Providence Little Co of Mary Med Ctr San Pedro

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45774 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Patient Rights as evidenced by: 1. The facility failed to ensure one of 30 sampled patients (Patient 1) was free from physical abuse while at the facility. This deficient practice resulted in Patient 1 being involved in two separate physical altercation with facility staff members Mental Health Worker 1 (MHW 1), Security Officer 1 (SO 1), and Registered Nurse 1 (RN 1) on the same day that resulted in a violation of Patient 1 ’ s rights, which could have potentially caused serious harm to Patient 1. (Refer to A-0145). 2. The facility failed to follow its policy and procedures (P&P) for de-escalation (a method to prevent violence) and use of force (physical efforts used to control an aggressive individual) resulting in unnecessary chemical and physical restraint ( use of a drug or manual hold to restrict a person from moving) on one of thirty sampled patients (Patient 1). This deficient practice resulted in staff-initiated escalation (to make something more severe) directly contributing to unsafe physical handling and unnecessary restraint use which created an immediate jeopardy to Patient 1’s health and safety. (Refer to A-0154). 3. Ensure seven out of eight sampled hospital staff (Registered Nurse 1, Registered Nurse 5, Registered Nurse 6, Registered Nurse 7, Registered Nurse 8, Mental Health Worker1, and Assistant Nurse Manager1) completes yearly “use of force” training (a training program designed to teach personnel how to evaluate, decide upon, and apply the appropriate level of physical control to overcome the resistance of an individual) per facility ’ s “use of force” (The application of physical techniques or tactics , chemical agents or weapons to another person) policy and procedure. This deficient practice resulted in hospital staff who are not yearly trained to recognize when to execute use of force face significant legal, ethical, and safety risks, that can potentially lead to severe, and sometimes fatal, outcomes for patients and staff alike. Without proper, ongoing training, staff may fail to use de-escalation (a method to prevent violence) techniques, leading to unnecessary, excessive, or inappropriately timed physical intervention. (Refer to A-194). The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“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: 45774 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by the facility ’ s failure to: 1. Ensure required restraint (use of a device to restrict movement of a person) monitoring documentation was completed for one of thirty sampled patients (Patient 1) when 1:1 sitter (a specific monitoring arrangement where a single staff member is assigned to observe, monitor, and document on a patient that may be a danger to self or others) observation coverage changed resulting in the incomplete documentation of patient monitoring while Patient 1 remained on a 5150 hold (a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves]) . This deficient practice resulted in an inability to verify ongoing assessment and monitoring of a patient while on a 5150-hold placing the patient at risk for unmet needs and compromised safety. (Refer to A-398). 2. Ensure intravenous (IV- a small tube inserted into a vein) tubing was labeled with a date and time for two of thirty sampled patients (Patient 6 and Patient 7) who were receiving IV therapy (a process that delivers fluids, medications and nutrients directly into a person ’ s vein) per the facilities policy and procedures (P&P- guidelines dictating an organization ’ s directions on a topic and step-by-step instructions how to carry out tasks) and accepted standards of practice. This deficient practice had the potential to result in Patient 6 and Patient 7 IV tubing to remain in place beyond recommended timeframes, increasing the risk of infection and compromising patient safety. And ensure IV tubing was properly labeled to allow staff to verify compliance with required tubing change intervals. (Refer to A-398). 3. Ensure pain was reassessed (assessment that includes a pain scale uses numbers from 0 to 10, with 0 representing no pain and 10 representing the worst pain possible, location of pain, character of pain, and duration of pain, performed after medication has been giving to see if pain medication was effective) on three of thirty sampled patients (Patient 7, Patient 15, and Patient 30) after administration of pain medication in accordance with the facilities policy and procedure (P&P- guidelines dictating an organization ’ s directions on a topic and step-by-step instructions how to carry out tasks) . This deficient practice resulted in staff failed to reassess and document pain following intravenous (IV- a small tube inserted into a vein) opioid (a drug used to reduce moderate to severe pain) administration puts the patient at risk for unrelieved pain and potential adverse (negative or harmful) effects for Patient 7, Patient 15, and Patient 30. (Refer to A-398) 4. Ensure for two of 30 sampled patients (Patient 28 and Patient 29), the policies and procedures were implemented when: A. Patient 28, who was at medium risk for fall, was not wearing a fall risk armband (a yellow armband indicating the patient was at risk for fall). B. Patient 29, who was at high risk for fall, was not wearing a fall risk armband and yellow non-skid socks indicating the patient was at high risk for fall. These deficient practices had the potential to result in an unsafe care that may lead to Patient 28 and Patient 29 suffering from a fall injury. (Refer to A-398). The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 45774 Based on observation, interview, and record review the facility failed to ensure one of 30 sampled patients (Patient 1) was free from physical abuse while at the facility. This deficient practice resulted in Patient 1 being involved in two separate physical altercation with facility staff members Mental Health Worker 1 (MHW 1), Security Officer 1 (SO 1), and Registered Nurse 1 (RN 1) on the same day that resulted in a violation of Patient 1 ’ s rights, which could have potentially caused serious harm to Patient 1. On 2/5/2026 at 4:26 PM, the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Nursing Officer (CNO), the Executive Director of Quality (EDQ), the Clinical Risk Manager (CRM), the Accreditation Program Manager (APM). The above-mentioned facility administrators were informed of the IJ situation regarding the failure to ensure one of 30 sampled patients (Patient 1) was free from physical abuse while at the facility. This deficient practice resulted in Patient 1 being involved in two separate physical altercation with facility staff members Mental Health Worker 1 (MHW 1), Security Officer 1 (SO 1), and Registered Nurse 1 (RN 1) on the same day that resulted in a violation of Patient 1 ’ s rights, which could have potentially caused serious harm to Patient 1. Patient 1 was admitted to the facility on 12/16/2025 on a 5150 hold for psychosis (a condition usually caused by mental illness in which a person has a difficult time thinking clearly, behaving appropriately, or understanding what is real and what is not) after eloping (escaping) from Outpatient Behavioral Center (OBHC). On 2/2/2026 at 1:14PM, The Director of Behavioral Health (DBH) stated that the facility reported two incidents of staff to patient abuse occurring on 1/1/2026. The first incident occurred at 08:50AM involving MHW 1 who physically grabbed the right arm of patient 1 using both hands and forcefully swung Patient 1 to the ground pushing Patient 1 ’ s head to the floor, after crossing into a restricted area. In the same incident, SO 1, at 8:55 AM, used inappropriate technique by using his hands forcefully on Patient 1 ’ s spine and neck area. The second incident occurred on 1/1/2026 at 10:30 PM involving RN 1 who forcefully pulled Patient 1 ’ s hair twice, after patient fell on his head in dayroom. On 2/9/2026 at 2:48 PM, while onsite, the IJ was removed after verifying and confirming the facility’s implementation of the IJ Removal Plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) through observation, interview, and record review, in the presence of the EDQ, the CNO, the CRM, the APM, the Chief Administrative Officer (CAO). The IJ Removal Plan included the following: Corrective Action(s) Identified for the Deficient Practice to Prevent Reoccurrence: · 100% of present and incoming Emergency Department, Bridges, and Outpatient Behavioral Health Center employees educated on the Abuse/Assault/Neglect/Trafficking policy (Started 1/7/2026, to be completed by 3/6/2026) o Reporting any episode of abuse, assault, neglect, or trafficking by any caregiver, vendor, physician, volunteer, student, Board member, or patient immediately o Notifying Risk Management immediately for any abuse that occurs on-site o Speak up if you observe anyone engaging in any level of abuse, assault, neglect, or trafficking o See Attachment A: Abuse/Assault/Neglect/Trafficking policy Addendum E o See Attachment B: Edu-Gram Abuse/Assault/Neglect/Trafficking o See Attachment C: Speak Up for Safety Escalation Using CUS o Education status as of February 9, 2026: § Emergency Department: 52/85 total employees = 61.1% § Bridges: 24/47 total employees = 51% § Outpatient Behavioral Health Center: 23/38 total employees = 60.5% · 100% of present and incoming Emergency Department, Bridges, and Outpatient Behavioral Health Center employees educated on the Use of Force policy. We identified a gap in our AVADE education and found that AVADE does not include Use of Force as part of the AVADE program. (Started 2/5/2026, to be completed by 3/6/2026) o Use of force levels: § Level 1 – Presence § Level 2 – Soft techniques § Level 3 – Hard techniques § Level 4 – Less-lethal force § Level 5 – Lethal o Utilizing the least restrictive interventions at all times o Implementing trauma-informed, patient-centered approaches to reduce escalation o Following all requirements for safe application, monitoring, and documentation when force is used o Ensuring all actions are consistent with regulatory standards, organizational policy, and patient rights o Immediately reporting and documenting any use of force event in accordance with hospital policy o Participating in ongoing education, drills, and competency validation related to Use of Force o See Attachment D: PSJH-RESO-1403 Use of Force o Education status as of February 9, 2026: § Emergency Department: 52/85 total employees = 61.1% § Bridges: 24/47 total employees = 51% § Outpatient Behavioral Health Center: 23/38 total employees = 60.5% · Behavioral Health Unit safety check rounds performed every 2-4 hours by Behavioral Health leader on Monday – Friday during normal business hours, and after hours and weekends to be performed by House Supervisor (Started 1/10/2026, ongoing) o Identify any violent/aggressive patient, recent escalation situations, recent Code Gray incidents, patients requiring emergency behavioral interventions, any other safety concerns, and provide additional support, resources, and/or interventions as needed o See Attachment E: Behavioral Health Unit Rounding Log · Code Grays, 5150 patients, and patients flagged as risk-for-violence are discussed in leadership safety huddle daily (Started 1/10/2026, ongoing) o For awareness and to provide additional support, resources, and/or interventions as needed o See Attachment F: Safety Huddle Standard Work · Implement code gray simulation with an emphasis on de-escalation and trauma informed care, performed on a quarterly basis (By 3/31/2026) Corrective Action(s) Identified for the Deficient Practice: · On the dates that leadership was made aware of the incidents (1/6/2026 & 1/8/2026), MHW1 and RN1 were placed on administrative leave and caregiver relations consultations submitted for support with investigation and corrective actions to be taken (Completed 1/6/2026 & 1/8/2026) · Investigation conducted. All involved employees were interviewed starting on 1/9/2026 and interviews concluded on 1/26/2026 · Director of Behavioral Health and Director of Risk Management met with the patient ’ s father to inform him of the two incidents (Completed 1/9/2026) · CAO, CNO, Director of Behavioral Health, Risk Management, CHRO, Executive Director of Quality, Security Manager met to review events, discuss opportunities, and determine actions for improvement (Completed 1/9/2026) · Hospitalists to respond to all Code Grays in Bridges (Started on 1/10/2026) How the Facility Will Identify Other Patient(s) Having the Potential to be Affected by the Same Deficient Practice: · Behavioral Health Unit safety check rounds performed every 2-4 hours by Behavioral Health leader on Monday – Friday during normal business hours, and after hours and weekends to be performed by House Supervisor (Started 1/10/2026, ongoing) o Identify any violent/aggressive patient, recent escalation situations, recent Code Gray incidents, patients requiring emergency behavioral interventions, any other safety concerns, and provide additional support, resources, and/or interventions as needed o See Attachment E: Behavioral Health Unit Rounding Log · Implement Code Gray debrief to occur immediately after the Code Gray situation has been stabilized (Started 1/12/2026, ongoing) o Quick 10-min huddle to facilitate reflection and learning following a Code Gray event to help us understand the circumstances, interventions, and opportunities for improvement o See Attachment G: Code Gray Debrief form · Multi-disciplinary meeting to occur within 24 hours of Code Gray in behavioral health areas. Participants include physician, nursing, pharmacy, and spiritual care. Recommendations from the review will be added to patient ’ s care plan (Started 1/12/2026, ongoing) o To review the Code Gray event to help us understand the circumstances, interventions, and opportunities for improvement. Feedback will help guide the patient ’ s care plan review and improve future safety and team coordination. Review any medical, behavioral, pharmaceutical, and social needs. Discuss the plan for ongoing monitoring and reassessment. o See Attachment H: Multidisciplinary debrief forms · Code Grays, 5150 patients, and patients flagged as risk-for-violence are discussed in leadership safety huddle daily (Started 1/10/2026, ongoing) o For awareness and to provide additional support, resources, and/or interventions as needed o See Attachment F: Safety Huddle Standard Work · Body cam video footage and surveillance video footage reviewed within 24 hours for any instances of excessive use of force. Video review performed by security, Risk Management, and department leader, for all Code Grays on Bridges or Code Grays that result in takedowns in areas outside of Bridges (Started 1/10/2026, ongoing) o See Attachment I: Post Code Gray Video Review Tracker · 100% of present and incoming Emergency Department, Bridges, and Outpatient Behavioral Health Center employees educated on the Abuse/Assault/Neglect/Trafficking policy (Started 1/7/2026, to be completed by 3/6/2026) o Reporting any episode of abuse, assault, neglect, or trafficking by any caregiver, vendor, physician, volunteer, student, Board member, or patient immediately o Notifying Risk Management immediately for any abuse that occurs on-site o Speak up if you observe anyone engaging in any level of abuse, assault, neglect, or trafficking o See Attachment A: Abuse/Assault/Neglect/Trafficking policy Addendum E o See Attachment B: Edu-Gram Abuse/Assault/Neglect/Trafficking o See Attachment C: Speak Up for Safety Escalation Using CUS o Education status as of February 9, 2026: § Emergency Department: 52/85 total employees = 61.1% § Bridges: 24/47 total employees = 51% § Outpatient Behavioral Health Center: 23/38 total employees = 60.5% · 100% of present and incoming Emergency Department, Bridges, and Outpatient Behavioral Health Center employees educated on the Use of Force policy. We identified a gap in our AVADE education and found that AVADE does not include Use of Force as part of the AVADE program. (Started 2/5/2026, to be completed by 3/6/2026) o Use of force levels: § Level 1 – Presence § Level 2 – Soft techniques § Level 3 – Hard techniques § Level 4 – Less-lethal force § Level 5 – Lethal o Utilizing the least restrictive interventions at all times o Implementing trauma-informed, patient-centered approaches to reduce escalation o Following all requirements for safe application, monitoring, and documentation when force is used o Ensuring all actions are consistent with regulatory standards, organizational policy, and patient rights o Immediately reporting and documenting any use of force event in accordance with hospital policy o Participating in ongoing education, drills, and competency validation related to Use of Force o See Attachment D: PSJH-RESO-1403 Use of Force o Education status as of February 9, 2026: § Emergency Department: 52/85 total employees = 61.1% § Bridges: 24/47 total employees = 51% § Outpatient Behavioral Health Center: 23/38 total employees = 60.5% · Implement code gray simulation with an emphasis on de-escalation and trauma informed care, performed on a quarterly basis (By 3/31/2026) Measures Put in Place and Systemic Changes Made to Ensure that the Deficient Practice Does Not Reoccur: · Behavioral Health Unit safety check rounds performed every 2-4 hours by Behavioral Health leader on Monday – Friday during normal business hours, and after hours and weekends to be performed by House Supervisor (Started 1/10/2026, ongoing) o Identify any violent/aggressive patient, recent escalation situations, recent Code Gray incidents, patients requiring emergency behavioral interventions, any other safety concerns, and provide additional support, resources, and/or interventions as needed o See Attachment E: Behavioral Health Unit Rounding Log · Implement Code Gray debrief to occur immediately after the Code Gray situation has been stabilized (Started 1/12/2026, ongoing) o Quick 10-min huddle to facilitate reflection and learning following a Code Gray event to help us understand the circumstances, interventions, and opportunities for improvement o See Attachment G: Code Gray Debrief form · Multi-disciplinary meeting to occur within 24-hours of Code Gray in behavioral health areas. Participants include physician, nursing, pharmacy, and spiritual care. Recommendations from the review will be added to patient ’ s care plan (Started 1/12/2026, ongoing) o To review the Code Gray event to help us understand the circumstances, interventions, and opportunities for improvement. Feedback will help guide the patient ’ s care plan review and improve future safety and team coordination. Review any medical, behavioral, pharmaceutical, and social needs. Discuss the plan for ongoing monitoring and reassessment. o See Attachment H: Multidisciplinary debrief forms · Code Grays, 5150 patients, and patients flagged as risk-for-violence are discussed in leadership safety huddle daily (Started 1/10/2026, ongoing) o For awareness and to provide additional support, resources, and/or interventions as needed o See Attachment F: Safety Huddle Standard Work · Body cam video footage and surveillance video footage reviewed within 24 hours for any instances of excessive use of force. Video review performed by security, Risk Management, and department leader, for all Code Grays on Bridges or Code Grays that result in takedowns in areas outside of Bridges (Started 1/10/2026, ongoing) o See Attachment I: Post Code Gray Video Review Tracker · 100% of present and incoming Emergency Department, Bridges, and Outpatient Behavioral Health Center employees educated on the Abuse/Assault/Neglect/Trafficking policy (Started 1/7/2026, to be completed by 3/6/2026) o Reporting any episode of abuse, assault, neglect, or trafficking by any caregiver, vendor, physician, volunteer, student, Board member, or patient immediately o Notifying Risk Management immediately for any abuse that occurs on-site o Speak up if you observe anyone engaging in any level of abuse, assault, neglect, or trafficking o See Attachment A: Abuse/Assault/Neglect/Trafficking policy Addendum E o See Attachment B: Edu-Gram Abuse/Assault/Neglect/Trafficking o See Attachment C: Speak Up for Safety Escalation Using CUS o Education status as of February 9, 2026: § Emergency Department: 52/85 total employees = 61.1% § Bridges: 24/47 total employees = 51% § Outpatient Behavioral Health Center: 23/38 total employees = 60.5% · 100% of present and incoming Emergency Department, Bridges, and Outpatient Behavioral Health Center employees educated on the Use of Force policy. We identified a gap in our AVADE education and found that AVADE does not include Use of Force as part of the AVADE program. (Started 2/5/2026, to be completed by 3/6/2026) o Use of force levels: § Level 1 – Presence § Level 2 – Soft techniques § Level 3 – Hard techniques § Level 4 – Less-lethal force § Level 5 – Lethal o Utilizing the least restrictive interventions at all times o Implementing trauma-informed, patient-centered approaches to reduce escalation o Following all requirements for safe application, monitoring, and documentation when force is used o Ensuring all actions are consistent with regulatory standards, organizational policy, and patient rights o Immediately reporting and documenting any use of force event in accordance with hospital policy o Participating in ongoing education, drills, and competency validation related to Use of Force o See Attachment D: PSJH-RESO-1403 Use of Force o Education status as of February 9, 2026: § Emergency Department: 52/85 total employees = 61.1% § Bridges: 24/47 total employees = 51% § Outpatient Behavioral Health Center: 23/38 total employees = 60.5% · Implement code gray simulation with an emphasis on de-escalation and trauma informed care, performed on a quarterly basis (By 3/31/2026) Corrective Action(s) are Monitored to Ensure Solutions are Substantiated and the Deficient Practice Does Not Reoccur: · Safety check round logs are audited on a weekly basis (Started 1/10/2026, ongoing) · Code Gray debrief review form audited by Director of Behavioral Health in real-time. Opportunities for improvement are escalated to the Chief Nursing Officer (Started 1/12/2026, ongoing) · To monitor for any potential instances of excessive use of force, body cam video footage and surveillance video footage is reviewed for all Code Grays on the Acute Psychiatric Unit or Code Grays that result in takedowns in areas outside of Acute Psychiatric Unit (Started 1/10/2026, ongoing) o See Attachment I: Post Code Gray Video Review Tracker o Any identified occurrences of excessive use of force/abuse/assault will be escalated to the Executive Leadership Team, reported to the appropriate regulatory bodies, caregiver relations ticket will be submitted, involved caregiver(s) will be place on an administrative leave o Excessive use of force data will be reported to the Environment of Care Committee, the Quality & Patient Safety Committee, and to the Governing Board Findings: During a review of Patient 1 ’ s “History & Physical” (H&P) 12/16/2025 was admitted to the facility on 12/16/2025 on a 5150 hold for psychosis (a condition usually caused by mental illness in which a person has a difficult time thinking clearly, behaving appropriately, or understanding what is real and what is not) after eloping (escaping) from Outpatient Behavioral Center (OBHC). During an interview on 2/2/2026 at 1:14PM with The Director of Behavioral Health (DBH), the DBH stated that the facility reported two incidents of staff to patient abuse (an action that intentionally causes harm or injures another person) occurred on 1/1/26. The first incident occurred at 08:50AM involving Mental Health Worker (MHW 1) who physically grabbed the right arm of patient 1 using both hands and forcefully swung Patient 1 to the ground pushing Patient 1 ’ s head to the floor, after crossing into a restricted area. In the same incident, SO 1, at 8:55 AM, used inappropriate technique by using his hands forcefully on Patient 1 ’ s spine and neck area. The second incident occurred on 1/1/2026 at 10:30 PM involving RN 1 who forcefully pulled Patient 1 ’ s hair twice, after patient fell on his head in dayroom. During an observation on 2/3/2026 at 10:18AM, with the DBH, Security Manager (SM), the Chief Executive Officer (CEO), the Director of Risk Management (DRM), the security footage from 1/1/2026 was viewed. The following events were observed at the indicated timestamps in the video: 08:52:43. - Patient 1 was in the dayroom sitting in a chair. 08:52:43. -Patient 1 got up from chair and walked to right side door towards the restricted area, while Mental Health Worker (MHW 1) followed behind. 08:53:31- Patient 1 crossed red tape on floor into restricted area that has two doors both were locked and secured. MHW 1 followed behind Patient 1 and immediately grabbed Patient 1 ’ s right arm, swung him around and brought Patient 1 face down to the floor then landed on top of Patient 1 horizontally. 08:53:38 AM- Code Grey (a message that goes over the public intercom in the hospital, indicates an emergency response for a combative or violent person) called, while MHW 1 was still on top of Patient 1 with his whole body horizontally across Patient 1. 08:54:28 AM- MHW 1 was still on top of Patient 1, MHW 1 ’ s left hand pushed Patient 1 ’ s head down forcefully on the floor. 08:55AM- Two security officers (SO 1, 2) arrived first and SO 1 restrained (limiting a person ’ s movement) Patient 1 ’ s left arm pinning to the floor and SO 2 restrained Patient 1 ’ s right arm pinning to the floor. MHW 1 was still on top of Patient 1. Two additional (SO 3 and SO 4) arrived and SO 1 switched place with SO 4, while SO 3 pinned Patient 1 ’ s feet. 08:55:31AM- MHW 1 got off Patient 1. 08:58:38AM- Walking soft restraints (a soft material or fabric that is padded and designed to safely fit around the limbs of an individual to limit the movement to prevent self-harm or harm to others) was placed on Patient 1 ’ s right and left ankle. 09:00:15AM- Medications were given by intramuscular (deep into the muscle) injection (IM). Haldol (a medication used to treat psychotic disorders) 5milligrams (mg-a way to measure how much medicine is given, Benadryl (a medication used to treat symptoms of allergies and allergic reactions) 50milliliters (ml- a unit of measurement used to measure the amount of liquid given), and Ativan (medication used to treat feelings of fear, or uneasiness) 2mg. 09:03:04AM- Handcuffs (metal loops placed around a person ’ s wrist that can be locked) applied to left and right wrist by SO2. 09:05:52AM- Security Officers, MHW 1, and 1:1 sitter (a specific monitoring arrangement where one staff member stays with a patient to prevent self-harm or harm to others) walked Patient 1 to the seclusion (placing a person alone in a room or area where person is physically prevented from leaving) room on a 4-points restraint bed (a bed that has 4 soft restraints 2 at the top and 2 at the bottom). Both ankle walking restraints were removed, and two ankle bed restraints applied. 09:07:54AM- Handcuffs removed after 4 minutes and 50 seconds. 09:08:36AM- MHW 1 in a seclusion room applied right and left arm bed restraints on Patient 1. During an interview on 2/2/2026 at 1:14PM with the Director of Behavioral Health (DBH), the DBH stated that this incident on 1/1/2026 was not reported to Risk Management until after Mental Health Worker (MHW2) informed DBH on 1/6/2026 and reported to California Department of Public Health (CDPH) on 1/7/2026. During an interview on 2/2/2026 at 3:50PM with MHW 1, MHW 1 stated that after the incident with Patient 1 occurred the facility contacted him to work. During a concurrent interview and record review on 2/4/2026 at 3:36PM with the DBH, MHW 1 ’ s “Timecard” dated 1/1/2026 to 1/08/2026 was reviewed. The timecard indicated MHW 1 worked on 1/4/2026, 1/5/2026, and 1/6/2026. DBH stated, MHW1 did work those days and worked half a shift on 1/6/2026 as MHW 1 was placed on administrative leave (an employee is temporarily no longer allowed on site at their workplace) that day. During an interview on 2/3/2026 at 11:28AM with the DBH, the DBH stated that the actions of MHW 1 were not appropriate and could have been avoided if MHW1 did not put hands on Patient 1. Multiple things could have been done to de-escalate (a method to prevent violence) that were not done. During an interview on 2/3/2026 at 11:30AM with the Security Manager (SM), the SM stated that the staff were trained to use physical techniques when imminent (the presence of clear and immediate threat) harm was present. In this case with Patient 1, there is no imminent danger. When the Patient is facing down and someone is pushing down on the back of the head, that’s not what we teach. SM stated during restraint training, staff are educated to avoid areas such as the neck and head area because those are high risk areas and can hurt patients even more. SM stated SO1 used inappropriate technique with Patient 1. SO1 placed his hands on Patient 1 ’ s spine and neck area which is not appropriate technique and what is taught in training. During a concurrent interview and record review on 2/4/2026 at 10:51AM with the SM, Security Officer (SO 1 ’ s) “Timecard” was reviewed. The SM stated, SO 1 continued to work from 1/1/2026 to 1/9/2026 following the incident with Patient 1. SM stated the staff were overreacting (responding to something with unnecessary or excessive action) towards Patient 1SM stated SO 1 was suspended for inappropriate use of force on 1/9/2026 (total 8 days after the incident). During an observation on 2/3/2026 at 11:31AM, with the DBH, the SM, the Chief Executive Officer (CEO), the Clinical Risk Manager (CRM), the security footage from 1/1/2026 was viewed. The following events were observed at the indicated timestamps in the video: 10:30PM- Patient 1 sitting in dayroom eating at table. 10:34PM- 10:35PM –Registered Nurse (RN 1) stood next to Patient 1 and then exits room 10:35PM –10:36PM- RN1 returns to dayroom and then exits again. 10:40:03PM- Patient 1 stands up, stretches and suddenly falls on his own to the floor, landing on back of his head. (no one pushed him). 10:40:15PM- Rapid Response (a team composed of nurses and respiratory therapist who are trained to assist when there are signs that a patient is getting sicker) called. 10:41PM- RN 1 next to Patient 1 while Patient 1 is still on floor. 10:41:30PM- Patient 1 awakes and is trying to get up off the floor and is agitated. Code Grey called. 10:41:50 PM- Patient 1 is placed in a chair to sit down and be assessed (a process used to learn about a patient ’ s condition) by RN1. 10:42PM- RN1 has hand on Patient 1 ’ s hair. 10:43:43PM- RN 1 pulled Patient 1 ’ s hair back forcefully. 10:45:38PM- RN 1 pulled Patient 1 ’ s hair back forcefully again. 10:45:50PM: Mental Health Associate 1(MHA 1) seen yelling to RN1. 10:46:08PM-RN 1 leaves the dayroom. 10:46:30PM – Rapid Response team enters. During an interview on 2/2/2026 at 3:20PM, with RN1, RN 1 stated that after Patient 1 fell to the floor, RN1 was trying to arouse (to awake from sleep) Patient 1, and Patient 1 woke up disoriented (feeling lost or confused), aggressive and stood up. RN1 placed Patient 1 in a chair to assess Patient 1 ’ s head after the fall. Patient 1 remained aggressive and tried to bite RN 1. During a review of the facility’s policies and procedures (P&P) titled “Abuse/Assault/Neglect/Trafficking” dated 6/2023, the P&P indicated, “In the event a patient alleges abuse caused by an employee (“caregiver”), physician, volunteer, student, or other affiliated individual: 1. Notify Department Leader, House Supervisor, Human Resources, and Risk Management immediately. Medical Staff will be notified as appropriate if accused individual is a member of the medical staff. 2. Accused individual to be placed on administrative leave pending investigation and removed from patient care activities. 1. As soon as possible, Human Resources, Risk Management, and/or designee will interview accused individual. 3. Risk Management or designee will conduct interview with patient making abuse allegation...5. Risk Management will coordinate reporting to CDPH Licensing & Certification ....8. Risk Management is also to be notified immediately for any abuse that occurs on-site that involves a patient” During a review of the facility’s policies and procedures (P&P) titled “Bridges: Patient Rights W&I 5325” dated 5/2023, the P&P indicated, “A right to be free from harm, including unnecessary or excessive physical restraint, isolation, abuse, medication, or neglect Medication shall not be used as a punishment, or for the convenience of staff, or a substitute for program, or in quantities that interfere with the treatment program.” During a review of the facility ’ s policy and procedure (P&P), titled “1403 Use of Force” dated 9/2023, the P&P indicated “[Name of Facility] workforce members may use force as part of their physical security duties when considered reasonable under the totality of the circumstances. [Name of Facility] expects the use of the lowest level of force (required by the circumstances) but recognizes that varying degrees of force are justified according to the severity of the physical confrontation. Please note that some ministries or organizations use the term “Category” rather than the word “level.” These use of force levels were adapted from the United States National Institute of Justice. -Level 1 Presence is the attempt to “de-escalate” by exhibiting a physical security presence, giving verbal commands, and shielding other personnel from the individual to allow time or distance to de-escalate. -Level 2 Soft Techniques are the force necessary to gain positive control or compliance with little or no probability of injury to overcome resistance (e.g. escorting, etc.) -Level 3 Hard Techniques are the force necessary to “detain and control” the individual to prevent harm to themself or others. The use of hard techniques may result in notable discomfort, minor injury, but without causing serious bodily injury or death (e.g. control holds, handcuffs, etc.). -Level 4 Less Lethal force means utilizing tools or devices and physical techniques when there is an imminent danger of serious bodily injury or death. Less-lethal force may cause serious bodily injury or death (e.g. baton, chemical sprays, taser, etc.) -Level 5 Lethal Force is the force used only when there is an imminent danger of serious bodily injury or death. The use of lethal force is likely to result in serious bodily injury and death (e.g. firearms, strikes to sensitive areas, etc.)...3. All use of force incidents, including health care interventions, will be reported a. Regional Security Services Staff must report to a supervisor, as soon as practical, any staff that uses excessive force on a threat or who fails to follow use-of- force procedures.” During a review of the facility’s policies and procedures (P&P) titled “Restraint for Violent/Seclusion/Self-Destructive Behavior” dated 5/2025, the P&P indicated, “ ...Patients will be treated with dignity and therefore be free from neglect, exploitation, abuse, harassment, racism, or discrimination. Patients have the right to receive considerate, compassionate and respectful care, and be free from physical or mental abuse and corporal punishment.””

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 45774 Based on observation, interview, and record review the facility failed to follow its policy and procedures (P&P) for de-escalation (a method to prevent violence) and use of force (physical efforts used to control an aggressive individual) resulting in unnecessary chemical and physical restraint ( use of a drug or manual hold to restrict a person from moving) on one of thirty sampled patients (Patient 1). This deficient practice resulted in staff-initiated escalation (to make something more severe) directly contributing to unsafe physical handling and unnecessary restraint use which created an immediate jeopardy to Patient 1’s health and safety. On 2/5/2026 at 4:26 PM, the survey team called a second Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Nursing Officer (CNO), the Executive Director of Quality (EDQ), the Clinical Risk Manager (CRM), the Accreditation Program Manager (APM). The above-mentioned facility administrators were informed of the IJ situation regarding the facility failed to follow its own policy and procedure (P&P) for deescalation, use of force, and restraint application, resulting in a staff-initiated escalation and the unnecessary use of physical and chemical restraints without justification (the action of showing something to be right) for one of 30 sampled patients (Patient 1). Additionally, the 1:1 sitter failed to notify the charge nurse, preventing timely leadership intervention. These failures placed Patient 1 at risk for serious injury, serious harm, serious impairment, or death. Patient 1 was admitted to the facility on 12/16/2025 on a 5150 hold for psychosis (a condition usually caused by mental illness in which a person has a difficult time thinking clearly, behaving appropriately, or understanding what is real and what is not) after eloping (escaping) from Outpatient Behavioral Center (OBHC). On 2/2/2026 at 1:14PM, The Director of Behavioral Health (DBH) stated that the facility reported two incidents of staff to patient abuse occurring on 1/1/2026. The first incident occurred at 08:50AM involving MHW 1 who physically grabbed the right arm of patient 1 using both hands and forcefully swung Patient 1 to the ground pushing Patient 1 ’ s head to the floor, after crossing into a restricted area. In the same incident, SO 1, at 8:55 AM, used inappropriate technique by using his hands forcefully on Patient 1 ’ s spine and neck area. The second incident occurred on 1/1/2026 at 10:30 PM involving RN 1 who forcefully pulled Patient 1 ’ s hair twice, after patient fell on his head in dayroom. On 2/9/2026 at 2:48 PM, while onsite, the IJ was removed after verifying and confirming the facility’s implementation of the IJ Removal Plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) through observation, interview, and record review, in the presence of the EDQ, the CNO, the CRM, the APM, the Chief Administrative Officer (CAO). The IJ Removal Plan included the following: Corrective Action(s) Identified for the Deficient Practice to Prevent Reoccurrence: · 100% of present and incoming Bridges and Outpatient Behavioral Health Center employees educated on the Abuse/Assault/Neglect/Trafficking policy (Started 1/7/2026, to be completed by 3/6/2026) o Reporting any episode of abuse, assault, neglect, or trafficking by any caregiver, vendor, physician, volunteer, student, Board member, or patient immediately o Notifying Risk Management immediately for any abuse that occurs on-site o Speak up if you observe anyone engaging in any level of abuse, assault, neglect, or trafficking o See Attachment A: Abuse/Assault/Neglect/Trafficking policy Addendum E o See Attachment B: Edu-Gram Abuse/Assault/Neglect/Trafficking o See Attachment C: Speak Up for Safety Escalation Using CUS o Education status as of February 9, 2026: § Bridges: 24/47 total employees = 51% § Outpatient Behavioral Health Center: 23/38 total employees = 60.5% · 100% of present and incoming Bridges and Outpatient Behavioral Health Center employees educated on the Use of Force policy. We identified a gap in our AVADE education and found that AVADE does not include Use of Force as part of the AVADE program. (Started 2/5/2026, to be completed by 3/6/2026) o Use of force levels: § Level 1 – Presence § Level 2 – Soft techniques § Level 3 – Hard techniques § Level 4 – Less-lethal force § Level 5 – Lethal o Utilizing the least restrictive interventions at all times o Implementing trauma-informed, patient-centered approaches to reduce escalation o Following all requirements for safe application, monitoring, and documentation when force is used o Ensuring all actions are consistent with regulatory standards, organizational policy, and patient rights o Immediately reporting and documenting any use of force event in accordance with hospital policy o Participating in ongoing education, drills, and competency validation related to Use of Force o See Attachment D: PSJH-RESO-1403 Use of Force o Education status as of February 9, 2026: § Bridges: 24/47 total employees = 51% § Outpatient Behavioral Health Center: 23/38 total employees = 60.5% · 100% of present and incoming Bridges and Outpatient Behavioral Health Center employees educated on the Bridges: Patient Rights W&I 5325 policy and OBHC: Patient Rights policy (Started 2/5/2026, to be completed by 3/6/2026) o No patient shall be deprived of any right, benefit, or privilege guaranteed by law while receiving care on the Bridges Psychiatric Unit. o The rights listed in the policy—including but not limited to the right to wear personal clothing, maintain personal possessions, access visitors, make and receive confidential phone calls, receive and send unopened mail, and maintain personal storage space—must be protected at all times. o All caregivers are responsible for protecting, supporting, and upholding patient rights as part of safe, ethical, and legally compliant patient care. o Any restriction or denial of patient rights requires: § A physician order renewed every 24 hours, § Documentation of good cause consistent with W&I Codes §§5325–5326.7, and § Completion of the Notification to Patient of Rights Denied form, including informing the patient of the denial and conditions for restoration. o I am responsible for immediately notifying the RN or clinical leadership if I observe or become aware of any situation in which patient rights may be violated or restricted. o Upholding patient rights is both a regulatory requirement and an essential component of trauma-informed, dignified, and patient-centered care. o See Attachment J: Bridges: Patient Rights W&I 5325 policy and OBHC: Patient Rights policy o Education status as of February 9, 2026: § Bridges: 24/47 total employees = 51% § Outpatient Behavioral Health Center: 23/38 total employees = 60.5% · 100% of present and incoming Bridges and Outpatient Behavioral Health Center employees educated on the Bridges: Denial of Rights and OBHC: Denial of Rights policies (Started 1/7/2026, to be completed by 3/6/2026) o Rights may only be denied for one of the following reasons (good cause): § The exercise of the specific right would be injurious to the patient; or § There is evidence that the specific right, if exercised, would seriously infringe on the rights of others; or § The institution or facility would suffer serious damage if the specific right is not denied; and § There is no less restrictive way of protecting the interest specified in (1), (2), or (3). o See Attachment K: Bridges: Denial of Rights and OBHC: Denial of Rights policies o Education status as of February 9, 2026: § Bridges: 24/47 total employees = 51% § Outpatient Behavioral Health Center: 23/38 total employees = 60.5% · 100% of present and incoming Security employees educated on the PSJH-CLIN-1217 Restraint for Violent/Seclusion/Self-Destructive Behavior policy (Started 2/5/2026, to be completed by 3/6/2026) o See Attachment L: Restraint for Violent/Seclusion/Self-Destructive Behavior, section 2b under Policy section · 100% of present and incoming Security employees educated on AVADE de-escalation techniques (Started 2/5/2026, to be completed by 3/6/2026) o See Attachment M: AVADE training material regarding identifying behaviors and de-escalation o Education status as of February 9, 2026: § Security: 18/21 total employees = 85.7% · 100% of present and incoming Security employees educated on the PSJH-RESO-1402 Use of Defensive Tools/Handcuff policy (Started 2/5/2026, to be completed by 3/6/2026) o See Attachment N: PSJH-RESO-1402 Use of Defensive Tools/Handcuff policy o Education status as of February 9, 2026: § Security: 18/21 total employees = 85.7% Corrective Action(s) Identified for the Deficient Practice: · On the dates that leadership was made aware of the incidents (1/6/2026 & 1/8/2026), MHW1 and RN1 were placed on administrative leave and caregiver relations consultations submitted for support with investigation and corrective actions to be taken (Completed 1/6/2026 & 1/8/2026) · Investigation conducted. All involved employees were interviewed starting on 1/9/2026 and interviews concluded on 1/26/2026 · Director of Behavioral Health and Director of Risk Management met with the patient ’ s father to inform him of the two incidents (Completed 1/9/2026) · CAO, CNO, Director of Behavioral Health, Risk Management, CHRO, Executive Director of Quality, Security Manager met to review events, discuss opportunities, and determine actions for improvement (Completed 1/9/2026) · Hospitalists to respond to all Code Grays in Bridges (Started on 1/10/2026) How the Facility Will Identify Other Patient(s) Having the Potential to be Affected by the Same Deficient Practice: · Behavioral Health Unit safety check rounds performed every 2-4 hours by Behavioral Health leader on Monday – Friday during normal business hours, and after hours and weekends to be performed by House Supervisor (Started 1/10/2026, ongoing) o Identify any violent/aggressive patient, recent escalation situations, recent Code Gray incidents, patients requiring emergency behavioral interventions, any other safety concerns, and provide additional support, resources, and/or interventions as needed o See Attachment E: Behavioral Health Unit Rounding Log · Implement Code Gray debrief to occur immediately after the Code Gray situation has been stabilized (Started 1/12/2026, ongoing) o Quick 10-min huddle to facilitate reflection and learning following a Code Gray event to help us understand the circumstances, interventions, and opportunities for improvement o See Attachment G: Code Gray Debrief form · Multi-disciplinary meeting to occur within 24-hours of Code Gray in behavioral health areas. Participants include physician, nursing, pharmacy, and spiritual care. Recommendations from there view will be added to patient ’ s care plan (Started 1/12/2026, ongoing) oTo review the Code Gray event to help us understand the circumstances, interventions, and opportunities for improvement. Feedback will help guide the patient ’ s care plan review and improve future safety and team coordination. Review any medical, behavioral, pharmaceutical, and social needs. Discuss the plan for ongoing monitoring and reassessment. oSee Attachment H: Multidisciplinary debrief forms · Code Grays, 5150 patients, and patients flagged as risk-for-violence are discussed in leadership safety huddle daily (Started 1/10/2026, ongoing) OFor awareness and to provide additional support, resources, and/or interventions as needed oSee Attachment F: Safety Huddle Standard Work · Body Cam video footage and surveillance video footage reviewed within 24hours for any instances of excessive use of force. Video review performed by security, Risk Management, and department leader, for all Code Grays on Bridges or Code Grays that result in takedowns in areas outside of Bridges (Started 1/10/2026, ongoing) oSee Attachment I: Post Code Gray Video Review Tracker · 100% of present and incoming Bridges and Outpatient Behavioral Health Center employees educated on the Abuse/Assault/Neglect/Trafficking policy (Started1/7/2026, to be completed by 3/6/2026) oReporting any episode of abuse, assault, neglect, or trafficking by any caregiver, vendor, physician, volunteer, student, Board member, or patient immediately oNotifying Risk Management immediately for any abuse that occurs on-site oSpeak up if you observe anyone engaging in any level of abuse, assault, neglect, or trafficking oSee Attachment A: Abuse/Assault/Neglect/Trafficking policy Addendum E oSee Attachment B: Edu-Gram Abuse/Assault/Neglect/Trafficking oSee Attachment C: Speak Up for Safety Escalation Using CUS oEducation status as of February 9, 2026: §Bridges: 24/47 total employees = 51% §Outpatient Behavioral Health Center: 23/38 total employees =60.5% · 100% of present and incoming Emergency Department, Bridges, and Outpatient Behavioral Health Center employees educated on the Use of Force policy. We identified a gap in our AVADE education and found that AVADE does not include Use of Force as part of the AVADE program. (Started2/5/2026, to be completed by 3/6/2026) oUse of force levels: §Level 1–Presence §Level 2–Soft techniques §Level 3–Hard techniques §Level 4–Less-lethal force §Level 5–Lethal oUtilizing the least restrictive interventions at all times oImplementing trauma-informed, patient-centered approaches to reduce escalation o Following all requirements for safe application, monitoring, and documentation when force is used o Ensuring all actions are consistent with regulatory standards, organizational policy, and patient rights o Immediately reporting and documenting any use of force event in accordance with hospital policy o Participating in ongoing education, drills, and competency validation related to Use of Force o See Attachment D: PSJH-RESO-1403 Use of Force o Education status as of February 9, 2026: § Bridges: 24/47 total employees = 51% § Outpatient Behavioral Health Center: 23/38 total employees = 60.5% · 100% of present and incoming Bridges and Outpatient Behavioral Health Center employees educated on the Bridges: Patient Rights W&I 5325 policy and OBHC: Patient Rights policy (Started 2/5/2026, to be completed by 3/6/2026) o No patient shall be deprived of any right, benefit, or privilege guaranteed by law while receiving care on the Bridges Psychiatric Unit. o The rights listed in the policy—including but not limited to the right to wear personal clothing, maintain personal possessions, access visitors, make and receive confidential phone calls, receive and send unopened mail, and maintain personal storage space—must be protected at all times. o All caregivers are responsible for protecting, supporting, and upholding patient rights as part of safe, ethical, and legally compliant patient care. o Any restriction or denial of patient rights requires: § A physician order renewed every 24 hours, § Documentation of good cause consistent with W&I Codes §§5325–5326.7, and § Completion of the Notification to Patient of Rights Denied form, including informing the patient of the denial and conditions for restoration. o I am responsible for immediately notifying the RN or clinical leadership if I observe or become aware of any situation in which patient rights may be violated or restricted. o Upholding patient rights is both a regulatory requirement and an essential component of trauma-informed, dignified, and patient-centered care. o See Attachment J: Bridges: Patient Rights W&I 5325 policy and OBHC: Patient Rights policy o Education status as of February 9, 2026: § Bridges: 24/47 total employees = 51% § Outpatient Behavioral Health Center: 23/38 total employees = 60.5% · 100% of present and incoming Bridges and Outpatient Behavioral Health Center employees educated on the Bridges: Denial of Rights and OBHC: Denial of Rights policies (Started 1/7/2026, to be completed by 3/6/2026) o Rights may only be denied for one of the following reasons (good cause): § The exercise of the specific right would be injurious to the patient; or § There is evidence that the specific right, if exercised, would seriously infringe on the rights of others; or § The institution or facility would suffer serious damage if the specific right is not denied; and § There is no less restrictive way of protecting the interest specified in (1), (2), or (3). o See Attachment K: Bridges: Denial of Rights and OBHC: Denial of Rights policies o Education status as of February 9, 2026: § Bridges: 24/47 total employees = 51% § Outpatient Behavioral Health Center: 23/38 total employees = 60.5% · 100% of present and incoming Security employees educated on the PSJH-CLIN-1217 Restraint for Violent/Seclusion/Self-Destructive Behavior policy (Started 2/5/2026, to be completed by 3/6/2026) o See Attachment L: Restraint for Violent/Seclusion/Self-Destructive Behavior, section 2b under Policy section · 100% of present and incoming Security employees educated on AVADE de-escalation techniques (Started 2/5/2026, to be completed by 3/6/2026) o See Attachment M: AVADE training material regarding identifying behaviors and de-escalation o Education status as of February 9, 2026: § Security: 18/21 total employees = 85.7% · 100% of present and incoming Security employees educated on the PSJH-RESO-1402 Use of Defensive Tools/Handcuff policy (Started 2/5/2026, to be completed by 3/6/2026) o See Attachment N: PSJH-RESO-1402 Use of Defensive Tools/Handcuff policy o Education status as of February 9, 2026: § Security: 18/21 total employees = 85.7% · Implement code gray simulation with an emphasis on de-escalation and trauma informed care, performed on a quarterly basis (By 3/31/2026) Measures Put in Place and Systemic Changes Made to Ensure that the Deficient Practice Does Not Reoccur: · Behavioral Health Unit safety check rounds performed every 2-4 hours by Behavioral Health leader on Monday – Friday during normal business hours, and after hours and weekends to be performed by House Supervisor (Started 1/10/2026, ongoing) o Identify any violent/aggressive patient, recent escalation situations, recent Code Gray incidents, patients requiring emergency behavioral interventions, any other safety concerns, and provide additional support, resources, and/or interventions as needed o See Attachment E: Behavioral Health Unit Rounding Log · Implement Code Gray debrief to occur immediately after the Code Gray situation has been stabilized (Started 1/12/2026, ongoing) o Quick 10-min huddle to facilitate reflection and learning following a Code Gray event to help us understand the circumstances, interventions, and opportunities for improvement o See Attachment G: Code Gray Debrief form · Multi-disciplinary meeting to occur within 24 hours of Code Gray in behavioral health areas. Participants include physician, nursing, pharmacy, and spiritual care. Recommendations from the review will be added to patient ’ s care plan (Started 1/12/2026, ongoing) o To review the Code Gray event to help us understand the circumstances, interventions, and opportunities for improvement. Feedback will help guide the patient ’ s care plan review and improve future safety and team coordination. Review any medical, behavioral, pharmaceutical, and social needs. Discuss the plan for ongoing monitoring and reassessment. o See Attachment H: Multidisciplinary debrief forms · Code Grays, 5150 patients, and patients flagged as risk-for-violence are discussed in leadership safety huddle daily (Started 1/10/2026, ongoing) o For awareness and to provide additional support, resources, and/or interventions as needed o See Attachment F: Safety Huddle Standard Work · Body cam video footage and surveillance video footage reviewed within 24 hours for any instances of excessive use of force. Video review performed by security, Risk Management, and department leader, for all Code Grays on Bridges or Code Grays that result in takedowns in areas outside of Bridges (Started 1/10/2026, ongoing) o See Attachment I: Post Code Gray Video Review Tracker · 100% of present and incoming Bridges and Outpatient Behavioral Health Center employees educated on the Abuse/Assault/Neglect/Trafficking policy (Started 1/7/2026, to be completed by 3/6/2026) o Reporting any episode of abuse, assault, neglect, or trafficking by any caregiver, vendor, physician, volunteer, student, Board member, or patient immediately o Notifying Risk Management immediately for any abuse that occurs on-site o Speak up if you observe anyone engaging in any level of abuse, assault, neglect, or trafficking o See Attachment A: Abuse/Assault/Neglect/Trafficking policy Addendum E o See Attachment B: Edu-Gram Abuse/Assault/Neglect/Trafficking o See Attachment C: Speak Up for Safety Escalation Using CUS o Education status as of February 9, 2026: § Bridges: 24/47 total employees = 51% § Outpatient Behavioral Health Center: 23/38 total employees = 60.5% · 100% of present and incoming Emergency Department, Bridges, and Outpatient Behavioral Health Center employees educated on the Use of Force policy. We identified a gap in our AVADE education and found that AVADE does not include Use of Force as part of the AVADE program. (Started 2/5/2026, to be completed by 3/6/2026) o Use of force levels: § Level 1 – Presence § Level 2 – Soft techniques § Level 3 – Hard techniques § Level 4 – Less-lethal force § Level 5 – Lethal o Utilizing the least restrictive interventions at all times o Implementing trauma-informed, patient-centered approaches to reduce escalation o Following all requirements for safe application, monitoring, and documentation when force is used o Ensuring all actions are consistent with regulatory standards, organizational policy, and patient rights o Immediately reporting and documenting any use of force event in accordance with hospital policy o Participating in ongoing education, drills, and competency validation related to Use of Force o See Attachment D: PSJH-RESO-1403 Use of Force o Education status as of February 9, 2026: § Bridges: 24/47 total employees = 51% § Outpatient Behavioral Health Center: 23/38 total employees = 60.5% · 100% of present and incoming Bridges and Outpatient Behavioral Health Center employees educated on the Bridges: Patient Rights W&I 5325 policy and OBHC: Patient Rights policy (Started 2/5/2026, to be completed by 3/6/2026) o No patient shall be deprived of any right, benefit, or privilege guaranteed by law while receiving care on the Bridges Psychiatric Unit. o The rights listed in the policy—including but not limited to the right to wear personal clothing, maintain personal possessions, access visitors, make and receive confidential phone calls, receive and send unopened mail, and maintain personal storage space—must be protected at all times. o All caregivers are responsible for protecting, supporting, and upholding patient rights as part of safe, ethical, and legally compliant patient care. o Any restriction or denial of patient rights requires: § A physician order renewed every 24 hours, § Documentation of good cause consistent with W&I Codes §§5325–5326.7, and § Completion of the Notification to Patient of Rights Denied form, including informing the patient of the denial and conditions for restoration. o I am responsible for immediately notifying the RN or clinical leadership if I observe or become aware of any situation in which patient rights may be violated or restricted. o Upholding patient rights is both a regulatory requirement and an essential component of trauma-informed, dignified, and patient-centered care. o See Attachment J: Bridges: Patient Rights W&I 5325 policy and OBHC: Patient Rights policy o Education status as of February 9, 2026: § Bridges: 24/47 total employees = 51% § Outpatient Behavioral Health Center: 23/38 total employees = 60.5% · 100% of present and incoming Bridges and Outpatient Behavioral Health Center employees educated on the Bridges: Denial of Rights and OBHC: Denial of Rights policies (Started 1/7/2026, to be completed by 3/6/2026) o Rights may only be denied for one of the following reasons (good cause): § The exercise of the specific right would be injurious to the patient; or § There is evidence that the specific right, if exercised, would seriously infringe on the rights of others; or § The institution or facility would suffer serious damage if the specific right is not denied; and § There is no less restrictive way of protecting the interest specified in (1), (2), or (3). o See Attachment K: Bridges: Denial of Rights and OBHC: Denial of Rights policies o Education status as of February 9, 2026: § Bridges: 24/47 total employees = 51% § Outpatient Behavioral Health Center: 23/38 total employees = 60.5% · 100% of present and incoming Security employees educated on the PSJH-CLIN-1217 Restraint for Violent/Seclusion/Self-Destructive Behavior policy (Started 2/5/2026, to be completed by 3/6/2026) o See Attachment L: Restraint for Violent/Seclusion/Self-Destructive Behavior, section 2b under Policy section · 100% of present and incoming Security employees educated on AVADE de-escalation techniques (Started 2/5/2026, to be completed by 3/6/2026) o See Attachment M: AVADE training material regarding identifying behaviors and de-escalation o Education status as of February 9, 2026: § Security: 18/21 total employees = 85.7% · 100% of present and incoming Security employees educated on the PSJH-RESO-1402 Use of Defensive Tools/Handcuff policy (Started 2/5/2026, to be completed by 3/6/2026) o See Attachment N: PSJH-RESO-1402 Use of Defensive Tools/Handcuff policy o Education status as of February 9, 2026: § Security: 18/21 total employees = 85.7% · Implement code gray simulation with an emphasis on de-escalation and trauma informed care, performed on a quarterly basis (By 3/31/2026) Corrective Action(s) are Monitored to Ensure Solutions are Substantiated and the Deficient Practice Does Not Reoccur: · Safety check round logs are audited on a weekly basis (Started 1/10/2026, ongoing) · Code Gray debrief review form audited by Director of Behavioral Health in real-time. Opportunities for improvement are escalated to the Chief Nursing Officer (Started 1/12/2026, ongoing) · To monitor for any potential instances of excessive use of force, body cam video footage and surveillance video footage review for all Code Grays on the Acute Psychiatric Unit or Code Grays that result in takedowns in areas outside of Acute Psychiatric Unit (Started 1/10/2026, ongoing) o See Attachment I: Post Code Gray Video Review Tracker o Any identified occurrences of excessive use of force/abuse/assault will be escalated to the Executive Leadership Team, reported to the appropriate regulatory bodies, caregiver relations ticket will be submitted, involved caregiver(s) will be place on an administrative leave o Excessive use of force data will be reported to the Environment of Care Committee, the Quality & Patient Safety Committee, and to the Governing Board Findings: During a review of Patient 1 ’ s “History & Physical” (H&P) 12/16/2025 was admitted to the facility on 12/16/2025 on a 5150 hold for psychosis (a condition usually caused by mental illness in which a person has a difficult time thinking clearly, behaving appropriately, or understanding what is real and what is not) after eloping (escaping) from Outpatient Behavioral Center (OBHC). During an interview on 2/2/2026 at 1:14PM with The Director of Behavioral Health (DBH), the DBH stated that the facility reported two incidents of staff to patient abuse (an action that intentionally causes harm or injures another person) occurred on 1/1/2026. The first incident occurred at 8:50AM involving Mental Health Worker (MHW1) who physically grabbed the right arm of patient 1 using both hands and forcefully swung Patient 1 to the ground pushing Patient 1 ’ s head to the floor, after crossing into a restricted (can only be entered by certain people) area and was placed in restraints. During an observation on 2/3/2026 at 10:18AM, with the DBH, Security Manager (SM), The Chief Executive Officer (CEO), The Director of Risk Management (DRM), the security footage from 1/1/2026 was viewed. The following events were observed at the indicated timestamps in the video: 08:52:43. - Patient 1 was in the dayroom sitting in a chair. 08:52:43. -Patient 1 gets up from chair and walks to right side door towards the restricted area, while MHW 1 follows behind. 08:53:31- Patient crosses red tape on floor into restricted area that has two doors both are locked and secured. MHW 1 follows behind Patient 1 and immediately grabs Patient 1 ’ s right arm swinging him around and bringing Patient 1 face down to the floor then landing on top of Patient 1 horizontally. 08:53:38 AM- Code Grey (a message that goes over the public intercom in the hospital, indicates an emergency response for a combative or violent person) called, while MHW 1 was still on top of Patient 1 with his whole body horizontally across Patient 1. 08:54:28 AM- MHW 1 was still on top of Patient 1, MHW 1 ’ s left hand pushes Patient 1 ’ s head down forcefully on the floor. 08:55AM- Two security officers (SO 1 and SO 2) arrived first and SO 1 restrained (limiting a person ’ s movement) Patient 1 ’ s left arm pinning to the floor and SO 2 restrained Patient 1 ’ s right arm pinning to the floor. MHW 1 was still on top of Patient 1. Two additional (SO 3and SO 4) arrived and SO 1 switched place with SO 4, while SO 3 pinned Patient 1 ’ s feet. 08:55:31AM- MHW 1 got off Patient 1. 08:58:38AM- Walking soft restraints (a soft material or fabric that is padded and designed to safely fit around the limbs of an individual to limit the movement to prevent self-harm or harm to others) was placed on Patient 1 ’ s right and left ankle. 09:00:15AM- Medications were given by intramuscular injection (IM-a technique for delivering medication deep into the muscles). Haldol (a medication used to treat psychotic disorders) 5milligrams (mg-a way to measure how much medicine is given, Benadryl (a medication used to treat symptoms of allergies and allergic reactions) 50milliliters (ml- a unit of measurement used to measure the amount of liquid given), and Ativan (medication used to treat feelings of fear, or uneasiness) 2mg. 09:03:04AM- Handcuffs (metal loops placed around a person ’ s wrist that can be locked) applied to left and right wrist by SO2. 09:05:52AM- Security Officers, MHW 1, and 1:1 sitter (a specific monitoring arrangement where one staff member stays with a patient to prevent self-harm or harm to others) walked Patient 1 to the seclusion (placing a person alone in a room or area where person is physically prevented from leaving) room on a 4-points restraint bed (a bed that has 4 soft restraints 2 at the top and 2 at the bottom). Both ankle walking restraints were removed, and two ankle bed restraints applied. 09:07:54AM- Handcuffs removed after 4 minutes and 50 seconds. 09:08:36AM- MHW 1 in a seclusion room applying right and left arm bed restraints on Patient 1. During an interview on 2/3/2026 at 11:28AM with the Director of Behavioral Health (DBH), the DBH stated that the actions of MHW 1 were not appropriate and could have been avoided if MHW1 did not put hands on Patient 1. DBH stated multiple things could have been done to de-escalate (a method to prevent violence) that were not done. During an interview on 2/3/2026 at 11:30AM with the Security Manager (SM), the SM stated that the staff are trained to use physical techniques when imminent (the presence of clear and immediate threat) harm was present. SM stated in this case with Patient 1, there was no imminent danger. When the Patient is facing down and someone is pushing down on the back of the head, that’s not what we teach. SM stated during restraint training, staff are educated to avoid areas such as the neck and head area because those are high risk areas and can hurt patients even more. SM stated security officer (SO1) used inappropriate technique with Patient 1. SO1 placed his hands on Patient 1 ’ s spine and neck area which is not appropriate technique and what is taught in training. During an interview on 2/4/2026 at 10:51AM with the SM, the SM stated the staff were overreacting (responding to something with unnecessary or excessive action) towards Patient 1. SM stated SO 1 was suspended for inappropriate use of force on 1/9/2026. During an interview on 2/4/2026 at 3:28PM with the DBH, the DBH stated MHW 1 should have verbally redirected and done some type of therapeutic (making a person feel happier and more relaxed) communication. DBH stated if MHW 1 would have verbally redirected Patient 1, then it would not have gotten physical. DBH stated we have a better method to de-escalate called a “2 man escort”, where one person goes on each side of the Patient and escorts them to the seclusion (placing a person alone in a room or area where person is physically prevented from leaving) room. DBH stated once MHW 1 physically put hands on Patient 1, Patient 1 was not going to respond in an appropriate way. DBH stated there was no justification (the action of showing something to be right) to touch any patient, only in defensive mode (protecting yourself) if the Patient is attacking you. DBH stated that prior to MHW 1 getting physical, Patient 1 was not a danger to self or anyone at that current time. DBH stated that the 1:1 sitter (a specific monitoring arrangement where a single staff member is assigned to observe, monitor, and document on a patient that may be a danger to self or others) failed to inform the charge nurse about the incident. DBH stated it would be important to suspend (temporary removal of a person from a place) employees involved in abuse incidents we don’t want them to reoffend (repeating behavior) or intimidate (to make someone afraid) other patients. It would be our duty; the offender (a person who committed a crime) must be removed and not have any contact with patients. DBH stated “reporting is important, we have governing body (a group of people given the power and authority to steer the overall direction of a company) that regulates, and we have to follow the guidelines.” During a review of the facility ’ s policy and procedure (P&P), titled “Bridges: Patient Rights W&I 5325” dated 5/2023, the P&P indicated, “A right to be free from harm, including unnecessary or excessive physical restraint, isolation, abuse, medication, or neglect Medication shall not be used as a punishment, or for the convenience of staff, or a substitute for program, or in quantities that interfere with the treatment program.” During a review of the facility ’ s policy and procedure (P&P), titled “1403 Use of Force” dated 9/2023, the P&P indicated “[Name of Facility] workforce members may use force as part of their physical security duties when considered reasonable under the totality of the circumstances. [Name of Facility] expects the use of the lowest level of force (required by the circumstances) but recognizes that varying degrees of force are justified according to the severity of the physical confrontation. Please note that some ministries or organizations use the term “Category” rather than the word “level.” These use of force levels were adapted from the United States National Institute of Justice. -Level 1 Presence is the attempt to “de-escalate” by exhibiting a physical security presence, giving verbal commands, and shielding other personnel from the individual to allow time or distance to de-escalate. -Level 2 Soft Techniques are the force necessary to gain positive control or compliance with little or no probability of injury to overcome resistance (e.g. escorting, etc.) -Level 3 Hard Techniques are the force necessary to “detain and control” the individual to prevent harm to themself or others. The use of hard techniques may result in notable discomfort, minor injury, but without causing serious bodily injury or death (e.g. control holds, handcuffs, etc.). -Level 4 Less Lethal force means utilizing tools or devices and physical techniques when there is an imminent danger of serious bodily injury or death. Less-lethal force may cause serious bodily injury or death (e.g. baton, chemical sprays, taser, etc.) -Level 5 Lethal Force is the force used only when there is an imminent danger of serious bodily injury or death. The use of lethal force is likely to result in serious bodily injury and death (e.g. firearms, strikes to sensitive areas, etc.)...3. All use of force incidents, including health care interventions, will be reported a. Regional Security Services Staff must report to a supervisor, as soon as practical, any staff that uses excessive force on a threat or who fails to follow use-of- force procedures.” During a review of the facility’s policies and procedures (P&P) titled “Abuse/Assault/Neglect/Trafficking” dated 6/2023, the P&P indicated, “In the event a patient alleges abuse caused by an employee (“caregiver”), physician, volunteer, student, or other affiliated individual: 1. Notify Department Leader, House Supervisor, Human Resources, and Risk Management immediately. Medical Staff will be notified as appropriate if accused individual is a member of the medical staff. 2. Accused individual to be placed on administrative leave pending investigation and removed from patient care activities. 1. As soon as possible, Human Resources, Risk Management, and/or designee will interview accused individual. 3. Risk Management or designee will conduct interview with patient making abuse allegation...5. Risk Management will coordinate reporting to CDPH Licensing & Certification ....8. Risk Management is also to be notified immediately for any abuse that occurs on-site that involves a patient.” During a review of the facility’s policies and procedures (P&P) titled “Restraint for Violent/Seclusion/Self-Destructive Behavior” dated 5/2025, the P&P indicated, “ ...All patients have the right to be free from restraint, in any form, imposed as a means of coercion, discipline, convenience, or retaliation by caregiver. Patients will be treated with dignity and therefore be free from neglect, exploitation, abuse, harassment, racism, or discrimination. Patients have the right to receive considerate, compassionate and respectful care, and be free from physical or mental abuse and corporal punishment ...Determine the least restrictive method for restraints to ensure the patient and others safety.””

“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: 45774 Based on interview and record review, the facility failed to ensure seven out of eight sampled hospital staff (Registered Nurse 1, Registered Nurse 5, Registered Nurse 6, Registered Nurse 7, Registered Nurse 8, Mental Health Worker1, and Assistant Nurse Manager1) completed yearly “use of force” training (a training program designed to teach personnel how to evaluate, decide upon, and apply the appropriate level of physical control to overcome the resistance of an individual) per facility ’ s “use of force” (The application of physical techniques or tactics , chemical agents or weapons to another person) policy and procedure. This deficient practice resulted in hospital staff who were not yearly trained to recognize when to execute use of force face significant legal, ethical, and safety risks, that can potentially lead to severe, and sometimes fatal, outcomes for patients and staff alike. Without proper, ongoing training, staff might fail to use de-escalation (a method to prevent violence) techniques, leading to unnecessary, excessive, or inappropriately timed physical intervention. Findings: During a review of the seven of eight hospital staff (Registered Nurse 1, Registered Nurse 5, Registered Nurse 6, Registered Nurse 7, Registered Nurse 8, Mental Health Worker1, and Assistant Nurse Manager1) training records on 2/6/2025 at 2:00 p.m., on HealthStream (a cloud-based repository that tracks employee competencies, continuing education credits, and professional license), it was noted that (Registered Nurse 1, Registered Nurse 5, Registered Nurse 6, Registered Nurse 7, Registered Nurse 8, Mental Health Worker1, and Assistant Nurse Manager1) has no yearly training records of “use of force” (The application of physical techniques or tactics , chemical agents or weapons to another person). During a concurrent interview and record review on 2/6/2026 at 4:20PM, with the Security Manager (SM), a review of the a training material titled “AVADE Workplace Violence Prevention” (a comprehensive workplace violence prevention training program that focuses on educating employees to proactively identify risks, de-escalate (a method to prevent violence) conflicts, and defend against aggression, fostering a safer work environment) indicated that anytime force was used, the hospital staff trainee should take into consideration their ability, agency policies and procedures and laws in the state and country in which the trainee reside. The training program did not dictate policies or procedures for arrest, detention, control and restraint, self-defense, use of force or any physical intervention authorized for use by a department/agency or private individual. Individual, department or agency was responsible for developing their own “policies and procedures” regarding use of force, self-defense, physical intervention, physical restraints, physical control, arrest and detention for their personnel. Hospital staff should have a strong understanding of their agency policies and procedures regarding use of force and self-defense. The Security Manager stated that he provided and conducted the in-person “AVADE Workplace Violence Prevention” to all hospital staff that required it. This program did not dictate staff when to execute use of force, the hospital (Hospital 1) has its own “use of force” policy and procedure that all staff that required them should be trained and adhere to. Security Manager added that he did not provide or know of a separate training program for the hospital ’ s own “Use of Force” policy and procedure. Seven of eight sampled staff (Registered Nurse 1, Registered Nurse 5, Registered Nurse 6, Registered Nurse 7, Registered Nurse 8, Mental Health Worker1, and Assistant Nurse Manager1) required that they completed the hospital ’ s (Hospital 1) “Use of Force” training and that none of them had records on file of completing them yearly. During a concurrent interview and record review on 2/9/2026 at 1:29 p.m., with Accreditation Program Manager (APM), stated that the use of force was only applied to security staffs. APM provided training certification for Security Officer (SO1) only but not able to provide use of force training documentation for staff (Registered Nurse 1, Registered Nurse 5, Registered Nurse 6, Registered Nurse 7, Registered Nurse 8, Mental Health Worker1, and Assistant Nurse Manager1). During a review of the facility ’ s policy & procedure (P&P) titled “Use of Force,” last reviewed 9/2024, the P&P indicated the following: Workforce members engaged in conducting physical security responsibilities that may result ln the use of force shall receive appropriate training in industry best practices for physical control techniques, non-lethal tools or devices, and other industry specific training. 1. Use of force training shall be required annually at a minimum for workforce members to conduct physical security responsibilities. Frequency may change depending on the level of training necessary to maintain qualifications for less-lethal tools or devices workforce members carry in their role. 2. Certification and training services shall be provided by certified instructors where required and/or industry recognized subject matter experts (SME’s). 3. Training records are maintained for personnel engaged in physical security responsibilities. Certificates for training received should be added to training files for workforce members. Records shall be archived after the separation of employment in accordance with record retention policies. 4. Training reviews are conducted annually at minimum to continuously improve physical security related methods and maintain industry best practices in health care security and safety.”

“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: 45774 ased on observation, interview and record review, the facility failed to: 1. Ensure required restraint (use of a device to restrict movement of a person) monitoring documentation was completed for one of thirty sampled patients (Patient 1) when 1:1 sitter (a specific monitoring arrangement where a single staff member is assigned to observe, monitor, and document on a patient that may be a danger to self or others) observation coverage changed resulting in the incomplete documentation of patient monitoring while Patient 1 remained on a 5150 hold (a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves]) . This deficient practice failed to ensure restraint monitoring documentation was completed as required resulted in an inability to verify ongoing assessment and monitoring of a patient while on a 5150-hold placing the patient at risk for unmet needs and compromised safety. 2. The facility failed to ensure intravenous (IV- a small tube inserted into a vein) tubing was not labeled with a date and time for two of thirty sampled patients (Patient 6 and Patient 7) who were receiving IV therapy (a process that delivers fluids, medications and nutrients directly into a person ’ s vein) per the facilities policy and procedures (P&P- guidelines dictating an organization ’ s directions on a topic and step-by-step instructions how to carry out tasks) and accepted standards of practice. This deficient practice had the potential to result in Patient 6 and Patient 7 IV tubing to remain in place beyond recommended timeframes, increasing the risk of infection and compromising patient safety. And ensure IV tubing was properly labeled to allow staff to verify compliance with required tubing change intervals. 3. Ensure pain was reassessed (assessment that includes a pain scale uses numbers from 0 to 10, with 0 representing no pain and 10 representing the worst pain possible, location of pain, character of pain, and duration of pain, performed after medication has been giving to see if pain medication was effective) on three of thirty sampled patients (Patient 7 , Patient 15 and Patient 30) after administration of pain medication in accordance with the facilities policy and procedure (P&P- guidelines dictating an organization ’ s directions on a topic and step-by-step instructions how to carry out tasks) . This deficient practice resulted in staff failed to reassess and document pain following intravenous (IV- a small tube inserted into a vein) opioid (a drug used to reduce moderate to severe pain) administration puts the patient at risk for unrelieved pain and potential adverse (negative or harmful) effects for Patient 7, Patient 15, and Patient 30. 4. Ensure for two of 30 sampled patients (Patient 28 and Patient 29), the policies and procedures were implemented when: A. Patient 28, who was at medium risk for fall, was not wearing a fall risk armband (a yellow armband indicating the patient was at risk for fall). B. Patient 29, who was at high risk for fall, was not wearing a fall risk armband and yellow non-skid socks indicating the patient was at high risk for fall. These deficient practices had the potential to result in an unsafe care that may lead to Patient 28 and Patient 29 suffering from a fall injury. Findings: 1.During a review of Patient 1 ’ s ’ History and Physical” (H&P), dated 12/16/2025, the H&P indicated that Patient 1 was admitted to the facility on a 5150 hold (a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves]) for psychosis (a condition usually caused by mental illness in which a person has a difficult time thinking clearly, behaving appropriately, or understanding what is real and what is not) after eloping(escaping) from outpatient behavioral center (OBHC). During a concurrent interview and record review on 2/5/2026 at 1:33PM, with the Director of Behavioral Health (DBH) and Certified Nursing Assistant 1 (CNA 1) a review of Patient 1 ’ s “Constant Observer (CO) Documentation Flowsheet” dated 1/1/2026 was reviewed, the flowsheet indicated that Patient 1 had no documentation of CO at 1300 (1:00pm) and 1315 (1:15pm). The DBH stated it is the expectation that CO flowsheet be completed as required. CNA 1 who at times serves as a 1: 1 sitter, stated it is the expectation to complete the 1:1 CO flowsheet because without documentation staff are unable to determine what occurred during that monitored time. CNA 1 stated it is policy to document every 15 minutes. CNA 1 stated that a consequence of not documenting every 15 minutes, the patient can do self-harm. During a review of the facilities policy and procedure (P&P- guidelines dictating an organization ’ s directions on a topic and step-by-step instructions how to carry out tasks) titled, “Constant Observer”, dated 5/2025, indicated, “For suicidal or self-harm patients document no less than every 15 minutes or as directed by primary or charge registered nurse (RN). 2. During a review of Patient 6 ’ s “History and Physical indicated that Patient 6 was admitted to the facility on 1/31/2026 for complaints of weakness and chronic obstructive pulmonary disease (COPD- a disease caused by damage to the lungs, making it hard to breath.) During a review of Patient 7 ’ s “History and Physical” indicated that Patient 7 was admitted to the facility on 2/2/26 for complaints of abdominal (stomach) pain, and gastrointestinal (stomach) bleed. During an observation on 2/2/ 2026 at 1:47 PM, IV tubing (delivers fluids, medication directly into the vein) was observed hanging on an IV pole infusing (a method of putting fluids including drugs into the bloodstream) into Patient 7 ’ s left arm. And at 1:50PM, IV tubing was observed hanging on an IV pole infusing into Patient 6 ’ s right arm. Both Patient 6 and Patient 7 were observed with no label indicating a date, time and which staff hung the IV tubing. During an interview on 2/2/2026 at 1:51 PM with Registered Nurse 3 (RN3), RN 3 stated, It was important to label IV tubing to let other others know when we hung it, the consequences of not labeling IV tubing would be we would not know when it would expire or time to change. RN3 stated IV tubing should be labeled every 24 hours. During a review of the facilities policies and procedure (P&P- guidelines dictating an organization ’ s directions on a topic and step-by-step instructions how to carry out tasks) titled “Comprehensive Vascular Access Management” dated 5/2023, indicated, “Label IV tubing with the date and time tubing is to be changed” 3.A. During a review of Patient 7 ’ s “History and Physical” indicated that Patient 7 was admitted to the facility on 2/2/2026 for complaints of abdominal (stomach) pain, and gastrointestinal (stomach) bleed. During a review of Patient 7’s “Physician order” (the instructions a doctor gives for a patient’s treatment, care, or a specific course of action), dated 1/31/2026 at 9:24PM, Morphine (an opioid used to treat moderate to severe pain) 1-2 milligrams (mg-unit of measurement) was ordered every two hours as needed (PRN) During a review of Patient 7’s “Medical Administration Record” (MAR, legal document used by nurses and other healthcare professionals to track all medications administered to a patient) dated 1/31/2026 at 1:51PM, indicated Morphine 2mg was administered to Patient 7 one time by IV. During a concurrent interview and record review on 2/5/2026 at 3:00PM with Nurse Manager of Telemetry (NMT). Patient 7 ’ s “Pain flow sheet” dated 2/3/2026 at 1:51PM, was reviewed. The flowsheet indicated Patient 7 had a pain rating of 8 (pain scale uses numbers from 0 to 10, with 0 representing no pain and 10 representing the worst pain ). The flow sheet also indicated that the post medication administered pain reassessment was not done. During an interview on 2/5/2026 at 3:00PM with NMT, the NMT stated it is important to reassess pain because we have to see if the treatment was effective and its overall holistic (caring for the whole person, and providing care for physical, mental, spiritual and social needs) care of the patient. NMT stated that the consequences of not reassessing pain could be patient satisfaction, it can affect vital signs (measurements of the body ’ s most basic functions, including body temperature, heartrate, and breathing rate) sleep patterns (the number of times a person wakes up during sleep), and can delay their healing if they were still in pain. B. During a review of Patient 15’s “History & Physical” (H&P), a formal and complete assessment of the patient and the problem),” dated 2/3/2026, the H&P indicated Patient 15 ’ s was admitted on 2/3/2026 due to anterior dislocation of left elbow (severe injury occurring when the forearm bones shift in front of the humerus) and hyponatremia (condition defined by a serum sodium concentration is low in desire range. During a review of Patient 15’s “Nursing Flowsheet” documentation tool in Electronic Health Records (EHRs) or paper charts used to record routine, repetitive, and chronological patient data, such as vital signs, intake/output, and assessments), indicated Patient 15 ’ s pain level is 10/10 ((pain scale is a numerical scale used to assess pain intensity, where 0 indicates no pain and 10 represents the worst pain imaginable), on 2/2/2026 at 11:00 a.m. During a review of Patient 15’s Medication Administration Report (MAR) dated 2/2/2026 at 11:05 a.m., Hydrocodone-Acetaminophen 5-325 milligram (mg) 1 tablet was given for moderate or severe pain (Norco, is a powerful opioid analgesic used to treat moderate to severe pain). During a concurrent interview and record review on 2/4/2026 at 11:05 a.m., with Emergency Department Manager (EDM), Patient 15’s MAR and Nursing flowsheet were reviewed and patient was complaining left hand pain 10/10 on 2/2/2026 at 11:00 a.m., pain medication Hydrocodone-Acetaminophen 5-325 mg 1 tablet was on 2/2/2026 at 11:05 a.m., concurrently, pain reassessment was done on 2/2/2026 at 1:00 p.m. documented in the nursing flowsheet, which is 1 hour 55 minutes later. EDM concurred that the nurse should reassess and document the pain reassessment within 75 minutes if pain medication is administered by mouth to see if pain medication is effective or not. During a review of the facilities policies and procedure (P&P- guidelines dictating an organization ’ s directions on a topic and step-by-step instructions how to carry out tasks) titled “Pain Management Standards of Care” dated 12/2022, indicated, ...The pain intensity and pain relief will be assessed and documented .....after each pain medication intervention based on method of administration (within 45 minutes for IV, within 75 minutes for all other methods of administration). During a review of the facilities P&P titled, “Medication Management” dated 6/2023, indicated ...When a narcotic or hypnotic has been administered there must be documentation on the nurses note of the patient ’ s response to the medication. C. During a review of Patient 30 ’ s “History & (and) Physical (H&P),” dated 1/24/2026, the H&P indicated Patient 30 was admitted to the facility with a diagnosis of multiple fractures. During a review of Patient 30 ’ s “Medication Administration Report (MAR)” dated 2/5/2026, the MAR indicated a physician ’ s order for Patient 30 to receive the following: -Tylenol (pain medication) 500 mg (mg-a unit of measurement) oral (PO, by mouth) every 8 hours 3 times per day. Administration Instructions: Mild pain: give as first line medication. If ineffective, give with NSAID (NSAID, Nonsteroidal Anti-Inflammatory Drug, a class of medication used to reduce pain, fever, and inflammation) as ordered. Moderate pain: give with NSAID as ordered. If ineffective, give with opioid as ordered. Severe pain: Give acetaminophen (Tylenol) with NSAID and opioid as ordered, with a start day of 1/26/2026; and, -Tramadol (narcotic pain medication) 50 mg (mg-a unit of measurement) oral every 6 hours as needed (PRN) pain, with a start day of 1/31/2026. During a concurrent interview and record review, on 2/5/2026 at 2:52 p.m., with Director of Nursing for Acute Rehabilitation Unit (DON 1), DON 1 verified Patient 30 ’ s pain assessment in the medical record (MR) titled, “Flowsheets-Pain/Comfort,” was incomplete. DON 1 verified Patient 30 ’ s MAR indicated the following medication administration: -On 2/1/2026 at 7:28 p.m. Patient 30 was administered Tramadol 50 mg PO, the pain score was not documented, it did not indicate the pain rating, pain body location, pain quality, and duration of pain. The corresponding (related) pain reassessment was not documented. During a concurrent interview and record review on 2/5/2026 at 3:00 p.m., with DON 1, DON 1 stated a complete pain assessment includes the pain rating score, location of pain, pain quality, and duration of pain. DON 1 stated a complete pain assessment was not performed by nursing care and the expectation is to document the full pain assessment prior to medication administration and reassessment to be completed in one hour after pain medication administration for Patient 30. During a review of the facility ’ s policy and procedure (P&P) titled, “Pain Management Standards of Care,” dated 12/2022, the P&P indicated, “It is the goal of [Name of the Facility] to provide consistent high quality, interdisciplinary patient care related to pain management across the service area that is based on national standards of practice. The patient ’ s rights to pain management is an essential aspect of quality and safety ...5. The pain intensity and pain relief will be assessed and documented ... D. after each pain management intervention based on method of administration (within 45 minutes for IV (in the vein) within 75 minutes for all other methods of administration) ...” 4. A. During an observation on 2/2/2026 at 2:19 p.m., with Registered Nurse 4 (RN 4) and Clinical Risk Manager (CRM), Patient 28 ’ s room was observed to have a “fall risk” (indicated the patient was at risk for fall) signage by the door. Patient 28 was observed sitting alone in a wheelchair in her room, alert and oriented. During a concurrent observation and interview, on 2/2/2026 at 2:19 p.m., with RN 4, RN 4 stated Patient 28 was at moderate risk for fall. RN 4 stated fall risk intervention included a yellow armband, yellow socks, signage on the patient ’ s room, and bed alarm on. Subsequently, Patient 28 was observed not wearing a yellow fall risk armband. RN 4 stated the importance of the fall risk armband is so that anyone that comes in Patient ’ s 28 room would monitor the patient closely to prevent a fall. During a review of Patient 28’s “History & (and) Physical” (H&P - a formal and complete assessment of the patient and the problem), dated 1/24/2026, the H&P indicated Patient 28 was admitted to the facility with a chief complainant of cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), left hemiparesis (weakness or partial paralysis affecting one side of the body)and impaired self-care. The document also indicated Patient 28 had impaired communication/cognition (difficulties in speaking, listening, reading, or writing caused by underlying brain dysfunction). During a review of Patient 28 ’ s “Morse Fall Risk” flowsheet (a form in an electronic medical record that collects all the necessary information and displays it for easier review), dated 2/2/2026, at 07:55 a.m., the flowsheet indicated Patient 28 score of a 35 on the Morse Fall Risk Score (a tool used to assess a patient ’ s risk of falling in a healthcare setting 0-24 indicates low fall risk, universal interventions, 25-44 indicate moderate risk for fall and 45 and above indicate high fall risk implement (start) high risk fall interventions). During a concurrent interview and record review on 2/5/2026 at 1:58 a.m., with Director of Nursing for Acute Rehabilitation Unit (DON 1), DON 1 verified Patient 28 ’ s “Morse Fall Risk” flowsheet, dated 2/2/2026, at 07:55 a.m., the flowsheet indicated Patient 28 was at “High Risk for Injury due to coagulation (patient taking blood thinners medications).” DON 1 stated the importance to apply yellow fall risk armband is for everyone to identify Patient 28 who is at risk for fall and to ensure patient is safe. During a review of the facility’s policy and procedure (P&P), titled “Falls Management Prevention,” dated 5/2025, the P&P indicated, “Moderate risk for fall: 1. Scores 25-44 on Morse scale 2. Implement the following nurse driven interventions: a. Universal interventions b. Apply Yellow fall risk armband and yellow fitted non-skid socks ....” B. During an observation on 2/2/2026 at 2:05 p.m., with Registered Nurse 4 (RN 4) and Clinical Risk Manager (CRM), Patient 29 ’ s room was observed to have a “fall risk” (indicated the patient was at risk for fall) signage by the door. Patient 29 was observed in his room resting in bed, alert and oriented to name accompanied by his spouse at bedside. During a concurrent observation and interview, on 2/2/2026 at 2:05 p.m., with RN 4, RN 4 stated Patient 29 was at high risk for fall. RN 4 stated fall risk intervention included a yellow armband, yellow socks, signage on the patient ’ s room, and bed alarm on. Subsequently, Patient 29 was observed not wearing a yellow fall risk armband and no fitted yellow non-skid socks instead Patient 29 was wearing oversize (3xxx large) gray socks. RN 4 stated the gray socks were too big for Patient 29 and the importance of the fall risk armband and yellow socks is so that anyone that comes in Patient ’ s 29 room would monitor the patient closely to prevent a fall. During a review of Patient 29’s “History & (and) Physical” (H&P - a formal and complete assessment of the patient and the problem), dated 1/29/2026, the H&P indicated Patient 29 was admitted to the facility with a chief complainant of cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain). stroke, left body involvement. The document also indicated Patient 29 had impaired self-care, decreased functional ability and history of falls. During a review of Patient 29 ’ s “Morse Fall Risk” flowsheet (a form in an electronic medical record that collects all the necessary information and displays it for easier review), dated 2/2/2026, at 11:11 a.m., the flowsheet indicated Patient 29 score of a 75 on the Morse Fall Risk Score (a tool used to assess a patient ’ s risk of falling in a healthcare setting 0-24 indicates low fall risk, universal interventions, 25-44 indicate moderate risk for fall and 45 and above indicate high fall risk implement (start) high risk fall interventions). During a concurrent interview and record review on 2/5/2026 at 2:30 p.m., with Director of Nursing for Acute Rehabilitation Unit (DON 1), DON 1 verified Patient 29 ’ s “Morse Fall Risk” flowsheet, dated 2/2/2026, at 11:11 a.m., the flowsheet indicated Patient 29 was at “High Risk for Injury due to Patient ’ s 29 age greater than 80 years old. DON 1 stated the importance of applying yellow fall risk armband and yellow non-skid socks is for everyone to identify Patient 29 who is at risk for fall and to ensure patient is free of falls. During a review of the facility’s policy and procedure (P&P), titled “Falls Management Prevention,” dated 5/2025, the P&P indicated, “High risk for fall: 1. Scores 45 and above on Morse scale. 2. Implement the following nurse driven interventions: a. Universal Interventions b. Apply Yellow fall risk armband and yellow fitted non-skid socks ....””

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 45774 Based on interview and record review, the facility failed to employ an effective system for preventing and controlling transmission of bloodborne infections among personnel and patients, by not verifying hepatitis B immune (Hepatitis B [hep B] is a potentially life-threatening infection caused by the hepatitis B virus, HBV, that can cause both acute and chronic liver disease and places people at high risk of death from cirrhosis and liver cancer. The virus can be transmitted through exposure to blood or body fluids of an infected individual.) status of its 10 out 10 Medical Staff. This deficient practice placed the facility ’ s practitioners and patients at risk of acquiring or transmitting HBV infection that could lead to serious liver disease. Findings: On 2/3/2026 at 3:00 pm, the credential files of ten (10) selected sample of the facility ’ s Medical Staff, which included documentation of the practitioners ’ health screening information, were reviewed with the assistance of the Medical Staff Director (MSD), Medical Staff Coordinator (MSC), and Credentialing Coordinator (CC). The files of ten out of ten (10/10) sampled providers (P1-P10) contained no documentation of their hepatitis B immune status. During concurrent interview, the MSD reported that the facility does not address or verify hep B immune status of its Medical Staff, that it has never collected such information from any providers on the Medical Staff. On 2/4/2026 at 1:40pm, during an interview with the facility ’ s Infection Preventionist (IP) and the Senior Manager of Infection Prevention (SMIP) and concurrent review of the facility document titled “Infection Prevention Program Plan and Risk Assessment,” the issue of the lack of documentation of hepatitis B immune status of the facility ’ s Medical Staff was raised. The IP and SMIP stated that the “Caregiver Health program” described in the document refers to an employee program, and providers are considered non-employees. The IP and SMIP added that the document does not apply to physicians and mid-level providers at the facility as they are independent contractors. On 2/4/2026 at 2pm, during an interview with the facility ’ s Director of Emergency Department (DED), the Director stated that infection prevention is a facility-wide program and that the Caregiver Health program should apply to all healthcare workers in the facility, including providers, as well as nursing and other staff. On 2/6/2026 at 1:55pm, during a telephone interview with the Medical Staff Director, the MSD was asked about the facility ’ s practitioners being excluded from the Caregiver Health program. The MSD stated that practitioners are not employees technically, but the Caregiver Health program covers all healthcare workers of the facility, including physicians and allied health professionals. The MSD further stated that upon hire, at orientation, information about Caregiver Health program is provided to every provider, including flu (acute respiratory infection caused by influenza viruses), TB (tuberculosis, an infectious disease caused by bacteria that most often affects the lungs), and COVID (infectious disease caused by the SARS-CoV-2 virus) screening and vaccinations; the MSD added the information does not address hep B vaccination, but “if a provider asks for hep B vaccine, then the facility offers it.” The facility document, “Infection Prevention Program Plan and Risk Assessment,” last revised in March 2025, states: “The purpose of the Infection Prevention Program (IPP) is to identify infections and mitigate the risks of disease transmission through development and implementation of preventive measures. The mission of this program is to ensure safe, cost-effective care for our patients, caregivers, visitors, and other healthcare workers.” Under Section V. Caregiver Health, the document reads: “The Caregiver Health program reduces the risk of disease transmission among healthcare workers, Licensed Independent Practitioners (LIPs), contract workers, students and volunteers.” According to the document, the caregiver health program includes processes for health screening, childhood illness/immunization, tuberculosis screening, immunization for hepatitis B and influenza, and evaluation and assessment of post-exposure follow-up. At the time of initial employment, all employees have a baseline health screening which includes: medical history, including immunization status and assessment for conditions that may predispose personnel to acquiring or transmitting communicable diseases; tuberculosis screening via Q-Gold testing; screening for vaccine-preventable diseases. The employees are offered appropriate immunizations for communicable diseases based on regulatory requirements and CDC, California Occupational Safety and Health Administration (Cal/OSHA) or Advisory Committee on Immunization Practices (ACIP) recommendations for healthcare workers. The facility policy, “Bloodborne Pathogens Exposure Control Plan,” last revised 10/2023, states under the segment on Hepatitis B Vaccination: Hepatitis B vaccination shall be made available after the caregiver has received the training and within ten (10) working days of initial assignment to all employees who have occupational exposure unless the employee has previously received the complete hepatitis B vaccination series, antibody testing has revealed that the caregiver is immune, or the vaccine is contraindicated for medical reasons. [ ...] Caregiver Health Services, Wellness & Injury Prevention shall assure that caregivers who decline to accept hepatitis B vaccination offered by the [organization] sign a statement of declination.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 45774 Based on observation and interview, and record review, the facility failed to ensure that the compartment encasing the waterspout of one of two sampled ice and drinking water dispensing machines (water dispensing machine 1) was free from a buildup of white substance, in accordance with the facility ’ s policy regarding infection control and prevention. This deficient practice could lead to the contamination of ice and drinking water, increasing the risk of harmful bacteria growth, which poses a health hazard to patients and staff who consume the water. Findings: During a concurrent observation and interview on 2/2/2026 at 2:43 p.m. with Clinical Risk Manager (CRM), in the Medical Surgical unit (a unit that provides care for adults with a variety of health issues that are non-critical), CRM stated she (CRM) observed white buildup surrounding the compartment encasing the spout of ice/water dispensing machine 1. During a concurrent observation and interview on 2/2/2026 at 2:45 p.m. with Charge Nurse 2 (CN 2), in the Medical Surgical unit, CN 2 stated the area surrounding the compartment encasing the spout of ice/water dispensing machine 1 looked dirty and with white buildup. During a concurrent interview on 2/5/2026 at 10:03 a.m. with Environmental Services (EVS, department responsible for maintaining a clean working environment) Director (EVSD), EVSD stated on 2/2/2026 the surrounding compartment encasing the spout of ice for the water dispensing machine 1 was replaced due to calcium buildup and stated the rest of the compartment was cleaned with vinegar. EVSD stated it is the responsibility of the EVS department to clean the compartment encasing the waterspout every day and stated there is a potential for particles to go into the ice and drinking water. EVSD stated the EVS Department did not have any records/logs of daily or weekly ice machine service indicating cleaning addressing the spout compartment. During a concurrent interview on 2/5/2026 at 10:33 a.m. with Environmental Services Staff (EVS 1), EVS 1 stated it was her (EVS 1) responsibility for daily cleaning of the surrounding compartment encasing the spout of ice for the water dispensing machines in the facility. EVS 1 stated “we are supposed to clean the compartment with vinegar, around the spout, clips can be removed and wipe with vinegar the inside and outside with disinfecting wipes for 1 minute.” EVS 1 stated the white substance surrounding the compartment encasing the waterspout indicated the ice machine was not clean. EVS 1 stated there is a potential for harmful bacteria and we (EVS) do not want any patients or staff to get sick. EVS 1 stated the EVS department did not have any logs of daily ice machine service to indicate cleaning addressing the spout compartment. During a review of the facility ’ s document titled, “Infection Prevention Program Plan Section IV,” undated, provided by the facility the document indicated, “IV. Environment A. [Name of the Facility] has developed specific Policies and procedures to address the hospital environment, including: ...4. Techniques for safely cleaning and disinfecting the environment: a. Regular disinfection of all restrooms, countertops, furniture, televisions, telephones, bedding, office equipment, and surfaces in patient rooms, nursing stations, and storage units is be provided by Environmental Services. Regular disinfection all surfaces in common areas in the facility such as elevators, meetings rooms, and lounges is also provided by Environmental Services ...” During a review of the facility ’ s policy and procedure (P&P) titled, “EVS: Ice Machine Cleaning,” dated 10/2022, the P&P indicated, “It is the policy of [Name of the Facility] to routinely clean the exterior and interior of ice machines throughout the facility to provide a safe and healthy environment for patients, staff and visitors ...EVS: 1. On a daily basis, using a disinfectant cloth, wipe down all exterior surfaces of the ice machine. These surfaces include spout, front face, drip tray, tray grate, and buttons. 2. On a daily basis, using disinfectant cloth, reach as far inside spout as possible to disinfect inside of spout. After three (3) minute contact time, rinse with clean water to remove any residue. 3. On a weekly basis, wipe using straight vinegar to assist with the removal of calcium buildup on the spout, drip tray and grate ... “ During a review of the facility ’ s document titled, “Patient Rights and Responsibilities,” undated, provided by the facility the document indicated, “To a safe environment: You have the right to receive care in a safe setting ...””