Agave Ridge Behavioral Hospital

“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 review of Hospital policy, observation during on-site tour, medical record review 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 A-0144: Failure to ensure a patient receives care in a safe setting. Specifically, the presence within patient care areas of ligature points Cross reference A-0166 Failure to ensure the use of restraint or seclusion must be in accordance with a written modification to the patient’s plan of care. Cross reference A-0167 Failure to ensure the use of restraint or seclusion must be implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. Cross reference A-0175 Failure to ensure the condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria at an interval determined by hospital policy. Cross reference A-0178 Failure to ensure 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 By a Physician or other licensed practitioner; or a Registered nurse who has been trained. Cross reference A-0194 Failure to ensure a patient restraint was implemented according to hospital policy. Cross reference A-0204 Failure to ensure the hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary. The cumulative effect of these systemic deficient practices resulted in the Hospital’s failure to meet the requirement for the Condition of Participation for Patient Rights.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 52829 Based on review of Hospital policy, Hospital documents, video review, medical record review and staff interviews, it was determined that the Hospital failed to comply with requirements for infection prevention and control. Based on Hospital policy and procedure, policy and procedure request, Centers for Disease Control and Prevention reference, medical record, video monitoring footage review, and employee interview, the Department determined the Administrator failed to ensure infection prevention and control measures were implemented with a patient ’ s exposure to staff blood. This deficient practice resulted in a lack of patient intervention following exposure to staff blood, with failure to provide assessment and prophylactic treatment potentially resulting in bloodborne illness. Findings include: Hospital policy titled “Infection Prevention and Control Program,” Policy #19252268, Effective 11/2025, revealed “ ...The primary goal of an infection prevention and control (IPC) program is to reduce the transmission of pathogenic organisms between employees, practitioners, patients, and visitors ...It is the policy of this facility that all blood and bodily substances will be regarded as infectious or hazardous ....” Request was made for Hospital policy addressing patient intervention for exposure to staff blood and bodily substances. None was provided. Centers for Disease Control and Prevention (CDC) document titled “Management of Potentially Infectious Exposures and Illnesses,” dated April 12, 2024, revealed “...Recommendation ...Evaluating the exposure incident and source, including whether the source was potentially infectious ...Arranging for any needed testing ...options for and risks and benefits of postexposure prophylaxis or treatment ...need for specialty care ...follow-up testing and treatment ...signs and symptoms of illness to report after an exposure, including potential side effects of prophylaxis ....” Medical record for Patient #2 revealed the following: Document titled “AHC Progress Notes,” dated 1/02/2026, revealed “ ...Pt was observed standing by the door, (Patient #2) was redirected to go to day room/Noise room ...As soon as (Hospital employee) hit the fob, the pt bolted out the door and ran toward the second door ...Pt ran toward the cafeteria, (Employee #10) was on the way to Amethyst/Marigold Unit and saw the pt...verbally redirected (Patient #2), pt was combative and refused redirection ...Pt was physically restrained for 5 mins and was able to calm down afterwards ...Pt escorted to the Unit with other staffs, assessed for injuries ...No serious injuries was [sic] noted ...PRN Ativan for anxiety administered and pain meds &applied ice for headache ....” Document titled “Seclusion/Restraint One Hour Face to Face Assessment” revealed “ ...Initiation of Intervention ...Date: 1/02/2026 ...Time: 01:05 PM ...Type of Intervention ...Physical Restraint (checkbox checked) ...Patient ’ s Immediate Situation/Reaction to Restraint: ...Pt administered PRN Ativan, effective. Pt is calm & cooperative to staff directives. Pt reminded Unit expectations, (Patient #2) verbalized understanding ....” Interview with Employee #7, conducted on March 6, 2026, revealed the following: Employee #7 reported that, during the restraint event involving Patient #2, dated 1/2/2026, at the point where Employee #10 reengages after Employee #7 was observed tapping Employee #10, Patient #2 was seen “spitting blood.” Employee #7 reported Patient #2 “apparently bit” Employee #10. Employee #2 confirmed, during interviews conducted March 6, 2026 through March 12, 2026, knowledge that Patient #2 bit Employee #10 during the restraint event, had been exposed to Employee #10 ’ s blood, that no post-exposure intervention occurred with Patient #2, and that no policy addressing patient intervention for exposure to staff blood and bodily substances, at the time of the incident, was available for review at the time of the survey.”

“Special Medical Record Requirements CFR(s): Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals The medical records maintained by a psychiatric hospital must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution. This Condition is not met as evidenced by: 52829 Based on review of Hospital policy, Hospital documents, medical record review and staff interviews, it was determined that the Hospital failed to comply with Special Medical Record Requirements for Psychiatric Hospitals Cross reference A-1640: Failure to ensure each patient has an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. Cross reference A-1644: Failure to ensure the written plan includes the responsibilities of each member of the treatment team. The cumulative effect of these systemic deficient practices resulted in the Hospital’s failure to meet the requirement for the Condition of Participation for Special Medical Record Requirements for Psychiatric Hospitals.”

“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 hospital policy and procedure review, observation while on tour of the hospital premises, and employee interview, the Department determined that the hospital failed to ensure that the premises is to be free from any unsafe conditions or situations. This deficient practice poses a risk to the health and safety of patients. A review of hospital policy titled “Environmental Risk Assessment,” policy #SM-007, reviewed 4/24, revealed: “Purpose ...The assessment is used to evaluate the risks in the environment of care ...Responsibility ...The Safety Officer is responsible for managing the risk assessment process ...The responsibilities include ...Review results of the assessment to identify risks that require new, changed, or updated policies, procedures, and controls to eliminate or minimize the risks ....” Observations while on tour of the hospital premises, completed on March 10, 2026, revealed: Amethyst Unit: Room #101 Bathroom: Sharp corners on mirror. Sharp metal panel corners under sink. Room #103 Bathroom: Sharp corners on mirror. Sharp metal panel corners under sink. Loose screws in metal panel under sink. Electric Room #144: Door strike protruding out of door. Marigold Unit: Room #201 Bathroom: Gap behind metal panel above toilet. 2 protruding screws on mirror. Room #205: Gap behind wall outlet. Scarlet Unit: Room #302 Bathroom: Protruding screw on mirror. Protruding screw in metal panel above toilet. Room #306: Gap behind wall outlet. An interview with employee #11, completed on March 10, 2026, confirmed that rooms and bathrooms in the Scarlet, Amethyst, and Marigold units are not free of unsafe situations and/or conditions.”

“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 review of facility policies and procedures, medical records, and employee interview the Department determined the Administrator failed to ensure that patient care plans were updated after an incident of restraint or seclusion and accurately reflected the patient ’ s status. This deficient practice poses a potential risk to the health and safety of the patient when the patient’s treatment plan is not re-evaluated and updated accurately after a qualifying event to determine whether the current treatment plan is effective or needs to be modified per facility policy. Findings include: Review of hospital document titled “Restraint” Policy #164581816 last reviewed 05/2024 revealed, “ ... 12. The treatment plan shall be reviewed and revised following the first episode of restraint to include measures to prevent recurrence ....” Review of hospital document titled “Seclusion” Policy #16458185 last reviewed 05/2024 revealed, “ ... 11. The treatment plan shall be reviewed and revised following seclusion to include measures to prevent recurrence ....” Review of hospital document titled “Assessment and Reassessment” policy #16458215 last reviewed 05/2024 revealed “ ... each patient is reassessed as necessary based on the patient’s plan for care or change in their condition ....” Review of Patient #2 medical record, document titled “Seclusion/Restraint RN Assessment, dated 01/02/2026, revealed an instance of physical restraint. Request for documentation showing an update to Patient #2 treatment plan, including measures taken to prevent recurrence, was requested. None was provided. Review of Patient #6 medical record revealed the following: Document titled “Progress Notes,” dated 12/01/2025, revealed “ ...Patient began attempting to scratch and self-harm. Multiple staff responded, holding her hands and continued verbally de-escalating ....” Document titled “Nursing Note,” dated 12/01/2025, revealed “ ...(Patient #6) states having a difficult day but mentions feeling better now, reports having been restrained due to self-harming ....” Request for documentation showing an update to Patient #6 treatment plan, including measures taken to prevent recurrence, was requested. None was provided. Medical record for patient #10 revealed the following: Document titled “Progress Notes,” dated 1/05/2026, revealed: “ ...pt continued to escalate ...Pt was put in hold, refused to contract for safety and was escorted to seclusion room ...nurse ...received orders for IM medication ....” A request was made for patient #10 ’ s updated treatment plan document for the seclusion, physical restraint, and chemical restraint that occurred on 01/05/2026. None was provided during the time of survey. Review of patient #15 medical record, document titled “Seclusion/Restraint RN Assessment Agave Ridge Behavioral dated 3/01/2026 revealed, an instance of physical restraint, chemical restraint, and seclusion. Request for documentation showing an update to patient #15 treatment plan addressing measures taken to prevent recurrence was requested on survey conducted 3/10/2026 through 3/12/2026, none provided for review. Review of patient #17 medical record, document titled “Seclusion/Restraint RN Assessment Agave Ridge Behavioral dated 2/28/2026 revealed, an instance of seclusion. Request for documentation showing an update to patient #17 treatment plan addressing measures taken to prevent recurrence was requested on survey conducted 3/10/2026 through 3/12/2026, none provided for review. Review of patient #18 medical record, document titled “Seclusion/Restraint RN Assessment Agave Ridge Behavioral dated 2/19/2026 revealed, an instance of chemical restraint, Request for documentation showing an update to patient #18 treatment plan addressing measures taken to prevent recurrence was requested on survey conducted 3/10/2026 through 3/12/2026, none provided for review. Review of patient #19 medical record, document titled “Seclusion/Restraint RN Assessment Agave Ridge Behavioral dated 3/05/2026 revealed, an instance of chemical restraint. Request for documentation showing an update to patient #19 treatment plan addressing measures taken to prevent recurrence was requested on survey conducted 3/10/2026 through 3/12/2026, none provided for review. Review of patient #20 medical record, document titled “Seclusion/Restraint RN Assessment Agave Ridge Behavioral dated 2/02/2026 revealed, an instance of seclusion. Request for documentation showing an update to patient #20 treatment plan addressing measures taken to prevent recurrence was requested on survey conducted 3/10/2026 through 3/12/2026, none provided for review. Employee #2 confirmed in interview conducted 3/11/2026 that there was not an update made to patients #2, #6, #15, #17, #18, #19, and #20 treatment plan following the episodes of seclusion and/or restraint.”

“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: 52829 Based on Hospital policy and procedure, medical records, video monitoring footage review, and employee interviews, the Department determined the Administrator failed to ensure a patient restraint was implemented according to policy. This deficient practice resulted in a patient restraint that was not implemented according to policy, posing a risk to patient health and safety. Findings include: Hospital policy titled “Patient Rights,” Policy #16458240, Effective 05/2024, revealed “ ...f. Patients have the right to be treated with consideration, respect and full recognition of their dignity and individuality ...g. Patients have the right to be protected by the Hospital from neglect; from physical, verbal and emotional abuse (including corporal punishment); and from forms of misappropriation and/or exploitation ....” Hospital policy titled “Restraint,” Policy #16458186, Effective 05/2024, revealed “ ...Physical Restraint includes manual measures approved by CPI to limit or restrict body movement ...5. Patients will be restrained in the supine position, unless contraindicated and in accordance with CPI. Approved CPI holds are considered a physical restraint ....” Hospital confirmed training curriculum used for patient restraint is “Crisis Prevention Institute (CPI) ...Nonviolent Crisis Intervention Training.” Medical record for Patient #2 revealed the following: Document titled “AHC Progress Notes,” dated 1/02/2026, revealed “ ...Pt was observed standing by the door, (Patient #2) was redirected to go to day room/Noise room ...As soon as (Hospital employee) hit the fob, the pt bolted out the door and ran toward the second door ...Pt ran toward the cafeteria, (Employee #10) was on the way to Amethyst/Marigold Unit and saw the pt...verbally redirected (Patient #2), pt was combative and refused redirection ...Pt was physically restrained for 5 mins and was able to calm down afterwards ...Pt escorted to the Unit with other staffs, assessed for injuries ...No serious injuries was [sic] noted ...PRN Ativan for anxiety administered and pain meds &applied ice for headache ....” Document titled “Seclusion/Restraint One Hour Face to Face Assessment” revealed “ ...Initiation of Intervention ...Date: 1/02/2026 ...Time: 01:05 PM ...Type of Intervention ...Physical Restraint (checkbox checked) ...Patient ’ s Immediate Situation/Reaction to Restraint: ...Pt administered PRN Ativan, effective. Pt is calm & cooperative to staff directives. Pt reminded Unit expectations, (Patient #2) verbalized understanding ....” Hospital video monitoring footage, “Center Hallway 1,” dated 1/2/2026, reviewed with Employee #1 present, revealed the following: 01:17:58 PM - Employee #10 observed approaching Patient #2 in the main hallway. 01:18:01 PM - Employee #10 observed blocking Patient #2, followed by holding Patient #2 ’ s arms. 01:18:06 PM - Employee #10 observed lifting Patient #2 up and taking Patient #2 to the floor, with Patient #2 landing on his back. Employee #10, alone, observed attempting to hold Patient #2. 01:18:15 PM - Employees #8 and #9 observed kneeling down, appearing to hold Patient #2 ’ s legs and upper body area. Employee #5 observed standing to the side. 01:18:16 PM - Employee #10 appears to place a knee on a portion of Patient #2 ’ s upper body. Other staff are observed arriving and engaging. Employee #1 responded that the video view made it difficult to determine where Employee #10 ’ s knee was or if it was on Patient #2. 01:19:19 PM - Employee #7 observed tapping Employee #10, Employee #10 observed reengaging. 01:19:28 PM - Employee #7 observed physically pulling Employee #10 from Patient #2. Employee #10 observed disengaging and walking out of camera view. Interview with Employee #7, conducted on March 6, 2026, revealed the following: Employee #7 confirmed the response to Patient #2 was “a code call.” Employee #7 reported observing Patient #2 was “supine” on the floor upon arrival, with Patient #2 turned to a “prone” position on the floor, observing Employee #10 ’ s knee on Patient #2 ’ s neck. Employee #7 confirmed attempt to “tap out” Employee #10, stating that Employee #7 refused and went “back down” to Patient #2. Employee #7 confirmed an attempt to pull Employee #10 off of Patient #2, confirming that Employee #10 then disengaged. When asked if the intervention actions observed being employed by Employee #10 were CPI-approved restraint techniques, Employee #7 responded “no.” Employees #2 and #3 confirmed, during interviews conducted March 6, 2026 through March 12, 2026, that the restraint techniques used by Employee #10 on January 2, 2026, were not approved CPI techniques and not in accordance with Hospital policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 52829 Based on hospital policy and procedure review, hospital documentation review, patient medical record review, and employee interview, the Department determined that the administrator failed to ensure staff followed monitoring processes when patients are placed in seclusion and/or restraint (S/R). This deficient practice poses a risk that patient needs are not consistently monitored, and met while in seclusion and/or restraint, which poses a threat of harm or death to patients. Findings include: Review of hospital policy titled “Seclusion,” policy #16458185, revised 05/2024, revealed: “ ...The patient shall be monitored and reassessed through continuous in-person observation ....” Review of hospital policy titled “Restraint,” policy #16458186, revised 05/2024, revealed: “ ...The patient shall be monitored and reassessed through continuous in-person observation ....” Review of hospital documentation titled “Seclusion/Restraint Flowsheet,” revealed: “ ...Patient Monitoring ...RN evaluates need for continued seclusion/restraint. RN must complete an entry on patient monitoring flow sheet below ...Includes up to & including release ...on an ongoing basis during continuous in-person monitoring ...Document MINIMUM every 15 minutes. ....” Review of patient #12 ’ s medical record documentation titled “Seclusion/Restraint Flowsheet,” dated 01/13/2026, revealed: “ ...Seclusion/Restraint Type ...Physical Restraint ...Time In ...04:40 PM ...Time Out ...0510 PM ...Seclusion ...Time In ...04:55 PM ...Time Out ...05:10 PM ... Patient Monitoring ...RN evaluates need for continued seclusion/restraint. RN must complete an entry on patient monitoring flow sheet below ...Includes up to & including release ...on an ongoing basis during continuous in-person monitoring ...Document MINIMUM every 15 minutes ...Intervention ...Time ...04:40 PM ...S/R Action ...S/R Initiated ....” Patient monitoring documentation was not present at 04:55 PM, and 05:10 PM. A request was made for patient #12 ’ s patient monitoring documentation at 04:55 PM, and 05:10 PM. None was provided at the time of survey. An interview with employee #2, conducted on March 11, 2026, confirmed that patient #12 ’ s patient monitoring documentation for the seclusion, and restraint that occurred 01/13/2026, could not be provided.”

“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 review, hospital documentation review, patient medical record review and request, and employee interview, the Department determined that the administrator failed to ensure staff followed assessment processes when patients (pt(s)) 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, which poses a threat of harm or death to patients. Findings include: Review of hospital policy titled “Seclusion,” policy #16458185, revised 05/2024, revealed: “ ...A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status ....” Review of hospital policy titled “Restraint,” policy #16458186, revised 05/2024, revealed: “ ...A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status ....” Review of hospital documentation titled “Seclusion/Restraint Flowsheet,” revealed: “ ...Patient Monitoring * RN [sic] evaluates need for continued seclusion/restraint ...RN [sic] must complete an entry on patient monitoring flow sheet below AND document a narrative summary of patient assessment in Seclusion/ Restraint ...Progress Notes every HOUR (minimum) during duration of Seclusion/Restraint. Includes up to & including release ....” A review of Patient #6 ’ s medical record revealed the following: Document titled “Progress Notes,” dated 12/01/2025, revealed “ ...Patient began attempting to scratch and self-harm. Multiple staff responded, holding her hands and continued verbally de-escalating ....” Document titled “Nursing Note,” dated 12/01/2025, revealed “ ...(Patient #6) states having a difficult day but mentions feeling better now, reports having been restrained due to self-harming ....” A request was made for Patient #6 ’ s “Seclusion/Restraint One Hour Face to Face Assessment” document for the restraint dated 12/01/2025. None was provided. A review of Patient #8 ’ s medical record revealed the following: Document titled “Seclusion/Restraint Progress Note,” dated 12/21/2025, revealed “ ...Patient who had earlier endorse [sic] visual hallucinations ...during assessments and med pass at 20:55 ...About 5 minutes later, whilst there was no nurse at the nurse ’ s station, patient jumped over the counter into the nurses station in the unit ...Patient was immediately restrained, attempt at verbal de-escalation made but unsuccessful ...Patient was moved to seclusion room ....” A request was made for Patient #8 ’ s “Seclusion/Restraint One Hour Face to Face Assessment” document for the restraint dated 12/21/2025. None was provided. A review of patient #10 ’ s medical record revealed the following: Document titled “Progress Notes,” dated 1/05/2026, revealed: “ ...pt continued to escalate ...Pt was put in hold, refused to contract for safety and was escorted to seclusion room ...nurse ...received orders for IM medication ....” A request was made for patient #10 ’ s “Seclusion/Restraint One Hour Face to Face Assessment” for the seclusion, physical restraint, and chemical restraint that occurred on 01/05/2026. None was provided during the time of survey. An interview with Employee #2, conducted on March 11, 2026, confirmed that Patients #6 and #10 “Seclusion/Restraint One Hour Face to Face Assessment” documents could not be provided. An interview with Employee #3, conducted on March 11, 2026, confirmed that Patient #8 ’ s “Seclusion/Restraint One Hour Face to Face Assessment” document could not be provided. Employees #2 and #3 confirmed that hospital policy and procedure related to nursing assessment being completed within one hour after initiation of seclusion and/or restraint, was not followed for Patients #6, #8, and #10.”

“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 Hospital policy and procedure, medical records, video monitoring footage review, and employee interviews, the Department determined the Administrator failed to ensure a patient restraint was implemented according to policy. This deficient practice resulted in a patient restraint that was not implemented according to policy, posing a risk to patient health and safety. Findings include: Hospital policy titled “Restraint,” Policy #16458186, Effective 05/2024, revealed “ ...Physical Restraint includes manual measures approved by CPI to limit or restrict body movement ...5. Patients will be restrained in the supine position, unless contraindicated and in accordance with CPI. Approved CPI holds are considered a physical restraint ....” Hospital confirmed training curriculum used for patient restraint is “Crisis Prevention Institute (CPI) ...Nonviolent Crisis Intervention Training.” Medical record for Patient #2 revealed the following: Document titled “AHC Progress Notes,” dated 1/02/2026, revealed “ ...Pt was observed standing by the door, (Patient #2) was redirected to go to day room/Noise room ...As soon as (Hospital employee) hit the fob, the pt bolted out the door and ran toward the second door ...Pt ran toward the cafeteria, (Employee #10) was on the way to Amethyst/Marigold Unit and saw the pt...verbally redirected (Patient #2), pt was combative and refused redirection ...Pt was physically restrained for 5 mins and was able to calm down afterwards ...Pt escorted to the Unit with other staffs, assessed for injuries ...No serious injuries was [sic] noted ...PRN Ativan for anxiety administered and pain meds &applied ice for headache ....” Document titled “Seclusion/Restraint One Hour Face to Face Assessment” revealed “ ...Initiation of Intervention ...Date: 1/02/2026 ...Time: 01:05 PM ...Type of Intervention ...Physical Restraint (checkbox checked) ...Patient ’ s Immediate Situation/Reaction to Restraint: ...Pt administered PRN Ativan, effective. Pt is calm & cooperative to staff directives. Pt reminded Unit expectations, (Patient #2) verbalized understanding ....” Hospital video monitoring footage, “Center Hallway 1,” dated 1/2/2026, reviewed with Employee #1 present, revealed the following: 01:17:58 PM - Employee #10 observed approaching Patient #2 in the main hallway. 01:18:01 PM - Employee #10 observed blocking Patient #2, followed by holding Patient #2 ’ s arms. 01:18:06 PM - Employee #10 observed lifting Patient #2 up and taking Patient #2 to the floor, with Patient #2 landing on his back. Employee #10, alone, observed attempting to hold Patient #2. 01:18:15 PM - Employees #8 and #9 observed kneeling down, appearing to hold Patient #2 ’ s legs and upper body area. Employee #5 observed standing to the side. 01:18:16 PM - Employee #10 appears to place a knee on a portion of Patient #2 ’ s upper body. Other staff are observed arriving and engaging. Employee #1 responded that the video view made it difficult to determine where Employee #10 ’ s knee was or if it was on Patient #2. 01:19:19 PM - Employee #7 observed tapping Employee #10, Employee #10 observed reengaging. 01:19:28 PM - Employee #7 observed physically pulling Employee #10 from Patient #2. Employee #10 observed disengaging and walking out of camera view. Interview with Employee #7, conducted on March 6, 2026, revealed the following: Employee #7 confirmed the response to Patient #2 was “a code call.” Employee #7 reported observing Patient #2 was “supine” on the floor upon arrival, with Patient #2 turned to a “prone” position on the floor, observing Employee #10 ’ s knee on Patient #2 ’ s neck. Employee #7 confirmed attempt to “tap out” Employee #10, stating that Employee #7 refused and went “back down” to Patient #2. Employee #7 confirmed an attempt to pull Employee #10 off of Patient #2, confirming that Employee #10 then disengaged. When asked if the intervention actions observed being employed by Employee #10 were CPI-approved restraint techniques, Employee #7 responded “no.” Employees #2 and #3 confirmed, during interviews conducted March 6, 2026 through March 12, 2026, that the restraint techniques used by Employee #10 on January 2, 2026, were not approved CPI techniques and not in accordance with Hospital policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(v) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (v) Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary. This Standard is not met as evidenced by: 52829 Based on hospital policy and procedure, hospital documentation, medical record review, and employee interview, the Department determined that the hospital failed to ensure staff followed assessment processes to determine when patients that are placed in seclusion and/or restraint can safely be released. This deficient practice poses a risk that patients are not released from seclusion or restraint when it has been determined to be safe. Findings include: Review of hospital policy titled “Restraint” policy #16458186 last reviewed 05/2024 revealed, “ ... 9. The practitioner or trained registered nurse will make a determination to end the restraint ....” Review of hospital document titled “Seclusion” policy #16458185 last reviewed 05/2024 revealed, “ ... 8. The practitioner or trained registered nurse will make a determination to end the restraint ....” Review of Patient #6 medical record revealed the following: Document titled “Progress Notes,” dated 12/01/2025, revealed “ ...Patient began attempting to scratch and self-harm. Multiple staff responded, holding her hands and continued verbally de-escalating ....” Document titled “Nursing Note,” dated 12/01/2025, revealed “ ...(Patient #6) states having a difficult day but mentions feeling better now, reports having been restrained due to self-harming ....” Request for documentation for Patient #6 showing the assessment used to determine that it was safe to release the patient from restraint was requested. None was provided. Review of patient #15 medical record, document titled “Seclusion/Restraint RN Assessment Agave Ridge Behavioral dated 3/01/2026 revealed, an instance of physical restraint, chemical restraint, and seclusion. Request for documentation for patient #15 showing the assessment used to determine that it was safe to release the patient from restraint and/or seclusion was requested on survey conducted 3/10/2026 through 3/12/2026, none provided for review. Review of patient #17 medical record, document titled “Seclusion/Restraint RN Assessment Agave Ridge Behavioral dated 2/28/2026 revealed, an instance of seclusion. Request for documentation for patient #17 showing the assessment used to determine that it was safe to release the patient from restraint and/or seclusion was requested on survey conducted 3/10/2026 through 3/12/2026, none provided for review. Review of patient #18 medical record, document titled “Seclusion/Restraint RN Assessment Agave Ridge Behavioral dated 2/19/2026 revealed, an instance of chemical restraint, Request for documentation for patient #18 showing the assessment used to determine that it was safe to release the patient from restraint and/or seclusion was requested on survey conducted 3/10/2026 through 3/12/2026, none provided for review. Review of patient #19 medical record, document titled “Seclusion/Restraint RN Assessment Agave Ridge Behavioral dated 3/05/2026 revealed, an instance of chemical restraint. Request for documentation for patient #19 showing the assessment used to determine that it was safe to release the patient from restraint and/or seclusion was requested on survey conducted 3/10/2026 through 3/12/2026, none provided for review. Review of patient #20 medical record, document titled “Seclusion/Restraint RN Assessment Agave Ridge Behavioral dated 2/02/2026 revealed, an instance of seclusion. Request for documentation for patient #20 showing the assessment used to determine that it was safe to release the patient from restraint and/or seclusion was requested on survey conducted 3/10/2026 through 3/12/2026, none provided for review. Employee #2 confirmed in interviews conducted 3/11/2026 and 3/12/2026 that there was not documentation of an assessment to determine that patients #6, #15, #17, #18, #19, and #20 were safe to be removed from seclusion and/or restraint.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 52829 Based on Hospital policy and procedure, medical record, medical record request, and employee interview, the Department determined the Administrator failed to ensure patient discharge plans were signed by either patients or patient representatives. This deficient practice poses the risk that patients and/or patient representatives will not be involved in treatment planning, leading to a potential for lack of individualized treatment goals and adverse impacts to patient care. Findings include: Hospital policy titled “Treatment Planning,” Policy #17979207,” Effective 04/2025, revealed “ ...h. The patient (or legal representative) shall be given the opportunity to have input in the development of the Interdisciplinary Treatment Plan. This shall be accomplished by the therapist meeting with the patient and/or family member to review the recommendations of the treatment team. The therapist shall be responsible for obtaining the signature of the patient or legal representative to document acknowledgement of the Interdisciplinary Treatment Plan ....” Medical record for Patient #2 revealed the following: Document titled “Intake,” dated 12/25/2025, revealed “ ...(Patient #2) gave verbal permission to call dad ...and (Patient #2 ’ s father) stated (Patient #2 ’ s) mom is (Patient #2 ’ s) guardian and provided paperwork ....” Document titled “Interdisciplinary Treatment Plan Master Sheets,” dated 12/27/2025, revealed “ ...Legal Representative Signature (as applicable) ...Legal Representative Signature: (no signature appearing on signature line) ...Date: ...(blank) ...Time: (blank) ...Name: (no name appearing on name line) ...Refused to Participate (checkbox unchecked) ...Unable to Participate (checkbox unchecked) ...Legal Representative is unable to review in person (checkbox unchecked) ...” Request was made for the “Interdisciplinary Treatment Plan Master Sheets” document for Patient #2, signed by the legal representative for Patient #2. None was provided. Medical record for patient #17 revealed the following: Document titled “Interdisciplinary Treatment Plan Master Sheets,” dated 3/1/2026, revealed “ ...Legal Representative Signature (as applicable) ...Legal Representative Signature: (no signature appearing on signature line) ...Date: ...(blank) ...Time: (blank) ...Name: (no name appearing on name line) ...Refused to Participate (checkbox unchecked) ...Unable to Participate (checkbox unchecked) ...Legal Representative is unable to review in person (checkbox unchecked) ...” Request was made for the “Interdisciplinary Treatment Plan Master Sheets” document for Patient #17, signed by the legal representative for Patient #17. None was provided. Employee #3 confirmed, during an interview conducted on March 12, 2026, that the “Interdisciplinary Treatment Plan Master Sheets” document, dated 12/27/2025, for Patient #2 and “Interdisciplinary Treatment Plan Master Sheets” document, dated 3/01/2026 for patient #17 were not signed by the legal representative and that a “Interdisciplinary Treatment Plan Master Sheets” document containing the signature of the legal representative for Patient #2, and Patient #17 could not be provided at the time of the survey.”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 52829 Based on review of policies and procedures, medical records, and staff interview, the Department determined that the administrator failed to ensure policies and procedures were implemented for the process for developing and implementing a patient ’ s care plan/treatment plan. This deficient practice poses the potential risk of treatment plans not being completed entirely and patients not being involved in their treatment. This is a repeat deficiency from event ID 0164088 conducted 12/2/2025 through 12/4/2025 Findings include: Hospital document titled “Treatment Planning” policy #17979207 last revised 05/2024 revealed, “ ... An Interdisciplinary Treatment Plan shall be developed for each patient and included in the medical record, within 3 days of admission ....” Review of patient #15 medical record hospital document titled “Intake Agave Ridge Behavioral” Dated 2/27/2026 revealed, “ ... Time of arrival to facility 03:35pm ... time of assessment date:2/27/2026 Time: 04:27 PM ....” Review of patient #15 medical record hospital document titled “Interdisciplinary Treatment Plan Master Sheets” 3/02/2026 revealed time and date stamped electronic signatures for employee #1, #12, #13, #14, and #15 all of which are dated 3/02/2026. Review of patient #15 medical record hospital document titled “Initial Nursing Treatment Plan Agave Ridge Behavioral” revealed “ ... Date of admission: 2/25/2026 Time of admission: 01:15pm ....” Review of patient #17 medical record hospital document titled “Interdisciplinary Treatment Plan Master Sheets” revealed a date of 3/01/2026 and electronic signatures for employee #12, #14, and #16 dated 03/0382026. In interview conducted on 3/11/2026 employee #2 confirmed that the two patients’ treatment plans were initiated later than three days after admission per policy.”

“Treatment Plan - Team Responsibilities CFR(s): [The written plan must include] The responsibilities of each member of the treatment team; and This Standard is not met as evidenced by: 52829 Based on review of facility policies and procedures, medical records, and employee interview the Department determined the Administrator failed to ensure that patient care plans were updated after an incident of restraint or seclusion and accurately reflected the patient ’ s status. This deficient practice poses a potential risk to the health and safety of the patient when the patient’s treatment plan is not re-evaluated and updated accurately after a qualifying event to determine whether the current treatment plan is effective or needs to be modified per facility policy. Findings include: Review of hospital document titled “Restraint” Policy #164581816 last reviewed 05/2024 revealed, “ ... 12. The treatment plan shall be reviewed and revised following the first episode of restraint to include measures to prevent recurrence ....” Review of hospital document titled “Seclusion” Policy #16458185 last reviewed 05/2024 revealed, “ ... 11. The treatment plan shall be reviewed and revised following seclusion to include measures to prevent recurrence ....” Review of hospital document titled “Assessment and Reassessment” policy #16458215 last reviewed 05/2024 revealed “ ... each patient is reassessed as necessary based on the patient’s plan for care or change in their condition ....” Review of Patient #2 medical record, document titled “Seclusion/Restraint RN Assessment, dated 01/02/2026, revealed an instance of physical restraint. Request for documentation showing an update to Patient #2 treatment plan, including measures taken to prevent recurrence, was requested. None was provided. Review of Patient #6 medical record revealed the following: Document titled “Progress Notes,” dated 12/01/2025, revealed “ ...Patient began attempting to scratch and self-harm. Multiple staff responded, holding her hands and continued verbally de-escalating ....” Document titled “Nursing Note,” dated 12/01/2025, revealed “ ...(Patient #6) states having a difficult day but mentions feeling better now, reports having been restrained due to self-harming ....” Request for documentation showing an update to Patient #6 treatment plan, including measures taken to prevent recurrence, was requested. None was provided. Medical record for patient #10 revealed the following: Document titled “Progress Notes,” dated 1/05/2026, revealed: “ ...pt continued to escalate ...Pt was put in hold, refused to contract for safety and was escorted to seclusion room ...nurse ...received orders for IM medication ....” A request was made for patient #10 ’ s updated treatment plan document for the seclusion, physical restraint, and chemical restraint that occurred on 01/05/2026. None was provided during the time of survey. Review of patient #15 medical record, document titled “Seclusion/Restraint RN Assessment Agave Ridge Behavioral dated 3/01/2026 revealed, an instance of physical restraint, chemical restraint, and seclusion. Request for documentation showing an update to patient #15 treatment plan addressing measures taken to prevent recurrence was requested on survey conducted 3/10/2026 through 3/12/2026, none provided for review. Review of patient #17 medical record, document titled “Seclusion/Restraint RN Assessment Agave Ridge Behavioral dated 2/28/2026 revealed, an instance of seclusion. Request for documentation showing an update to patient #17 treatment plan addressing measures taken to prevent recurrence was requested on survey conducted 3/10/2026 through 3/12/2026, none provided for review. Review of patient #18 medical record, document titled “Seclusion/Restraint RN Assessment Agave Ridge Behavioral dated 2/19/2026 revealed, an instance of chemical restraint, Request for documentation showing an update to patient #18 treatment plan addressing measures taken to prevent recurrence was requested on survey conducted 3/10/2026 through 3/12/2026, none provided for review. Review of patient #19 medical record, document titled “Seclusion/Restraint RN Assessment Agave Ridge Behavioral dated 3/05/2026 revealed, an instance of chemical restraint. Request for documentation showing an update to patient #19 treatment plan addressing measures taken to prevent recurrence was requested on survey conducted 3/10/2026 through 3/12/2026, none provided for review. Review of patient #20 medical record, document titled “Seclusion/Restraint RN Assessment Agave Ridge Behavioral dated 2/02/2026 revealed, an instance of seclusion. Request for documentation showing an update to patient #20 treatment plan addressing measures taken to prevent recurrence was requested on survey conducted 3/10/2026 through 3/12/2026, none provided for review. Employee #2 confirmed in interview conducted 3/11/2026 that there was not an update made to patients #2, #6, #15, #17, #18, #19, and #20 treatment plan following the episodes of seclusion and/or restraint.”