). Patient seen through window throwing computer off desk...Follow up Action Taken: ...Psych provider notified and orders for B52 were given. Orders read back and verified with provider....” No documentation was provided confirming monitoring and assessment of Patient #23. Patient #33 - Document titled “Progress Note 02/29/2024 15:44” revealed “...Pt was upset that he/she wasn’t receiving pudding as his/her snack. BHT attempted to explain why there was no pudding and pt started yelling and showing staff his/her gums. Pt started yelling at BHT and head butt him/her on the head. Pt took PO B52 and told (Employee #21) that he/she would inform us if he/she started to get agitated with any peers or staff....” No documentation was provided confirming monitoring and assessment of Patient #33. Restraint packet documentation for Patients #23 and #33 for the aforementioned incidents was requested, none was provided. Employee #3 confirmed in interviews conducted on August 28, 2024 and August 29, 2024, that no restraint packet documentation including documentation of monitoring and assessment was completed for Patient #23 and Patient #33.”

“MEDICAL STAFF PERIODIC APPRAISALS CFR(s): 482.22(a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 45202 Based on review of Medical Staff Bylaws, credential files and staff interviews, it was determined the medical staff failed to periodically conduct appraisals of its members. This deficient practice can result in practitioners not being provided oversight resulting in inappropriate patient care and operating outside their scope. Findings include: Review of the Medical Staff Bylaws revealed: “...Develop criteria to be used for evaluating the performance of Practitioners when issues affecting the provision of safe, high quality patient care are identified and develop criteria that determine the type of performance monitoring to be conducted....” Policy titled “OPPE/FPPE” states “...Ongoing professional practice evaluation is conducted continuously and reported to the Medical Executive Committee for review and action...The Medical Executive Committee meets quarterly. The frequency of ongoing professional practice evaluations at ABHC is three eight month periods in order to accrue 3 OPP’E reports for review at the two-year approval period....” Interview with Employee #10 confirmed that he conducts “quarterly reviews of all providers.” Review of credential files for 5 of 5 providers (Employee #11, 12, 13, 14, & 15) revealed one written appraisals in their files during a 2 year period for titled “Q3 2023 Peer Review.” Employee #10 & #16 confirmed in an interview on August 29, 2024, that no other appraisals were available to review.”

“MEDICAL STAFF RESPONSIBILITIES - H&P CFR(s): 482.22(c)(5)(i) [ The bylaws must:] Include a requirement that-- (i) A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(5)(iii) of this section. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified individual in accordance with State law and hospital policy. This Standard is not met as evidenced by: 45202 Based on facility policy and procedure, facility documents and employee interview, the Department determined the administrator failed to ensure a History and Physical examination was completed within the timeframe determined by medical staff rules and regulations. This deficient practice poses the risk that patients will not receive timely healthcare services, leading to potential injury or death. Findings include: Facility policy titled “Medical Staff Bylaws, Rules and Regulations” revealed “...History & Physical Examination: ...A complete admission History and Physical examination shall be written or dictated within twenty-four (24) hours of the patient’s admission to the Hospital and signed within 48-hours or next visit, whichever comes first....” Review of facility patient medical records revealed the following: The medical record for Patient #17 documented an admission date and time of March 30, 2024 at 15:28. Review of document titled “History and Physical Exam 03/31/2024 12:38” revealed an electronic signature by Employee #17 at “...03/31/2024 19:54...” The medical record for Patient #16 documented an admission date and time of June 14, 2024 at 01:33. Review of document titled “History and Physical Exam 06/14/2024 23:47” revealed an electronic signature by Employee #18 at “...06/16/2024 09:05...” Employee #3 confirmed during an interview conducted on August 29, 2024, that the History and Physical examinations for Patients #16 and #17 were electronically signed by the completing providers after 24 hours of both patient admissions.”

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 45202 Based on facility policy and procedure, facility documents and employee interview, the Department determined the administrator failed to ensure practitioner orders were completed and signed as determined by medical staff rules and regulations. This deficient practice poses the risk that the person authenticating another practitioners’ orders will not know if the correct infomarmation was taken down by the transcribing RN for verbal orders. Findings include: Facility policy titled “Medical Staff Bylaws, Rules and Regulations” revealed “...All orders, either verbal or dictated over the telephone, shall be signed by the duly authorized person, to whom it was dictated, indicating the name of the Practitioner per his or her own name. These orders shall be read back to the Practitioner. The responsible Practitioner shall authenticate oral orders within 48 hours or the next visit, whichever occurs first....” The medical record for Patient #11 revealed the following: Document titled “Order to Admit, once, until further notice” that states “...Duration: Until further notice, start date: 03/21/2024 20:30...Ordered by (Employee #10)...Entered by (Employee #23)...Order Review (Employee #19)...03/22/2024 10:09...” The Order Review by Employee #19 contained an electronic signature. The medical record for Patient #12 revealed the following: Document titled “Order to Admit, once, until further notice” that states “...Duration: Until further notice, start date: 03/11/2024 12:00...Ordered by (Employee #19)...Entered by (Employee #24)...Order Review (Employee #11)...03/12/2024 11:08...” The Order Review by Employee #11 contained an electronic signature. The medical record for Patient #33 revealed the following: Document titled “Order to Admit, once, until further notice” that states: “...Duration: Until further notice, start date: 02/20/2024 14:30...Ordered by (Employee #19)...Entered by (Employee #20)...Order Review (Employee #11)...02/21/2024 18:10...” The Order Review by Employee #11 contained an electronic signature. Document titled “Lorazepam, 2mg x 1 tablet, oral, tablet, once, for 1 day” that states “...Duration: 1 day, start date: 02/29/2024 15:30, end date: 03/01/2024...Ordered by (Employee #10)...Entered by (Employee #21)...Order Review (Employee #19)...03/01/2024 08:58...” The Order Review by Employee #19 contained an electronic signature. Document titled “Diphenhydramine Hcl, 25mg x 2 tablet, oral, tablet, once, for 1 day” that states “...Duration: 1 day, start date: 02/29/2024 15:30, end date: 03/01/2024...Ordered by (Employee #10)...Entered by (Employee #21)...Order Review (Employee #19)...03/01/2024 08:58...” The Order Review by Employee #19 contained an electronic signature. Document titled “Haloperidol, 5mg x 1 tablet, oral, tablet, once, for 1 day” that states “...Duration: 1 day, start date: 02/29/2024 15:30, end date: 03/01/2024...Ordered by (Employee #10)...Entered by (Employee #21)...Order Review (Employee #19)...03/01/2024 08:58...” The Order Review by Employee #19 contained an electronic signature. The medical record for Patient #34 revealed the following: Document titled “Order to Admit, once, until further notice” that states “...Duration: Until further notice, start date: 03/18/2024 06:45...Ordered by (Employee #10)...Entered by (Employee #22)...Order Review (Employee #18)...03/18/2024 23:40...” The Order Review by Employee #18 contained an electronic signature. Employee #3 confirmed during an interview conducted on August 29, 2024, that the aforementioned practitioner orders for Patients #11, #12, #33 and #34 were given verbally by practitioners who did not authenticate their own verbal orders.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 45202 Based on review of facility policy and procedure, personnel records and employee interview, the Department determined the administrator failed to comply with EMTALA regulations by not establishing formal In-service training program records, schedules and reports. This deficient practice could result in staff being not adequately trained by a qualified/certified professional in a formalized manner that could result in inappropriate patient placement and/or patient harm. Findings Include: A request was made for facility policy and procedure regarding an EMTALA training program and facilitator requirements. Interview with Employee #1 on August 30, 2024, confirmed that a facility policy regarding an EMTALA training program and facilitator requirements was not available. Employee #1 provided a document titled “EMTALA Quick Sheet” with no date or identifying information, on August 30, 2024, that Employee #1 stated they review with staff. From this document, they provide a quiz to employees. A request for a policy on when, how often, which staff, and who can facilitate the training was requested on August 30, 2024. No policy was provided on EMTALA training requirements. Documentation for EMTALA staff training was requested for Employees (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16) on August 30, 2024. The following EMTALA quizzes were not provided as follows: Employee #1 No EMTALA annual competency were provided. Employee #4 No EMTALA quiz at hire were provided. Employee #6 No EMTALA quiz at hire were provided. Employee (#15) No EMTALA quiz at hire were provided. Employee (#16) No EMTALA quiz at hire were provided. Employee #12 No EMTALA quiz at hire, but annual competency was completed 4/26/2024. Employee #14 was missing an EMTALA quiz at hire, but annual competency was completed 4/22/2024. Employee #6 confirmed in an interview on August 30, 2024, that the above listed Employee’s did not have the required EMTALA in-service training’s available for review and no formal policy was available for review.”

“HOSPITAL MUST MAINTAIN RECORDS CFR(s): 489.20(r)(1) [The provider agrees,] in the case of a hospital as defined in §489.24(b), (including both the transferring and receiving hospitals), to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer. This Standard is not met as evidenced by: 45202 Based on review of policies and procedures, medical records and staff interviews, it was determined that the hospital failed to ensure the medical record was maintained with all required documentation for at least 5 years. This deficient practices can result in a patient not getting appropriate psychiatric and medical care if they need further treatment. Findings Include: Policy titled “Medical Staff Bylaws, Rules and Regulations” last revised May 2024, policy #15934421, states “...The attending Practitioner shall be responsible for the preparation of a complete and legible medical record for each patient....” Policy titled “Intake Admission Process” Effective August 2024, policy #16418805, states “...When a call or fax is received regarding a potential admission, registered nurse (RN), or Social Worker assigned to screen for admission will complete a clinical review...i. If the potential admission is coming directly from another facility, such as an emergency department, long term care facility, or in another inpatient unit, the patient is considered a Direct Admission. Upon receiving notification of a potential admission from another facility, the RN will complete a Nurse to Nurse staffing and obtain admission orders from a physician. Clinical data will be requested that includes: 1. Lab work obtained within the past 30 days 2. Nursing notes, including documentation of specific reason why the patient requires inpatient psychiatric hospitalization 3. If nursing notes do not specifically indicate clear admission criteria, additional clinical information may be requested... ii. If the potential admission is a referral from an outpatient provider’s office or a self-referral/ walk-in, the patient is considered an unscheduled Admission. The RN and/ or the Social Worker assigned to the Admission Department will complete an assessment of criteria, making every attempt to gather all possible information....” A request was made on August 29, 2024, for the clinical review, nursing review, nursing notes on specific reasons for referal, and all assessments including the MSE in the patient medical record was requested for Patient #24, #25, #26, #27, #28, #29, #30, #31, #32 who were reported to have been admitted but did not stay for treatment. None were provided. Telephonic interview with Employee #1 confirmed on August 29, 2024, that the paper portion of the assessment was also no longer available and had been shredded. Interview with Employee #3 on August 29, 2024, stated “If the patient does not stay after being assessed, the medical record is deleted.” Employee #3 confirmed that a MSE was performed on Patient #24, #25, #26, #27, #28, #29, #30, #31, #32, to determine if they were a psychiatric emergency, they were accepted for admission, and for reasons unknown to Employee #3, they did not stay for treatment and they no longer had a medical record available for review.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 45202 Based on document review and interview, it was determined that the facility failed to complete a medical screening examination (MSE) conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations to be qualified to complete an MSE. This deficient practice poses a risk to the health and safety of patients if life-threatening or potentially life threatening conditions are not recognized and stabilizing treatment provided. Findings include: The policy titled “EMTALA” states “... ‘Qualified Medical Person’ or ‘Qualified Medical Personnel’ means an individual or individuals determined qualified by Hospital bylaws or rules and regulations (and consistent with state licensure) to perform a Medical Screening Examination. In the Hospital, qualified medical personnel are limited to physicians, physician assistants, nurse practitioners, and registered nurses who have been deemed qualified....” Policy titled “Intake Admission Process” effective August 2024, policy #16418805, states “...the RN will complete the medical/ infection screening....” Patient #8’s medical record dated contained a MSE completed on March 14, 2024, by an LPN with no other signatures. Patient #13’s medical record dated contained a MSE completed on July 11, 21024, by a Social Worker with no other signatures. Employee #3 confirmed in an interview on August 30, 2024, that Patient #8 and Patient #13’s MSE’s were not completed by qualified individuals.”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 45202 Based on review of clinical records, policies and procedures, hospital documents, and staff interviews, it was determined the hospital the hospital delayed screening and treatment 7 out of 11 Patient’s to inquire about the individual’s method of payment or insurance status. This deficient practice resulted in unduly discouraging individuals from obtaining further evaluation. Findings include: Hospital policy titled, “EMTALA” effective August 2024, policy #16418781, states “...The Hospital will not base the provision of emergency services and care upon an individual’s race, ethnicity, religion, national origin, citizenship, culture, language age, sex, preexisting medical condition, physical or mental disability, insurance status, sexual orientation, gender identity or expression, economic status or ability to pay for medical services, except to the extent that a circumstance is relevant to the provision of appropriate medical care....” Document titled “Referral log” had the following patients and “Disposition” noted: 3/10/24 Patient #1 “no insurance” “0553am” 3/10/24 Patient #2 “Admitted” With insurance “903am” 3/10/24 Patient #3 “Declined no insurance” “1029am” 3/10/24 Patient #4 “Declined no insurance” “1031am” 3/10/24 Patient #5 “Declined no insurance” “1056am” 3/10/24 Patient #6 “Accepted” with insurance “1059am” 3/12/24 Patient #7 “Decline-no insurance” “2300pm” 3/12/24 Patient #8 “Accepted” with insurance “2357pm” 3/21/24 Patient #9 “Denied-No insurance” “947am” 3/21/24 Patient #10 “no insurance” “253pm” 3/21/24 Patient #11 “Accept” with insurance “308pm” Documentation regarding the Patient #1, 3, 4, 5, 7, 9, & 10’s referal was requested. None was provided. Interview with Employee #1 on August 29, 2024, stated that they were all shredded and the patient charts were not available. Interview with Employee #2 August 30, 2024, stated there should be a chart without a picture that is available for review but was not able to produce a chart for Patient #1, 3, 4, 5, 7, 9, & 10. Interview with Employee #2 confirmed that when a person is referred for intake for a psychiatric emergency, the facility reviews the packet for medical criteria to determine if they can support the patient’s needs. If they determine they can accept the patient they then provide the patient with a list of fees for services so that the “patient can decide if they want to get services here or not. They often decide not to because of the cost.” Interview with with Employee #2 confirmed on August 30, 2024, that patients are referred for psychiatric emergencies and the above patient’s did not get treatment at the facility due to not accepting the rates being billed reiterating that they don’t have insurance and have to agree to the rates prior to receiving any services at the hospital. Interview with Employee #3 on August 30, 2024, stated the patient charts were deleted if a patient did not stay for treatment after assessment. Interview with Employee #3 confirmed that the above patients were identified as having a psychiatric emergency and need for transfer to the facility and were not transferred and no charts were available for review.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 45202 Based on review of clinical records, policies and procedures, hospital documents, and staff interviews, it was determined the hospital the hospital refused to receive patients with a psychiatric emergency if they did not have the ability to pay. This deficient practice can result in patient harm or death. Findings include: Hospital policy titled, “EMTALA” effective August 2024, polic #16418781, states “...The Hospital will not base the provision of emergency services and care upon an individual’s race, ethnicity, religion, national origin, citizenship, culture, language age, sex, preexisting medical condition, physical or mental disability, insurance status, sexual orientation, gender identity or expression, economic status or ability to pay for medical services, except to the extent that a circumstance is relevant to the provision of appropriate medical care....” Document titled “Referral log” had the following patients and “Disposition” noted: 3/10/24 Patient #1 “no insurance” “0553am” 3/10/24 Patient #2 “Admitted” With insurance “903am” 3/10/24 Patient #3 “Declined no insurance” “1029am” 3/10/24 Patient #4 “Declined no insurance” “1031am” 3/10/24 Patient #5 “Declined no insurance” “1056am” 3/10/24 Patient #6 “Accepted” with insurance “1059am” 3/12/24 Patient #7 “Decline-no insurance” “2300pm” 3/12/24 Patient #8 “Accepted” with insurance “2357pm” 3/21/24 Patient #9 “Denied-No insurance” “947am” 3/21/24 Patient #10 “no insurance” “253pm” 3/21/24 Patient #11 “Accept” with insurance “308pm” Documentation regarding the Patient #1, 3, 4, 5, 7, 9, & 10’s referal was requested. None were provided. Employee #1 stated that they were all shredded and the patient charts were not available. Employee #3 stated the patient charts were deleted if a patient did not stay for treatment after assessment. Interview with Employee #2 confirmed that when a person is referred for intake for a psychiatric emergency, the facility reviews the packet for medical criteria to determine if they can support the patient’s needs. If they determine they can accept the patient they then provide the patient with a list of fees for services so that the “patient can decide if they want to get services here or not. They often decide not to because of the cost.” Employee #2 stated there should be a chart without a picture that is available for review but was not able to produce a chart for Patient #1, 3, 4, 5, 7, 9, & 10. Interview with with Employee #2 confirmed on August 30, 2024, that patients are referred for psychiatric emergencies and the above patient’s did not get treatment at the facility due to not accepting the rates being billed reiterating that they don’t have insurance and have to agree to the rates prior to receiving any services at the hospital. Interview with Employee #3 confirmed that the above patients were identified as having a psychiatric emergency and need for transfer to the facility and were not transferred and no charts were available for review.”