Good Samaritan Hospital, LP

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 37797 The hospital failed to meet the regulatory requirement for the Condition of Participation: CFR 482.13 PATIENT’S RIGHTS as evidenced by the following: 1. Based on observation, interview, and record review, the facility failed to identify and treat the immobilization of one of three sampled patient’s (Patient 16) arms with a bed sheet as a restraint. Staff tied a bed sheet around Patient 16’s arms in a manner that restricted his ability to move freely, but they did not classify this action as a restraint. This failure resulted in a violation of Patient 16’s right and placed Patient 16 at risk of injury or death. (Refer to A-0159) 2. Based on observation, interview, and record review, the facility failed to ensure seclusion [the involuntary confinement of a patient alone in a room or area from which they are physically prevented from leaving] was only used for the management of violent or self-destructive behavior that jeopardized the immediate physical safety of the patient, staff or others, for one of three sampled patients (Patient 17) when Patient 17 was placed in seclusion for non-violent and non self-destructive behavior such as restlessness, agitation, yelling, screaming, cursing, being loud, disrobing and others. This failure resulted in Patient 17’s rights being violated and placed Patient 17 at risk of injury and death. (Refer to A-0162) 3. Based on observation, interview, and record review, the facility failed to apply restraints only when less restrictive interventions have been determined to be ineffective to protect one of three sampled patients (Patient 16) when the facility tied Patient 16’s arms with a bed sheet while in bed without first attempting less restrictive measures. This failure resulted in Patient 16’s rights being violated and placed Patient 16 at risk of injury or death. (Refer to A-0164) 4. Based on observation, interview, and record review, the facility failed to create a personalized plan of care for the use of restraints for one of three sampled patients (Patient 16) when the facility immobilized Patient 16’s arms with a bed sheet preventing Patient 16’s from moving his arms freely, but did not create a plan of care indicating when and how to apply and remove the restraint and the monitoring needed to prevent harm from the use of the restraint. This failure resulted in Patient 16’s rights being violated and placed Patient 16 at risk of injury or death. (Refer to A-0166) 5. Based on observation, interview, and record review, the facility failed to apply safe and appropriate restraints techniques to one of three sampled patients (Patient 16) when the facility immobilized Patient 16’s arms with a bed sheet preventing Patient 16’s from moving his arms freely, an unapproved restraint technique. This failure resulted in Patient 16’s rights being violated and placed Patient 16 at risk of injury or death. (Refer to A-0167) 6. Based on observation, interview, and record review, the facility failed to ensure the use of restraints was implemented in accordance with a clear physician’s order for one of three sampled patients (Patient 16). The facility immobilized Patient 16’s hands/arms with a bed sheet preventing Patient 16’s from moving his arms freely without obtaining a valid physician order authorizing the application of this restraint. This failure resulted in Patient 16’s rights being violated and placed Patient 16 at risk of injury or death. (Refer to A-0168) 7. Based on interview and record review, the facility failed to discontinue seclusion [the involuntary confinement of a patient alone in a room or area from which they are physically prevented from leaving] at the earliest possible time for one of three sampled patients (Patient 17) when Patient 17 was kept in seclusion after she no longer exhibited violent or self-destructive behavior. This failure resulted in Patient 17’s rights being violated and increased Patient 17’s risk of injury and death. (Refer to A-0174) 8. Based on interview and record review, the facility failed to ensure ten of ten sampled staff (Licensed Vocational Nurse (LVN) 1, Registered Nurse (RN) 1, RN 2, RN 3, Mental Health Worker (MHW) 1, MHW 2, MHW 3, MHW 4, MHW 5, MHW 6) working in the Psychiatric Unit (PU) demonstrated competency in the application of restraints and implementation of seclusion [the involuntary confinement of a patient alone in a room or area from which they are physically prevented from leaving] upon hire as part of their orientation. This failure placed patients at risk of having their rights violated and risk of injury and death from improper application of restraints and seclusion. (Refer to A-0196) The cumulative effects of these systemic problems resulted in the failure of the hospital to ensure all patients’ rights were protected and care was provided in a safe setting in compliance with the Condition of Participation for PATIENT’S RIGHTS.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 40358 The hospital failed to meet the regulatory requirement for the Condition of Participation: CFR 482.42 INFECTION PREVENTION AND CONTROL AND ANTIBIOTIC STEWARDSHIP PROGRAMS as evidenced by the following: 1. Based on interview and record review, the facility failed to ensure the Infection Prevention and Control Program (IPCP - a system of policies, procedures, and practices designed to prevent/control the spread of infections) provided effective ongoing monitoring when the Infection Control Nurse (ICN) was not qualified by education, experience, and certified in infection prevention and control. This failure resulted in inadequate infection prevention and control oversight which jeopardized the safety and well-being of patients and staff (Refer to A-0748) 2. Based on observation, interview, and record review, the facility failed to ensure a system was in place for identifying, reporting, investigating, and controlling infections and communicable diseases in accordance with hospital policies, national standards and/or state building codes when: The Infection Prevention and Control Program (IPCP - a system of policies, procedures, and practices designed to prevent/control the spread of infection) failed to ensure the emergency eyewash station was positioned away from the decontamination (the removal of dangerous substances and germs) sink in the high-level disinfection (HLD, a process that kills all microbial organisms but not necessarily large numbers of bacterial spores) decontamination workroom. The IPCP failed to designate a supervisor for the Sterile Processing Department (SPD - an area of a health care facility where devices are decontaminated, cleaned, inspected, assembled into trays, and prepared for high-level disinfection and/or sterilization) and Endoscope Department (ED - a procedure area in the hospital where doctors use a thin, flexible tube with a camera and light to look inside a patient’s body, the instruments are cleaned and stored) that was qualified by training, experience, and certified in accordance with national standards. The IPCP failed to ensure clean gastrointestinal endoscopes (GI scopes - thin flexible tubes with a light and a camera used to examine the inside of the digestive tract) were stored in a clean environment and the storage cabinet was in a space compliant with the manufacturer’s instructions for use (IFU’s) and National Infection Control Standards (American National Standards Institute [ANSI]/Advancement of Medical Instrumentation [AAMI] - a non-profit organization that develops and publishes standards, guidance, and other technical documents to improve patient safety and healthcare outcomes in the medical device industry) which the hospital followed. The IPCP failed to ensure two of two new steam sterilizers were installed in the SPD according to statewide building code standards and Department of Health Care Access (HCAI - a California state agency that checks hospitals to make sure their buildings and equipment are safe for patients and workers) requirements. These failures increased the risk for the spread of communicable diseases (illnesses that can spread from one person to another) and cross-contamination (the transfer of harmful bacteria from one person, object, or place to another) thereby adversely affecting the health and safety of patients and staff in the hospital. (Refer to A-749) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure provision of quality health care in a safe environment in compliance with the Condition of Participation for INFECTION PREVENTION AND CONTROL AND ANTIBIOTIC STEWARDSHIP PROGRAMS.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 39356 The hospital failed to meet the regulatory requirements for the Condition of Participation: CFR 482.51 SURGICAL SERVICES as evidenced by the following: Based on observation and record review: 1. The facility failed to ensure a functional steam sterilizer (device such as an autoclaves that eliminates all forms of microbial life including bacteria, viruses and spores) was available on the day of a scheduled surgery (2/24/26) for one of one sampled patient (Patient 1). This failure resulted in the cancellation of Patient 1’s scheduled surgery, unnecessary medical treatments (blood sugar testing and insertion of intravenous [IV] line), emotional distress and had the potential for compromising Patient 1’s safety due to contamination risk. 2. The facility failed to ensure one of one sampled Sterile Processing Department Technician (SPDT) was in-serviced and competent in using new sterilizing (make something free from bacteria) equipment prior to its use. This failure had the potential for exposure of pathogens (germs) to patients and staff. 3. The facility failed to ensure one of two sampled Surgical Technician (ST) 1 was competent to perform sterilization of surgical instruments. This failure had the potential for exposure of pathogens to patients and staff. The cumulative effects of these systemic failures had the potential to negatively impact the health and safety of all patients seeking surgical services at the facility in compliance with the Condition of Participation for SURGICAL SERVICES. Findings 1. During a review of the hospital’s “Leak Test (LT - for a sterilizer it is a mandatory daily diagnostic procedure that measures the airtight integrity of the chamber and plumbing. The test verifies that seals, gaskets, and pipes are in good condition to prevent sterilization failure caused by air leaks)” dated 2/24/26 at 4:39 a.m., the LT indicated, “Insufficient Vac (vacuum) level to perform leak test.” During a review of Patient 1’s “Preoperative [Preop is the area where the patient is prepared for surgery] Record” (PR) dated 2/24/26, the PR indicated, Patient 1’s arrival time was 2/24/26 at 7:31 a.m. During a review of Patient 1’s “Surg [Surgical]) Admission Assessment (SAA) dated 2/24/26 at 8:02 a.m., the SAA indicated, “IV [intravenous (through the vein)] started at 8:31 a.m., Finger Stick Blood Sugar (FSBS) at 8:39 a.m., and Surgical Consent signed at 9:03 a.m.” During a review of Patient 1’s “Consent for Surgery and Procedure (CS)” dated 2/24/26 at 9 a.m., the CS indicated Patient 1’s operation to be performed was “Laparasopic Cholecystectomy [a surgery to remove the gallbladder. This surgery uses a Laparasopic, a tool that is inserted through small incisions to see inside the abdomen and remove the gallbladder].” During a review of Patient 1’s PR dated 2/24/26, the PR indicated, “9:07 a.m. - returned to Preop area by staff. 9:40 - Surgeon 1 at bedside, reason for canceling case explained, verbalized understanding. IV left wrist . . . dc’d [discontinued] . . . Ambulated to lobby, . . . Tears in eyes.” During an interview on 3/10/26 at 11:50 a.m. with Surgeon 1, Surgeon 1 stated she was told right before the surgical case for Patient 1 there was a substance which looked like blood on a pair of scissors, and there was no back up sterilized equipment for the case for Patient 1. Surgeon 1 stated she was unaware the sterilizer was not working. During an interview on 3/10/26 at 11:58 p.m. with Operating Room Registered Nurse (ORRN), ORRN stated the hospital did not have a sterilizer that was working on the day of a scheduled surgical case on 2/24/26 and there were no back up instruments in case the instruments utilized during the case were contaminated. During an interview on 3/10/26 at 12:02 p.m. with Surgical Technician (ST) 2, ST 2 stated there was a group text to the surgical staff team on 2/24/26 at 6:30 a.m. regarding the issues of the sterilizer not working. ST 2 stated our supervisors were aware of the non functioning sterilizer. ST 2 stated the supervisors asked the surgical team if they had the equipment needed to complete the case. ST 2 stated she felt uncomfortable with beginning the surgical case without any backup equipment. ST 2 stated, she began setting up her sterile field (a field used in the operating room to reduce the number of microbes present) and opening her instruments when she noted a dark brown spot, the size of a pen cap, on a pair of scissors. ST 2 stated when this was noted the supervisors canceled the surgery. During an interview on 3/10/26 at 2:12 p.m. with Chief Administration Officer (CAO) and Director of Operations (DOO), DOO stated there was no working sterilizers on the day of surgery for Patient 1. DOO stated there was multiple reasons for the cancellation of the surgery. DOO stated the case was canceled when the dark brown substance was found on the instrument. CAO stated surgical cases should not be started without a working sterilizer. During an interview on 3/10/26 at 2:32 p.m. with ORRN, ORRN stated he was aware there were multiple failed attempts (leak tests) of the sterilizer on the early morning of 2/24/26. ORRN stated around 6:30 a.m., the DOO was aware of no functioning sterilizer in the hospital. ORRN stated he wanted to let Surgeon 1 be aware of the situation as he felt Surgeon 1 would not want to begin the case without any back up equipment. ORRN stated they were bringing back Patient 1 to the operating room when ST 2 stated there was what appeared to be dried blood (dark brown color) on a instrument and as a result Patient 1’s surgery was canceled. During an interview on 3/11/26 at 8:40 a.m. with Sterile Processing Lead Tech (SPLT), SPLT stated there was no sterilizer working on 2/24/26. SPLT stated he ran at least 5 or 6 tests (leak test) and they all failed as there was not sufficient vacuum. SPLT stated he texted the DOO, and the surgical team around 6 a.m. on 2/24/26. SPLT stated he was unaware if cases were started and stated no cases should begin without a back up sterilizer. During an interview on 3/11/26 at 1:18 a.m. with Chief Nursing Officer(CNO), CNO stated she was unaware on 2/24/26 there was no sterilizing equipment available. CNO stated she found out after the case was canceled. CNO stated no surgeries should be started without a sterilizer. CNO stated the hospital follows state regulations and no acute hospital should run a operating room without a sterilizer that is working. During a review of the hospital’s policy and procedure (P&P) titled, “Processing Instruments for the Operating Room” dated, 5/25/23, the P&P indicated, “Purpose: To reduce the risk of the patient acquiring nosocomial infections. Sterilization provides the assurance that an object is free of viable microbes.” 2. During an interview on 3/9/26 at 10:40 a.m. with SPDT and DOO, SPDT stated he had just started employment at the hospital on 2/17/26. SPDT stated sterilizer #1 stopped working on 2/18/26 and sterilizer # 2 stopped working on 2/24/26. SPDT stated two new sterilizers arrived on 2/21/26 and 2/28/26 and the biomed inspections (testing equipment before use to ensure patient safety, verify device accuracy and maintain regulatory compliance) were completed on 2/26/26 and 3/2/26. DOO stated no surgeries, requiring sterilization, were completed between 2/24/26 to 2/26/26 and no surgeries requiring sterilization equipment were initiated until after 2/26/26. During a review of the hospital’s “Unscheduled Work Order (WO)” dated 2/26/26, the WO indicated, “Steam Sterilizer Services Performed dated 2/26/26 Incoming Inspection. [biomed inspection of equipment required before its use].” During a review of the hospital’s WO, dated 3/2/26, the WO indicated, “Steam Sterilizer Services Performed dated 3/2/26 Incoming Inspection.” During a concurrent interview and record review on 3/11/26 at 10 a.m. with Quality/Risk Director (QRD), the hospital’s ‘In-Service & Training (IST)” document for 2/23/26 and 3/3/26 and “[name of sterilizer] Sterilizer In-Service (SSIS)” undated were reviewed. QRD stated these training documents for the new sterilizing equipment were incomplete. QRD stated the IST conducted on 2/23/26 and 3/3/26 does not indicate who completed the training and the SSIS form was blank. During a concurrent interview and record review on 3/11/26 at 10:06 a.m. with SPDT and QRD, the IST dated 2/23/26 and 3/3/26 and SSIS were reviewed. SPDT stated the SSIS looks like a checklist and SPDT stated he has never seen this checklist, and the [name of sterilizer company] technician (unnamed) went over a few things and asked if we had any questions. SPDT stated there were no return demonstrations to ensure SPDT was competent to use the new sterilizers. During a concurrent interview and record review on 3/11/16 at 1:35 p.m. with Chief Nursing Officer (CNO), the IST dated 2/23/26 and 3/3/26 and SSIS undated were reviewed. CNO stated these forms do not include the information required to indicate staff were trained and competent in the use of the new sterilzing equipment and the SISS was just a checklist but was blank with no indication of training or competency from any staff. During a review of the hospital’s “Position Description (PD)” titled Central Supply Technician dated 1/27/26 signed by SPDT. The PD indicated, “Position Summary Under the general supervision of the Nurse Manager, Surgery Department, the Central Supply Technician is responsible for planning, organizing, and directing in the daily activities of the Central Supply department to provide for processing instrument trays and other supplies necessary for surgical procedures and for other within the facility. Essential Functions *Cleans,organizes and sterilizes instruments and equipments required by the surgery department to ensure ready availability for any procedure. Applies knowledge of specialized instruments, equipments and supplies utilized for patient care in the surgical department. Applies basic knowledge of infection control principles in the cleaning, disinfecting and stocking of all sterile equipment and supplies. *Utilizes all sterilization equipment (autoclave, flasher, steris, sterrad, etc.) in accordance with operational standards.” During a review of the facility’s policy and procedure (P&P) titled, “Staff Competency (SC)” dated 2/20/25, the SC indicated, “Purpose: To Establish a standardized process for assessing and documenting staff competency at established times and intervals to minimize risk of harm to patients, maintain a consistently high quality of care, and comply with laws and regulations. . . Performing Competency Assessments . . . The individual performing the competency assessment does the following: 1. Performs initial and ongoing competency assessments according to established schedules. 2. Identifies activities that allow the staff member to demonstrate the required competencies defined in the Staff List. 4. Uses one or more of the following methods to perform the assessment: *Observing the staff member performing the identified activities. *Asking the staff member questions intended to clarify or explain actions or demonstrate knowledge. *Seeking input from patients, staff members, and others who interact with the staff member during the competency assessment, as appropriate. * Using a written or oral examination *Other methods, as appropriate 7. Documents the competency assessment on the appropriate competency checklist including the follow details: *Name of the staff member * Name of the individual performing the assessment *Date(s) the assessment was completed *Activities related to job duties and responsibilities that were performed as part of the assessment *Observations related to the new staff member’s safe and effective performance of job duties and responsibilities *Result of the assessment (such as an individual found to be satisfactory or unsatisfactory for each assessed competency).” 3. During a review of Patient 1’s “Laparoscopy Tray (LT is a specialized, perforated container used to organize, protect, and sterilize delicate instruments during autoclaving [sterilize in an autoclave (sterilizer)], transportation and storage) dated 2/16/26, LT indicated, ST 1 had assembled the Fluoroscopy (an imaging technique that uses continuous x-rays) tray utilized on the date of surgery 2/24/26 (for Patient 1’s surgery on 2/24/26 with noted dark brown spots on instruments). During a review of Patient 1’s “Record Keeping Sheet (RKS - list of sterilized equipment used in Patient 1’s surgery on 2/24/26)” dated 2/16/26, the RKS indicated, ST 1 had sterilized the instruments that were used in Patient 1’s surgical procedure on 2/24/26 (with noted dark brown spots on instruments and subsequent cancellation.) During a concurrent interview and record review on 3/9/26 at 2:47 p.m. with ST 1 and QRD, Patient 1’s LT and RKS dated 2/16/26 were reviewed. ST 1 stated she had assembled and sterilized the instruments for the surgical case for Patient 1’s surgical procedure (on 2/24/26). ST 1 stated she was not certified in sterile processing (a critical healthcare function responsible for cleaning, disinfecting, sterilizing, storing and maintaining reusable surgical medical instruments) and has never worked in a sterile processing department (an area in the hospital used to clean, disinfect, sterilize, store, and maintain the reusable surgical medical instruments). ST 1 stated an employee who worked previously, provided her some training. ST 1 stated she had voiced her opinion against working in the sterile processing department but was told to step it up and help out by her previous manager. ST 1 stated she was told, a surgical technician has the skills to work in the sterile processing department. QRD stated this should not have happened and she has told staff to not do anything if they are not trained and competent. During a review of the facility’s policy and procedure (IP&IP) titled, “Staff Competency (SC)” dated 2/20/25, the SC indicated, “Purpose: To Establish a standardized process for assessing and documenting staff competency at established times and intervals to minimize risk of harm to patients, maintain a consistently high quality of care, and comply with laws and regulations. . . Performing Competency Assessments . . . The individual performing the competency assessment does the following: 1. Performs initial and ongoing competency assessments according to established schedules. 2. Identifies activities that allow the staff member to demonstrate the required competencies defined in the Staff List. 4. Uses one or more of the following methods to perform the assessment: *Observing the staff member performing the identified activities. *Asking the staff member questions intended to clarify or explain actions or demonstrate knowledge. *Seeking input from patients, staff members, and others who interact with the staff member during the competency assessment, as appropriate. * Using a written or oral examination *Other methods, as appropriate 7. Documents the competency assessment on the appropriate competency checklist including the follow details: *Name of the staff member * Name of the individual performing the assessment *Date(s) the assessment was completed *Activities related to job duties and responsibilities that were performed as part of the assessment *Observations related to the new staff member’s safe and effective performance of job duties and responsibilities *Result of the assessment (such as an individual found to be satisfactory or unsatisfactory for each assessed competency).””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(A) Definitions. (i) A restraint is- (A) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or This Standard is not met as evidenced by: 37797 Based on observation, interview, and record review, the facility failed to identify and treat the immobilization of one of three sampled patient’s (Patient 16) arms with a bed sheet as a restraint. Staff tied a bed sheet around Patient 16’s arms in a manner that restricted his ability to move freely, but they did not classify this action as a restraint. This failure resulted in a violation of Patient 16’s right and placed Patient 16 at risk of injury or death. Findings: During a review of Patient 16’s “Patient Information” sheet (PI), undated, the PI indicated Patient 16 was admitted to the facility’s Psychiatric Unit (PU) on 2/13/26 with an admission reason of “DTS” [danger to self is defined as a situation where an individual poses an imminent risk of serious physical harm to themselves, typically resulting from a mental disorder or an acute psychiatric crisis]. During a review of Patient 16’s “History and Physical” (H&P) dated 2/14/26, the H&P indicated Patient 16 had a diagnosis of Paranoid Schizophrenia (a chronic mental disorder characterized by intense, irrational suspicions (paranoia), along with auditory hallucinations (hearing voices) and delusions (false beliefs) such as feeling watched or plotted against, severely affecting thinking abilities, memory and senses. During an interview on 3/11/26 at 9:30 a.m. with Confidential Witness 1 (CW 1), CW 1 stated she witnessed staff restraining Patient 16 with bed sheets around his wrists, in his PU room. CW 1 stated staff tied Patient 16’s hands together with a bed sheet while in bed. CW 1 stated staff then covered Patient 16 with a blanket in bed to conceal the restraint. During an observation on 3/11/26 at 1:10 p.m. in the facility’s PU, Patient 16 was in his room lying in his bed covered by a blanket and observed by Mental Health Worker (MHW) 1. MHW 1 removed the blanket which revealed Patient 16’s hands tied together with a bed sheet. The bed sheet was tied to Patient 16’s arms with blind knots on the wrists and the forearms and then both arms were tied together with additional blind knots. MHW 1 untied the knots and removed the bed sheet around Patient 16’s arms. During an interview on 3/11/26 at 1:10 p.m., with PU Assistant Manager (PUAM), PUAM stated the bed sheet was a “coping mechanism” that made Patient 16 “feel safe” and was applied at Patient 16’s request to prevent Patient 16 from hitting himself with his hands. PUAM denied the bed sheets tied around the patient’s wrists and forearms was restraint, because Patient 16 could remove the bed sheet at will. During a concurrent interview and record review on 3/11/26 at 1:15 p.m. with the PUAM, Registered Nurse (RN) 3 (Patient 16’s nurse) and Quality/Risk Director (QRD), QRD and RN 3 stated staff tied Patient 16’s hands with a bed sheet, while in bed, to prevent him from punching himself and injuring his face. The staff have been tying the patient since 2/18/26. QRD and RN 3 stated it was not a restraint because Patient 16 requested the bed sheet to be tied around his wrists and arms and Patient 16 could remove the bed sheet at will. QRD and RN 3 were asked for documented evidence Patient 16 could remove the bed sheet at will. No documented evidence was provided that Patient 16 could remove the bed sheet at will. During an interview on 3/11/26 at 1:30 p.m. with Medical Doctor (MD) 1, MD 1 stated Patient 16 was under his care and he had approved the use of the bed sheet to immobilize Patient 16’s arms. MD 1 stated Patient 16 had behaviors of hitting his face with his hands and wrapping his hands with a bed sheet which protected him from self-harm. MD 1 denied the use of the bed sheet was a restraint because the bed sheet was applied at Patient 16’s request and Patient 16 could remove the bed sheet at any time. During an interview on 3/11/26 at 1:55 p.m. with the Chief Nursing Officer (CNO), CNO was asked for the definition of a restraint and stated a restraint was “anything that restricts body movement.” CNO was asked if she thought Patient 16 could independently remove the bed sheet and free his arms. CNO stated, “It [referring to untying the bed sheets from his arms] would be hard”. During a concurrent interview and observation on 3/11/26 at 2 p.m. with MHW 1 in Patient 16’s room, MHW 1 stated she tied Patient 16’s hands with a bed sheet after lunch per the patient’s request. MHW 1 stated the bed sheet was applied one to two times daily whenever Patient 16 asked, “Can you tie my hands?”. MHW 1 stated Patient 16 called it, “my bonding.” MHW 1 stated Patient 16 was able to remove the bed sheet and free his hands at any time. MHW 1 then asked Patient 16 if he wanted to have his “bonding”. Patient 16 was in a catatonic state (immobility, silence, rigidity, unresponsive to external stimuli - common in patients with Schizophrenia) and remained motionless and mute. MHW 1 took a bed sheet and tied a blind knot on each wrist of Patient 16 and tied both his hands with an additional blind knot using the same bed sheet. Patient 16 looked as if he had been handcuffed. MHW 1 asked Patient 16 to remove the bed sheet and free his hands. Patient 16 remained motionless and started speaking in monotone (without intonation or expressiveness), “There is nothing in the world I care about ... There is nothing in the world I care about... There is nothing in the world I care about...” Patient 16 made no attempt to follow MHW 1’s direction to remove the bed sheet and free his hands. During an interview on 3/11/26 at 2:20 p.m. with MD 2, MD 2 stated he co-chaired the PU with MD 1 and was familiar with Patient 16 and the use of the bed sheet to tie his arms. MD 2 denied it was a restraint. MD 2 stated the bed sheet was applied at Patient 16’s request and was removed any time Patient 16 requested. MD 2 stated Patient 16’s bed sheet was a “voluntary restraint.” MD 2 stated wrapping Patient 16’s hands with a bed sheet provided comfort to Patient 16 akin to a patient wearing earmuffs or a child holding a teddy bear. MD 2 stated the bed sheet prevented Patient 16 from injuring himself and was used instead of restraints and seclusion to manage his self-injury behavior. During a review of the American Psychiatric Association (APA) Resource Document titled “Seclusion [the involuntary confinement of a patient alone in a room or area from which they are physically prevented from leaving] or Restraint” (APA Resource Document), dated February 2022, the APA Resource Document indicated, “Seclusion or Restraint (S/R) is used as an intervention of last resort... These interventions carry considerable risks including, but not limited to, psychological distress, personal injury to the patient or staff, and/or death ... S/R should only be used as interventions of last resort to prevent harm to patients or others, when less restrictive means have failed (e.g. verbal de-escalation, environmental interventions, oral medications...) and for the least amount of time necessary...” During a review of facility policy and procedure (P&P) titled “Restraints” dated 2/13/26, the P&P indicated: “Definitions ... Restraints ... Physical: a physical restraint is any manual method, physical device of mechanical device, material, or equipment attached or adjacent to the patient’s body that he or she cannot easily remove and restricts freedom of movement or normal access to one’s body (i.e.: leg/arm restraints, hand mitts, soft ties or vests, lap cushions or lap trays, bed rails).” “In its broadest context, restraint is any method of restricting a patient’s freedom of movement, physical activity, or normal access to his or her body.” “Restraint or seclusion may only be used when less restrictive means is not sufficient to protect the physical safety of patients, staff members or others...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(ii) Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior. This Standard is not met as evidenced by: 37797 Based on observation, interview, and record review, the facility failed to ensure seclusion [the involuntary confinement of a patient alone in a room or area from which they are physically prevented from leaving] was only used for the management of violent or self-destructive behavior that jeopardized the immediate physical safety of the patient, staff or others, for one of three sampled patients (Patient 17) when Patient 17 was placed in seclusion for non-violent and non self-destructive behavior such as restlessness, agitation, yelling, screaming, cursing, being loud, disrobing and others. This failure resulted in Patient 17’s rights being violated and placed Patient 17 at risk of injury and death. Findings: During a review of Patient 17’s “Patient Information” sheet (PI), undated, the PI indicated Patient 17 was admitted to the facility’s Psychiatric Unit (PU) on 2/27/26 with an admission reasons of “DTS” [danger to self is defined as a situation where an individual poses an imminent risk of serious physical harm to themselves, typically resulting from a mental disorder or an acute psychiatric crisis ], “DTO” [danger to others is defined as a substantial likelihood, probability, or imminent risk that a patient will inflict serious physical harm or injury upon another person, often stemming from a mental disorder] and “GD” [grave disability is defined as a condition in which a person, as a result of a mental health disorder or a severe substance use disorder, is unable to provide for their basic personal needs for food, clothing, or shelter]. During a review of Patient 17’s “History and Physical” (H&P) “Admit Date 2/27/26”, the H&P indicated Patient 17 had a diagnosis of Schizoaffective Disorder Bipolar (a chronic mental health condition combining schizophrenia symptoms-like hallucinations [vivid sensory perceptions such as hearing, seeing, smelling, touching, or tasting things, that occur without external stimuli but feel profoundly real to the individual], delusions [false belief], or disorganized thinking with major mood episodes, specifically mania (highs) and sometimes depression). During a concurrent observation and interview on 3/9/26 at 11:35 a.m. with the Quality/Risk Director (QRD) in the PU, QRD showed the PU’s seclusion room. The seclusion room was a small, unfurnished, windowless, locked room, with a single concrete bed in the center. The bed was topped with a mattress and a clearance of a few feet around the bed. Adjoining the seclusion room was a small bathroom. QRD indicated this was the room used for seclusion of patients, where patients were kept locked and isolated for the management of behaviors. During a review of the PU’s “Restraint/Seclusion” log (RSL) (a spreadsheet indicating all patients put in restraints or seclusion) from 2/27/26 to 3/8/26, the RSL indicated Patient 17 had been placed in seclusion a total of 32 times during the period. The RSL indicated Patient 17’s seclusion periods were up to eight hours each time. During an interview on 3/9/26 at 12:15 p.m. with Patient 17, Patient 17 was crying and stated, “I don’t like that I have been locked up so many times [referring to being placed in the seclusion room].” During a concurrent interview and record review on 3/10/26 at 3:30 p.m. with the Chief Nursing Officer (CNO), the “Restraint/Seclusion Order Form” (RSOF) was reviewed. CNO stated the RSOF was a form completed whenever patients were placed in seclusion. The RSOF indicated, “Restraint/Seclusion Orders for Behavioral Management (Emergency Use Only) - The patient is exhibiting violent or self-destructive behavior that jeopardizes the safety of the patient, a staff member, or others.” CNO indicated seclusion could only be used for management of violent or self-destructive behavior. CNO stated “violent behavior” meant a patient was engaged in actual violence or was threatening violence towards others and “self-destructive behavior” meant self-harm, when a patient was hitting or physically hurting themselves. During a concurrent interview and record review on 3/10/26 at 3:40 p.m. with QRD, Patient 17’s “Restraints/Seclusion” packets (RSP) were reviewed. QRD stated the RSPs contained the documentation concerning the application of seclusion on patients. The RSPs included the RSOF (where staff documented the date and time of the seclusion was initiated), the “Official Record of Statutory Rights of Patients form” (ORSR - where staff documented the reasons for the initiation of seclusion) and the “Restraint/Seclusion Flow Sheet form” (RSFS - where staff documented the patient’s behaviors while in seclusion justifying the maintenance of seclusion). QRD stated documentation of restraints and seclusion was also found in the nursing notes (NN) on the computer system. A review of Patient 17’s RSPs and nursing notes indicated the following instances of seclusion was implemented without evidence of violent or self-destructive behavior: 1. During a review of RSOF dated 2/28/26 at 6 a.m., RSOF indicated Patient 17 was put in seclusion on 2/28/26 at 6 a.m. During a review of ORSR dated 2/28/26, ORSR indicated, “Restriction Imposed: seclusion. Explanation of ‘good cause’ for denial of rights, placement in seclusion: ‘Patient [2] was yelling in the unit, tried to go to other patients’ room. Disrobing. Wants to go home. Nonredirectable.” During a review of NN dated 2/28/26 at 6 a.m., NN indicated, “Patient [17] awake [sic] up and start cursing to staff, going to other patient’s room, disrobing, loud in unit, disrupting the unit... Patient is in the [sic] seclusion.” QRD was asked to indicate the violent or self-destructive behavior displayed by Patient 17 used to justify this seclusion. QRD was unable to provide documented evidence Patient 17 displayed violent or self-destructive behavior. 2. During a review of RSOF dated 3/3/26 at 9:30 a.m., RSOF indicated Patient 17 was put in seclusion on 3/3/26 at 9:30 a.m. During a review of ORSR dated 3/3/26, ORSR indicated, “Restriction Imposed: seclusion. Explanation of ‘good cause’ for denial of rights, placement in reclusion: ‘Patient [2] was highly agitated and restless screaming loudly disrobing unable to follow verbal redirection due to ongoing behavior reclusion for safety’.” During a review of NN dated 3/3/26 at 9:48 a.m., the NN indicated, “[Patient 17] observed to be highly agitated, anxious, irritable, and restless, exhibiting unpredictable behavior. [Patient 17] disrobed self and began screaming and yelling loudly in the quiet room. Attempts at verbal redirection and de-escalation were unsuccessful.” QRD was asked to indicate the violent or self-destructive behavior displayed by Patient 17 used to justify this seclusion. QRD was unable to provide documented evidence Patient 17 displayed violent or self-destructive behavior. 3. During a review of RSOF dated 3/4/26 at 6 a.m., RSOF indicated Patient 17 was put in seclusion on 3/4/26 at 6 a.m. During a review of ORSR dated 3/4/26, ORSR indicated, “Restriction Imposed: seclusion. Explanation of ‘good cause’ for denial of rights, placement in reclusion: ‘Patient [2] seen yelling, screaming, making delusional statements, disrobing, disrupting the unit.” During a review of NN dated 3/4/26 at 6:03 a.m., the NN indicated, “[Patient 17] is disrupting the unit, disrobing in the unit, making incoherent statements, making sexually inappropriate comments, yelling loudly, extremely agitated. MD was called and order for seclusion was obtained.” During a review of NN dated 3/4/26 at 6:34 a.m., NN indicated, “[Patient 17] received in the seclusion room due unpredictable behavior, including yelling, loud speech, screaming, and significant agitation... patient was pacing in the room and was undressed from the waist up... the patient was not verbally redirectable despite multiple attempts... She continued to display agitation, anxiety, irritability, and restlessness. Seclusion was continued at this time to maintain patient safety due to ongoing behaviors.” QRD was asked to indicate the violent or self-destructive behavior displayed by Patient 17 used to justify this seclusion. QRD was unable to provide documented evidence Patient 17 displayed violent or self-destructive behavior. 4. During a review of RSOF dated 3/8/26 at 3:30 a.m., RSOF indicated Patient 17 was put in seclusion on 3/8/26 at 3:30 a.m. The ORSR indicated, “Restriction Imposed: seclusion. Explanation of ‘good cause’ for denial of rights, placement in reclusion: ‘Observed [Patient 17] extremely agitated and yelling profanities towards staff. Patient was observed [illegible] and paranoid, delusional yelling “quiet on set [expletive]’ Glasses of 1:1 [one on one] staff were observed on the floor broken’.” During a review of NN dated 3/8/26 at 5:04 a.m., NN indicated, “At 0316 [3: 16 a.m.] heard a commotion on the quiet room. [Patient 17] yelling and screaming profanities to staff on the 1:1. Observed patient extremely agitated and yelling profanities. [Patient 17] was observed paranoid, delusional, responding to internal stimuli, making threats to staff, yelling quite on set. Glasses of 1:1 staff observed to be on the floor broken’.” QRD was asked to indicate the violent or self-destructive behavior displayed by Patient 17 used to justify this seclusion. QRD was unable to provide documented evidence Patient 17 displayed violent or self-destructive behavior. During a review of the American Psychiatric Association (APA) Resource Document titled “Seclusion or Restraint” (APA Resource Document), dated February 2022, the APA Resource Document indicated, “Seclusion or Restraint (S/R)... carry considerable risks including, but not limited to, psychological distress, personal injury to the patient or staff, and/or death ... S/R should only be used as interventions of last resort to prevent harm to patients or others, when less restrictive means have failed (e.g. verbal de-escalation, environmental interventions, oral medications ...) and for the least amount of time necessary...” During a review of the facility’s policy and procedure (P&P) titled, “Restraints” dated 2/13/26, the P&P indicated, “Seclusion should only be used for the management of violent or self-destructive behavior.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 37797 Based on observation, interview, and record review, the facility failed to apply restraints only when less restrictive interventions have been determined to be ineffective to protect one of three sampled patients (Patient 16) when the facility tied Patient 16’s arms with a bed sheet while in bed without first attempting less restrictive measures. This failure resulted in Patient 16’s rights being violated and placed Patient 16 at risk of injury or death. Findings: During a review of Patient 16’s “Patient Information” sheet (PI), undated, the PI indicated Patient 16 was admitted to the facility’s Psychiatric Unit (PU) on 2/13/26 with an admission reason of “DTS” [danger to self - defined as a situation where an individual poses an imminent risk of serious physical harm to themselves, typically resulting from a mental disorder or an acute psychiatric crisis]. During a review of Patient 16’s “History and Physical” (H&P) dated 2/14/26, the H&P indicated Patient 16 had a diagnosis of Paranoid Schizophrenia (a chronic mental disorder characterized by intense, irrational suspicions (paranoia), along with auditory hallucinations (hearing voices) and delusions (false beliefs) such as feeling watched or plotted against, severely affecting one’s thinking abilities, memories and senses. During an interview on 3/11/26 at 9:30 a.m. with Confidential Witness 1 (CW 1), CW 1 stated she has witnessed Patient 16 restrained with bed sheets in his room, which is located in the PU. CW 1 stated staff tied Patient 16’s hands together with a bed sheet while in bed. CW 1 stated staff covered Patient 16 with a blanket in bed to conceal the restraint. During an observation on 3/11/26 at 1:10 p.m. in the facility’s PU, Patient 16 was in his room lying in his bed covered by a blanket and being observed by Mental Health Worker (MHW) 1. MHW 1 removed the blanket which revealed Patient 16’s hands tied together with a bed sheet. The bed sheet was tied to Patient 16’s arms with blind knots on the wrists and the forearms and then both arms were tied together with additional blind knots. MHW 1 untied the knots and removed the bed sheet from Patient 16’s arms. During an interview on 3/11/26 at 1:10 p.m. with PU Assistant Manager (PUAM), PUAM stated the bed sheet was a “coping mechanism” that made Patient 16 “feel safe” and was applied at Patient 16’s request to prevent Patient 16 from hitting himself with his hands. PUAM denied it was restraint because Patient 16 could remove the bed sheet at will. During a concurrent interview and record review on 3/11/26 at 1:15 p.m. with PUAM, Registered Nurse (RN) 3 (Patient 16’s nurse) and Quality/Risk Director (QRD), QRD and RN 3 stated staff tie Patient 16’s hands with a bed sheet while in bed to prevent him from punching himself and injuring his face. Staff have been tying Patient 16’s arms with bed sheets since 2/18/26. QRD and RN 3 stated it was not a restraint because Patient 16 requested the bed sheet and Patient 16 could remove it at will. QRD and RN 3 were asked if alternative less restrictive methods for managing Patient 16’s self-injurious behavior were attempted, prior to tying his arms and hands with a bed sheet. RN 3 stated she attempted to provide Patient 16 hand towels for Patient 16 to hold to prevent the self-injurious behavior. RN 3 was asked for documentation this intervention was implemented and was found to be ineffective. None was provided. During a review of the “Code of Federal Regulations” (CFR), §482.13(e)(1) Definitions, the CFR indicated, “(i) A restraint is (A) any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely;” During a review of the American Psychiatric Association (APA) Resource Document titled “Seclusion or Restraint” (APA Resource Document), dated February 2022, the APA Resource Document indicated, “Seclusion or Restraint (S/R) is used as an intervention of last resort... These interventions carry considerable risks including, but not limited to, psychological distress, personal injury to the patient or staff, and/or death ... S/R should only be used as interventions of last resort to prevent harm to patients or others, when less restrictive means have failed (e.g. verbal de-escalation, environmental interventions, oral medications ...) and for the least amount of time necessary...” During a review of facility policy and procedure (P&P) titled “Restraints” dated 2/13/26, the P&P indicated, “Definitions ... Restraints ... Physical: a physical restraint is any manual method, physical device of mechanical device, material, or equipment attached or adjacent to the patient’s body that he or she cannot easily remove and restricts freedom of movement or normal access to one’s body (i.e.: leg/arm restraints, hand mitts, soft ties or vests, lap cushions or lap trays, bed rails).” “In its broadest context, restraint is any method of restricting a patient’s freedom of movement, physical activity, or normal access to his or her body.” “Restraint or seclusion may only be used when less restrictive means is not sufficient to protect the physical safety of patients, staff members or others...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 37797 Based on observation, interview, and record review, the facility failed to create a personalized plan of care for the use of restraints for one of three sampled patients (Patient 16) when the facility immobilized Patient 16’s arms with a bed sheet preventing Patient 16’s from moving his arms freely, but did not create a plan of care indicating when and how to apply and remove the restraint and the monitoring needed to prevent harm from the use of the restraint. This failure resulted in Patient 16’s rights being violated and placed Patient 16 at risk of injury or death. Findings: During a review of Patient 16’s “Patient Information” sheet (PI), undated, the PI indicated Patient 16 was admitted to the facility’s Psychiatric Unit (PU) on 2/13/26 with an admission reason of “DTS” [danger to self]. During a review of Patient 16’s “History and Physical” (H&P) dated 2/14/26, the H&P indicated Patient 16 had a diagnosis of Paranoid Schizophrenia (a chronic mental disorder characterized by intense, irrational suspicions (paranoia), along with auditory hallucinations (hearing voices) and delusions (false beliefs) such as feeling watched or plotted against), severely affecting one’s thinking abilities, memories and senses. During an interview on 3/11/26 at 9:30 a.m. with Confidential Witness 1 (CW 1), CW 1 stated she had witnessed Patient 16 restrained with bed sheets in his room in the PU. CW 1 stated staff tied Patient 16’s hands together with a bed sheet while in bed. CW 1 stated staff cover Patient 16 with a blanket in bed to conceal the restraint. During an observation on 3/11/26 at 1:10 p.m. in the facility’s PU, Patient 16 was in his room lying in his bed covered by a blanket and observed by Mental Health Worker (MHW) 1. MHW 1 removed the blanket which revealed Patient 16’s hands tied together with a bed sheet. The bed sheet was tied to Patient 16’s arms with blind knots on the wrists and the forearms and then both arms were tied together with additional blind knots. MHW 1 untied the knots and removed the bed sheet from Patient 16’s arms. During a concurrent interview with PU Assistant Manager (PUAM), PUAM stated the bed sheet was a “coping mechanism” that made Patient 16 “feel safe” and was applied at Patient 16’s request to prevent Patient 16 from hitting himself with his hands. PUAM denied it was restraint because Patient 16 could remove the bed sheet at will. During a concurrent interview and record review on 3/11/26 at 1:15 p.m. with the PU’s Assistant Manager (PUAM), Registered Nurse (RN) 3 (Patient 16’s nurse) and Quality/Risk Director (QRD), QRD and RN 3 stated staff tied Patient 16’s hands with a bed sheet while in bed to prevent him from punching himself and injuring his face since 2/18/26. QRD and RN 3 stated it was not a restraint because Patient 16 requested the bed sheet and Patient 16 could remove it at will. QRD and RN 3 stated a patient care plan was created for the use of the bed sheet and provided care plan (CP) titled “Address self-coping mechanism blanket for hands to prevent self har[m]” dated 3/11/26. The CP did not indicate that Patient 16’s hands were to be tied with a bed sheet, how they were to be tied, for how long, for what reasons and the monitoring needed. During an interview on 3/11/26 at 1:30 p.m. with Medical Doctor (MD) 1, MD 1 stated Patient 16 was under his care and he had approved the use of the bed sheet to immobilize Patient 16’s arms. MD 1 stated Patient 16 had behaviors of hitting his face with his hands and wrapping his hands with a bed sheet protected him from self-harm. MD 1 denied the use of the bed sheet was a restraint because the bed sheet was applied at Patient 16’s request and Patient 16 could remove the bed sheet at any time. During an interview on 3/11/26 at 1:55 p.m. with the Chief Nursing Officer (CNO), CNO was asked for the definition of a restraint and stated a restraint was “anything that restricts body movement.” CNO was asked if she thought Patient 16 could independently remove the bed sheet and free his arms. CNO stated, “It would be hard”. During a concurrent interview and observation on 3/11/26 at 2 p.m. with MHW 1 in Patient 16’s room, MHW 1 stated she had tied Patient 16’s hands with a bed sheet after lunch at his request. MHW 1 stated the bed sheet was applied one to two times daily whenever Patient 16 asked, “Can you tie my hands?”. MHW 1 stated Patient 16 called it, “my bonding.” MHW 1 stated Patient 16 was able to remove the bed sheet and free his hands at any time. MHW 1 asked Patient 16 if he wanted to have his “bonding”. Patient 16 was in a catatonic state (immobility, silence, rigidity, unresponsive to external stimuli - common in patients with Schizophrenia) and remained motionless and mute. MHW 1 took a bed sheet and tied a blind knot on each wrist of Patient 16 and tied both his hands with an additional blind knot using the same bed sheet. Patient 16 looked as if he had been handcuffed. MHW 1 asked Patient 16 to remove the bed sheet and free his hands. Patient 16 remained motionless and started speaking in monotone (without intonation or expressiveness), “There is nothing in the world I care about ... There is nothing in the world I care about... There is nothing in the world I care about...” During an interview on 3/11/26 at 2:20 p.m. with MD 2, MD 2 stated he co-chaired the PU with MD 1 and was familiar with Patient 16 and the use of the bed sheet. MD 2 denied it was a restraint. MD 2 stated the bed sheet was applied at Patient 16’s request and was removed any time Patient 16 requested. MD 2 stated Patient 16’s bed sheet was a “voluntary restraint.” MD 2 stated wrapping Patient 16’s hands with a bed sheet provided comfort to Patient 16 akin to a patient wearing earmuffs or a child holding a teddy bear. MD 2 stated the bed sheet prevented Patient 16 from injuring himself and was used instead of restraints and seclusion to manage his self-injury behavior. During a review of the “Code of Federal Regulations” (CFR), §482.13(e)(1) Definitions, the CFR indicated, “(i) A restraint is (A) any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely;” During a review of the American Psychiatric Association (APA) Resource Document titled “Seclusion or Restraint” (APA Resource Document), dated February 2022, the APA Resource Document indicated, “Seclusion or Restraint (S/R) is used as an intervention of last resort... These interventions carry considerable risks including, but not limited to, psychological distress, personal injury to the patient or staff, and/or death ... S/R should only be used as interventions of last resort to prevent harm to patients or others, when less restrictive means have failed (e.g. verbal de-escalation, environmental interventions, oral medications ...) and for the least amount of time necessary...” During a review of facility policy and procedure (P&P) titled “Restraints” dated 2/13/26, the P&P indicated: “Definitions ... Restraints ... Physical: a physical restraint is any manual method, physical device of mechanical device, material, or equipment attached or adjacent to the patient’s body that he or she cannot easily remove and restricts freedom of movement or normal access to one’s body (i.e.: leg/arm restraints, hand mitts, soft ties or vests, lap cushions or lap trays, bed rails). “In its broadest context, restraint is any method of restricting a patient’s freedom of movement, physical activity, or normal access to his or her body.” “Patients shall be monitored on an ongoing basis by staff members who are responsible for the patient’s assessment and evaluation. The observations and data collected during such monitoring shall be documented every 15 minutes at a minimum.” “Observe closely for signs of circulatory impairment, brush burns, redness, irritation, and edema [swelling]. As indicated, provide skin care using massage or lotion while the patient is restrained and when restraints are removed.” During a review of P&P titled “Nursing Diagnosis/Patient Problems/Care Plan”, dated 8/22/25, indicated: “The individualized patient care plan becomes a part of the permanent medical record. Patient care plans are legal records that provide documentation about the care administered, the patient’s response and revisions of the plan...” “A written patient care plan is developed for each hospitalized patient by use of the nursing process: a problem-solving method consisting of... planning, intervention [implementation], and evaluation...” “Planning:... develop interventions that are amenable to nursing and compatible with the medical plan of care.” “Implementation [intervention]: nurse interventions are actions, which the professional nurse enacts to help the patient reach his/her desired outcome goal(s)... Interventions reflect actions needed to resolve, diminish, or solve the patient’s problems.” “Evaluation: the purpose of evaluation is to assess the patient’s response to the nursing plan of care.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 37797 Based on observation, interview, and record review, the facility failed to apply safe and appropriate restraints techniques to one of three sampled patients (Patient 16) when the facility immobilized Patient 16’s arms with a bed sheet preventing Patient 16’s from moving his arms freely, an unapproved restraint technique. This failure resulted in Patient 16’s rights being violated and placed Patient 16 at risk of injury or death. Findings: During a review of Patient 16’s “Patient Information” sheet (PI), undated, the PI indicated Patient 16 was admitted to the facility’s Psychiatric Unit (PU) on 2/13/26 with an admission reason of “DTS” [danger to self - defined as a situation where an individual poses an imminent risk of serious physical harm to themselves, typically resulting from a mental disorder or an acute psychiatric crisis]. During a review of Patient 16’s “History and Physical” (H&P) dated 2/14/26, the H&P indicated Patient 16 had a diagnosis of Paranoid Schizophrenia (a chronic mental disorder characterized by intense, irrational suspicions (paranoia), along with auditory hallucinations (hearing voices) and delusions (false beliefs) such as feeling watched or plotted against, severely affecting one’s thinking abilities, memories and senses. During an interview on 3/10/26 at 9:53 a.m. with the PU Assistant Manager (PUAM), PUAM stated the approved restraint methods in the facility were soft restraint (padded, fabric limb holders applied to wrists or ankles and secured to bed frames) and hard restraints (heavy duty, leather limb holders applied to wrists or ankles and secured to bed frames). During an interview on 3/11/26 at 9:30 a.m. with Confidential Witness 1 (CW 1), CW 1 stated she had witnessed Patient 16 restrained with bed sheets in his room in the PU. CW 1 stated staff tied Patient 16’s hands together with a bed sheet while in bed. CW 1 stated staff cover Patient 16 with a blanket in bed to conceal the restraint. During an observation on 3/11/26 at 1:10 p.m. in the facility’s PU, Patient 16 was in his room lying in his bed covered by a blanket and observed by Mental Health Worker (MHW) 1. MHW 1 removed the blanket which revealed Patient 16’s hands tied together with a bed sheet. The bed sheet was tied to Patient 16’s arms with blind knots on the wrists and the forearms and then both arms were tied together with additional blind knots. MHW 1 untied the knots and removed the bed sheet from Patient 16’s arms. During a concurrent interview with PU Assistant Manager (PUAM), PUAM stated the bed sheet was a “coping mechanism” that made Patient 16 “feel safe” and was applied at Patient 16’s request to prevent Patient 16 from hitting himself with his hands. PUAM denied it was restraint because Patient 16 could remove the bed sheet at will. During an interview on 3/11/26 at 1:15 p.m. in the PU’s nurse’s station with the PU’s Assistant Manager (PUAM), Registered Nurse (RN) 3 (Patient 16’s nurse) and Quality/Risk Director (QRD), Patient 16’s clinical record was reviewed. QRD and RN 3 stated staff tied Patient 16’s hands with a bed sheet while in bed to prevent him from punching himself and injuring his face. QRD and RN 3 denied it was a restraint because the bed sheet was applied at Patient 16’s request and Patient 16 could untie the knots and remove the bed sheet at will. During an interview on 3/11/26 at 1:30 p.m. with Medical Doctor (MD) 1, MD 1 stated Patient 16 was under his care and he had approved the use of the bed sheet to immobilize Patient 16’s arms. MD 1 stated Patient 16 had behaviors of hitting his face with his hands and wrapping his hands with a bed sheet protected him from self-harm. MD 1 denied the use of the bed sheet was a restraint because the bed sheet was applied at Patient 16’s request and Patient 16 could remove the bed sheet at any time. During an interview on 3/11/26 at 1:55 p.m. with the Chief Nursing Officer (CNO), CNO was asked for the definition of a restraint and stated a restraint was “anything that restricts body movement.” CNO was asked if she thought Patient 16 could independently remove the bed sheet and free his arms. CNO stated, “It [referring to freeing his arms] would be hard”. During a concurrent interview and observation on 3/11/26 at 2 p.m. with MHW 1 in Patient 16’s room, MHW 1 stated she had tied Patient 16’s hands with a bed sheet after lunch at his request. MHW 1 stated the bed sheet was applied one to two times daily whenever Patient 16 asked, “Can you tie my hands?”. MHW 1 stated Patient 16 called it, “my bonding.” MHW 1 stated Patient 16 was able to remove the bed sheet and free his hands at any time. MHW 1 asked Patient 16 if he wanted to have his “bonding”. Patient 16 was in a catatonic state (immobility, silence, rigidity, unresponsive to external stimuli - common in patients with Schizophrenia) and remained motionless and mute. MHW 1 took a bed sheet and tied a blind knot on each wrist of Patient 16 and tied both his hands with an additional blind knot using the same bed sheet. Patient 16 looked as if he had been handcuffed. MHW 1 asked Patient 16 to remove the bed sheet and free his hands. Patient 16 remained motionless and started speaking in monotone (without intonation or expressiveness), “There is nothing in the world I care about ... There is nothing in the world I care about... There is nothing in the world I care about...” Patient 16 did not follow MHW 1’s direction to remove the bed sheet and free his hand. During an interview on 3/11/26 at 2:20 p.m. with MD 2, MD 2 stated he co-chaired the PU with MD 1 and was familiar with Patient 16 and the use of the bed sheet. MD 2 denied it was a restraint. MD 2 stated the bed sheet was applied at Patient 16’s request and was removed any time Patient 16 requested. MD 2 stated Patient 16’s bed sheet was a “voluntary restraint.” MD 2 stated wrapping Patient 16’s hands with a bed sheet provided comfort to Patient 16 akin to a patient wearing earmuffs or a child holding a teddy bear. MD 2 stated the bed sheet prevented Patient 16 from injuring himself and was used instead of restraints and seclusion to manage his self-injury behavior. During a review of the “Code of Federal Regulations” (CFR), §482.13(e)(1) Definitions, the CFR indicated, “(i) A restraint is (A) any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely;” During a review of the American Psychiatric Association (APA) Resource Document titled “Seclusion or Restraint” (APA Resource Document), dated February 2022, the APA Resource Document indicated, “Seclusion or Restraint (S/R) is used as an intervention of last resort... These interventions carry considerable risks including, but not limited to, psychological distress, personal injury to the patient or staff, and/or death ... S/R should only be used as interventions of last resort to prevent harm to patients or others, when less restrictive means have failed (e.g. verbal de-escalation, environmental interventions, oral medications ...) and for the least amount of time necessary...” During a review of facility policy and procedure (P&P) titled “Restraints” dated 2/13/26, the P&P indicated, “Definitions ... Restraints ... Physical: a physical restraint is any manual method, physical device of mechanical device, material, or equipment attached or adjacent to the patient’s body that he or she cannot easily remove and restricts freedom of movement or normal access to one’s body (i.e.: leg/arm restraints, hand mitts, soft ties or vests, lap cushions or lap trays, bed rails).... In its broadest context, restraint is any method of restricting a patient’s freedom of movement, physical activity, or normal access to his or her body... Approved restraints a) soft, quick release limb holders, b) hard/plastic locking restraints c) mittens d) body belt and e) 4side rails.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 37797 Based on observation, interview, and record review, the facility failed to ensure the use of restraints was implemented in accordance with a clear physician’s order for one of three sampled patients (Patient 16). The facility immobilized Patient 16’s hands/arms with a bed sheet preventing Patient 16’s from moving his arms freely without obtaining a valid physician order authorizing the application of this restraint. This failure resulted in Patient 16’s rights being violated and placed Patient 16 at risk of injury or death. Findings: During a review of Patient 16’s “Patient Information” sheet (PI), undated, the PI indicated Patient 16 was admitted to the facility’s Psychiatric Unit (PU) on 2/13/26 with an admission reason of “DTS” [danger to self]. During a review of Patient 16’s “History and Physical” (H&P) dated 2/14/26, the H&P indicated Patient 16 had a diagnosis of Paranoid Schizophrenia (a chronic mental disorder characterized by intense, irrational suspicions (paranoia), along with auditory hallucinations (hearing voices) and delusions (false beliefs), such as feeling watched or plotted against), severely affecting one’s thinking abilities, memories and senses. During an interview on 3/11/26 at 9:30 a.m. with Confidential Witness 1 (CW 1), CW 1 stated she had witnessed Patient 16 restrained with bed sheets in his room in the PU. CW 1 stated staff tied Patient 16’s hands together with a bed sheet while in bed. CW 1 stated staff covered Patient 16 with a blanket in bed to conceal the restraint. During an observation on 3/11/26 at 1:10 p.m. in the facility’s PU, Patient 16 was in his room lying in his bed covered by a blanket and observed by Mental Health Worker (MHW) 1. MHW 1 removed the blanket which revealed Patient 16’s hands/arms tied together with a bed sheet. The bed sheet was tied to Patient 16’s arms with blind knots on the wrists and the forearms and then both arms were tied together with additional blind knots. MHW 1 untied the knots and removed the bed sheet from Patient 16’s hands/arms. During an interview on 3/11/26 at 1:10 p.m. with PU Assistant Manager (PUAM), PUAM stated the bed sheet was a “coping mechanism” that made Patient 16 “feel safe” and was applied at Patient 16’s request to prevent Patient 16 from hitting himself with his hands. PUAM denied it was restraint because Patient 16 could remove the bed sheet at will. During an interview on 3/11/26 at 1:15 p.m. in the PU’s nurse’s station with the PU’s Assistant Manager (PUAM), Registered Nurse (RN) 3 (Patient 16’s nurse) and Quality/Risk Director (QRD), Patient 16’s clinical record was reviewed. QRD and RN 3 stated staff tied Patient 16’s hands with a bed sheet while in bed to prevent him from punching himself and injuring his face. QRD and RN 3 denied it was a restraint because the bed sheet was applied at Patient 16’s request and Patient 16 could untie the knots and remove the bed sheet at will. QRD and RN 3 stated the bed sheet was applied according to a physician’s order. QRD and RN 3 provided the physician’s order dated 2/18/26 at 1:54 p.m. indicating, “patient request COPING MECHANISM SHEET TO CHECK FREQUENTLY AND 1:1 SUPERVISION ALL THE TIME WITH SAFETY BLANKET.” The PO was unclear and did not indicate staff should tie Patient 16’s hands with a bed sheet, how the hands should be tied, how long the hands/arms should be tied, when the staff should use the bed sheets to tie the patients hands/arms and the type of monitoring needed. During an interview on 3/11/26 at 1:30 p.m. with Medical Doctor (MD) 1, MD 1 stated Patient 16 was under his care and he had approved the use of the bed sheet to immobilize Patient 16’s arms. MD 1 stated he had written the PO dated 2/18/26 “patient request COPING MECHANISM SHEET TO CHECK FREQUENTLY AND 1:1 SUPERVISION ALL THE TIME WITH SAFETY BLANKET.” MD 1 stated Patient 16 had behaviors of hitting his face with his hands and wrapping his hands with a bed sheet protected him from self-harm. MD 1 denied the use of the bed sheet was a restraint because the bed sheet was applied at Patient 16’s request and Patient 16 could remove the bed sheet at any time. During an interview on 3/11/26 at 1:55 p.m. with the Chief Nursing Officer (CNO), CNO was asked for the definition of a restraint and stated a restraint was “anything that restricts body movement.” CNO was asked if she thought Patient 16 could independently remove the bed sheet and free his arms. CNO stated, “It [referring to removing the bed sheet to free his arms] would be hard”. During a concurrent interview and observation on 3/11/26 at 2 p.m. with MHW 1 in Patient 16’s room, MHW 1 stated she had tied Patient 16’s hands with a bed sheet after lunch at his request. MHW 1 stated the bed sheet was applied one to two times daily whenever Patient 16 asked, “Can you tie my hands?”. MHW 1 stated Patient 16 called it, “my bonding.” MHW 1 stated Patient 16 was able to remove the bed sheet and free his hands at any time. MHW 1 asked Patient 16 if he wanted to have his “bonding”. Patient 16 was in a catatonic state (immobility, silence, rigidity, unresponsive to external stimuli - common in patients with Schizophrenia) and remained motionless and mute. MHW 1 took a bed sheet and tied a blind knot on each wrist of Patient 16 and tied both his hands with an additional blind knot using the same bed sheet. Patient 16 looked as if he had been handcuffed. MHW 1 asked Patient 16 to remove the bed sheet and free his hands. Patient 16 remained motionless and started speaking in monotone (without intonation or expressiveness), “There is nothing in the world I care about ... There is nothing in the world I care about... There is nothing in the world I care about...” Patient 16 did not follow MHW 1’s direction to remove the bed sheet and free his hands. During an interview on 3/11/26 at 2:20 p.m. with MD 2, MD 2 stated he co-chaired the PU with MD 1 and was familiar with Patient 16 and the use of the bed sheet. MD 2 denied it was a restraint. MD 2 stated the bed sheet was applied at Patient 16’s request and was removed any time Patient 16 requested. MD 2 stated Patient 16’s bed sheet was a “voluntary restraint.” MD 2 stated wrapping Patient 16’s hands with a bed sheet provided comfort to Patient 16 akin to a patient wearing earmuffs or a child holding a teddy bear. MD 2 stated the bed sheet prevented Patient 16 from injuring himself and was used instead of restraints and seclusion to manage his self-injury behavior. During a review of the “Code of Federal Regulations” (CFR), §482.13(e)(1) Definitions, the CFR indicated, “(i) A restraint is (A) any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely;” During a review of the American Psychiatric Association (APA) Resource Document titled “Seclusion or Restraint” (APA Resource Document), dated February 2022, the APA Resource Document indicated, “Seclusion or Restraint (S/R) is used as an intervention of last resort... These interventions carry considerable risks including, but not limited to, psychological distress, personal injury to the patient or staff, and/or death ... S/R should only be used as interventions of last resort to prevent harm to patients or others, when less restrictive means have failed (e.g. verbal de-escalation, environmental interventions, oral medications ...) and for the least amount of time necessary...” During a review of facility policy and procedure (P&P) titled “Restraints” dated 2/13/26, the P&P indicated, “Definitions ... Restraints ... Physical: a physical restraint is any manual method, physical device of mechanical device, material, or equipment attached or adjacent to the patient’s body that he or she cannot easily remove and restricts freedom of movement or normal access to one’s body (i.e.: leg/arm restraints, hand mitts, soft ties or vests, lap cushions or lap trays, bed rails). “In its broadest context, restraint is any method of restricting a patient’s freedom of movement, physical activity, or normal access to his or her body.” “Each episode of restraint shall be initiated: (1) upon the order of a licensed independent practitioner who is responsible for the patient.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 37797 Based on interview and record review, the facility failed to discontinue seclusion [the involuntary confinement of a patient alone in a room or area from which they are physically prevented from leaving] at the earliest possible time for one of three sampled patients (Patient 17) when Patient 17 was kept in seclusion after she no longer exhibited violent or self-destructive behavior. This failure resulted in Patient 17’s rights being violated and increased Patient 17’s risk of injury and death. Findings: During a review of Patient 17’s “Patient Information” sheet (PI), undated, the PI indicated Patient 17 was admitted to the facility’s Psychiatric Unit (PU) on 2/27/26 with an admission reason of “DTS” [danger to self is defined as a situation where an individual poses an imminent risk of serious physical harm to themselves, typically resulting from a mental disorder or an acute psychiatric crisis ], “DTO” [danger to others defined as a substantial likelihood, probability, or imminent risk that a patient will inflict serious physical harm or injury upon another person, often stemming from a mental disorder ] and “GD” [grave disability is a condition in which a person, as a result of a mental health disorder or a severe substance use disorder, is unable to provide for their basic personal needs for food, clothing, or shelter ]. During a review of Patient 17’s “History and Physical” (H&P) “Admit Date 2/27/26”, the H&P indicated Patient 17 had a diagnosis of Schizoaffective Disorder Bipolar (a chronic mental health condition combining schizophrenia symptoms-like hallucinations [vivid sensory perceptions-hearing, seeing, smelling, touching, or tasting things-that occur without external stimuli but feel profoundly real to the individual], delusions [false beliefs], or disorganized thinking with major mood episodes, specifically mania (highs) and sometimes depression. During a concurrent observation and interview on 3/9/26 at 11:35 a.m. with the Quality/Risk Director (QRD) in the PU, QRD showed the PU’s seclusion room. The seclusion room was a small, unfurnished, windowless, locked room, with a single concrete bed in the center topped with a mattress and a clearance of a few feet around the bed. Adjoining the seclusion room was a small bathroom. QRD indicated this was the room used for seclusion of patients, where patients were kept locked and isolated for management of behaviors. During a review of the PU’s “Restraint/Seclusion” log (RSL - a spreadsheet indicating all patients put in restraints or seclusion) from 2/27/26 to 3/8/26, the RSL Patient 17 had been placed in seclusion a total of 32 times during the period. The RSL indicated Patient 17’s seclusion periods of up to eight hours each time. During an interview on 3/9/26 at 12:15 p.m. with Patient 17, Patient 17 was crying and stated, “I don’t like that I have been locked up so many times.” During a concurrent interview and record review on 3/10/26 at 3:30 p.m. with the Chief Nursing Officer (CNO), the “Restraint/Seclusion Order Form” (RSOF) was reviewed. CNO stated the RSOF was a form completed whenever patients were put in seclusion. The RSOF indicated, “Restraint/Seclusion Orders for Behavioral Management (Emergency Use Only) - The patient is exhibiting violent or self-destructive behavior that jeopardizes the safety of the patient, a staff member, or others.” CNO indicated seclusion could only be used for management of violent or self-destructive behavior. CNO stated “violent behavior” meant a patient was engaged in actual violence or was threatening violence towards others and “self-destructive behavior” meant self-harm, when a patient was hitting or physically hurting themselves. During a concurrent interview and record review on 3/10/26 at 3:40 p.m. with QRD, Patient 17’s “Restraints/Seclusion” packets (RSP) were reviewed. QRD stated the RSPs contained the documentation concerning the application of seclusion on patients. The RSPs included the RSOF (where staff documented the date and time of the initiation of seclusion), the “Official Record of Statutory Rights of Patients form” (ORSR - where staff documented the reasons for the initiation of seclusion) and the “Restraint/Seclusion Flow Sheet form” (RSFS - where staff documented the patient’s behaviors while in seclusion justifying the maintenance of seclusion). QRD stated documentation of restraints and seclusion was also found in nursing notes (NN) on the computer system. A review of Patient 17’s RSPs and nursing notes indicated the following instances of Patient 17’s seclusion not being discontinued after Patient 17 no longer exhibited evidence of violent or self-destructive behavior: 1. During a review of RSOF dated 3/2/26 at 1:10 p.m., RSOF indicated Patient 17 was put in seclusion on 3/2/26 at 1:10 p.m. During a review of ORSR dated 3/2/26, ORSR indicated, “Restriction Imposed: seclusion. Explanation of ‘good cause’ for denial of rights, placement in reclusion: ‘Patient [2] was... making verbal threats toward staff and roommate assumed fighting posture... on going aggressive behavior patient escorted to seclusion for safety...” During a review of NN dated 3/2/26 at 1:41 p.m., NN indicated, “[Patient 17]... made verbal threats towards her roommate, stating she would punch her. Patient also yelled and threatened staff, stating she would start slapping them, and assumed a threatening posture toward staff. Patient became highly agitated and anxious, presenting an imminent risk of harm to others.” During a review of RSFS dated 3/2/26, RSFS indicated Patient 17 was kept in seclusion from 1:10 p.m. until 8:30 p.m. and during this period she exhibited the following behaviors: yelling and screaming, mumbling incoherently, talking coherently, being restless, and disrobing herself. RSFS contained no documentation of violent or self-destructive behavior. QRD stated the RSFS contained the record of Patient 17’s behavior while in seclusion. 2. During a review of RSOF dated 3/8/26 at 11:04 a.m., RSOF indicated Patient 17 was put in seclusion on 3/8/26 at 11:04 p.m. During a review of ORSR dated 3/8/26, ORSR indicated, “Restriction Imposed: seclusion. Explanation of ‘good cause’ for denial of rights, placement in reclusion: ‘Patient [2] became verbally aggressive and began yelling at peer... [Patient 17] shoved peer...” During a review of NN dated 3/8/26 at 11:37 a.m., NN indicated, “[Patient 17]... making suspicious and confused statements toward peer then she shoved peer.” During a review of RSFS dated 3/8/26, RSFS indicated Patient 17 was kept in seclusion from 11:04 a.m. until 3 p.m., but from 11:04 a.m. until 1:45 p.m. Patient 17 exhibited the following behaviors: yelling and screaming, mumbling incoherently, talking coherently, being restless. RSFS contained no documentation of violent or self-destructive behavior from 11:04 a.m. until 1:45 p.m.. QRD stated the RSFS contained the record of Patient 17’s behavior while in seclusion. During an interview on 3/11/26 at 10:20 a.m. with CNO, CNO stated seclusion should be discontinued as soon as the behavior that prompted the seclusion has been dissipated. CNO stated seclusion should be discontinued within 20 to 30 minutes of when the behavior has stopped. CNO stated there should be documentation of violent or self-destructive behavior in the RSFS. During a review of the American Psychiatric Association (APA) Resource Document titled “Seclusion or Restraint” (APA Resource Document), dated February 2022, the APA Resource Document indicated, “Seclusion or Restraint (S/R)... carry considerable risks including, but not limited to, psychological distress, personal injury to the patient or staff, and/or death ... S/R should only be used as interventions of last resort to prevent harm to patients or others, when less restrictive means have failed (e.g. verbal de-escalation, environmental interventions, oral medications ...) and for the least amount of time necessary...” During a review of the facility’s policy and procedure (P&P) titled, “Restraints” dated 2/13/26, the P&P indicated, “Seclusion should only be used for the management of violent or self-destructive behavior.” and “Restraint or seclusion shall be discontinued by a registered nurse. The decision to discontinue is based on the behaviors or situations that prompted intervention are assessed to no longer be harmful to the safety of the patient, staff members, or others.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(1) Training intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion- (i) Before performing any of the actions specified in this paragraph; (ii) As part of orientation; and (iii) Subsequently on a periodic basis consistent with hospital policy. This Standard is not met as evidenced by: 37797 Based on interview and record review, the facility failed to ensure ten of ten sampled staff (Licensed Vocational Nurse (LVN) 1, Registered Nurse (RN) 1, RN 2, RN 3, Mental Health Worker (MHW) 1, MHW 2, MHW 3, MHW 4, MHW 5, MHW 6) working in the Psychiatric Unit (PU) demonstrated competency in the application of restraints and implementation of seclusion [the involuntary confinement of a patient alone in a room or area from which they are physically prevented from leaving] upon hire as part of their orientation. This failure placed patients at risk of having their rights violated and risk of injury and death from improper application of restraints and seclusion. Findings: During a concurrent interview and record review on 3/9/26 at 9:50 a.m. with the Psychiatric Unit Assistant Manager (PUAM), the PU “Assignment Sheet” (AS) for 3/9/26 day shift [6:30 a.m. to 6:30 p.m.] was reviewed. The AS indicated the following staff were on duty: LVN 1, RN 1, RN 2, RN 3, MHW 1, MHW 2, MHW 3, MHW 4, MHW 5 and MHW 6. PUAM stated all staff in the AS were on duty. During a concurrent interview and record review on 3/9/26 at 3:05 p.m. with Human Resources Manager (HRM), the orientation and training records of LVN 1, RN 1, RN 2, RN 3, MHW 3, MHW 4 and MHW 5 were reviewed. HRM stated staff in the PU received training on the application of restraints and seclusion upon hire during orientation. HRM stated all training provided during orientation was documented either in the “New Hired (sic) Orientation & Annual Comp[etency]” form (NHOAC Form) or the “Department Specific Orientation” form (DSO Form). HRM provided the NHOC and DSO forms for LVN 1 dated 3/2/21, RN 1 dated 3/25/21, RN 2 dated 3/22/23, RN 3 dated 7/1/19, MHW 3 dated 8/22/24, MHW 4 dated 12/17/24 and MHW 5 dated 7/30/21. The NHOC and DSO forms provided consisted of a one page document indicating the training topics, staff and the instructor’s initials. For training on the application of restraints and seclusions, the NHOC and DSO forms indicated “Restrain and Seclusion”. HRM stated she did not know the content of the training or if it included competency demonstrations (where staff physically demonstrate their skills). HRM stated the Chief Nursing Officer (CNO) was responsible for the training of staff. During a concurrent interview and record review of 3/9/26 at 3:30 p.m. with the CNO, the NHOC and DSO forms for LVN 1 dated 3/2/21, RN 1 dated 3/25/21, RN 2 dated 3/22/23, RN 3 dated 7/1/19, MHW 3 dated 8/22/24, MHW 4 dated 12/17/24 and MHW 5 dated 7/30/21 were reviewed. CNO stated the training titled, “Restrain and Seclusion” on the NHOC and DSO forms was a “verbal going over” the topic. CNO stated the training did not include demonstration of competency on the application of restraints and seclusion. CNO was asked if there was any documentation of LVN 1, RN 1, RN 2, RN 3, MHW 3, MHW 4 and MHW 5 demonstrated competency in the application of restraints and seclusion upon hire as part of their orientation. CNO stated there was no competency demonstrated in the application of restraints and seclusion upon hire as part of their orientation for any of the staff mentioned. During a concurrent interview and record review on 3/10/26 at 8:45 a.m. with HRM and CNO, the NHOC and DSO forms of MHW 1 dated 5/18/21, MHW 2 dated 1/12/26 and MHW 6 dated 12/8/25 were reviewed. The NHOC and DSO forms for MHW 1, MHW 2 and MHW 6 indicated training for “Restraint and Seclusion”. CNO stated MHW 1, MHW 2 and MHW 6 did not demonstrate competency in the application of restraints and seclusion upon hire as part of their orientation. During a review of the facility’s policy and procedure (P&P) titled, “Restraints” dated 2/13/26, the P&P indicated, “Training... 1. Designated hospital staff shall receive training and competency assessment on the use of restraint and seclusion. Training shall take place during orientation and prior to the participation in use of restraint and seclusion.””

“INFECTION CONTROL PROFESSIONAL CFR(s): 482.42(a) Infection prevention and control program organization and policies. The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 40358 Based on interview and record review, the facility failed to ensure the Infection Prevention and Control Program (IPCP - a system of policies, procedures, and practices designed to prevent/control the spread of infections) provided effective ongoing monitoring when the Infection Control Nurse (ICN) was not qualified by education, experience, and certified in infection prevention and control. This failure resulted in inadequate infection prevention and control oversight which jeopardized the safety and well-being of patients and staff (Refer to A-749). Findings: During a review of the ICN job description titled “Infection Control Coordinator/Education Coordinator” (ICNJD) dated 11/27/23 and signed by ICN on 11/27/23, the ICNJD indicated: “II. Position Summary Under the supervision of the Chief Nursing Officer, the Infection Control Coordinator/Education coordinator is trained in hospital epidemiology (the study of how often diseases occur in different groups of people and why) principles and is responsible for the surveillance, analysis, and reporting of nosocomial (acquired in the hospital or healthcare facility) infections; educating employees about infection control; and the development of hospital policies and procedures to ensure rigorous infection control standards that meet JCAHO (Joint Commission on Accreditation of Healthcare Organizations - an organization that makes sure hospitals meet certain safety and quality standards), OSHA (Occupational Safety and Health Administration - a government agency responsible for ensuring safe and healthy working conditions for employees), California Department of Public Health (CDPH - state-level agency responsible for protecting and improving the health of people in California), and Center for Disease Control (CDC - a federal public health agency whose main role is to protect public health and safety by preventing and controlling disease) requirements and support services for Nursing Department in coordinating staff education/in-service, skills/competency evaluation, orientation programs, critical dates monitoring, and other related responsibilities in promoting continuing education and maintaining current competence of the Nursing Staff.” During an interview on 3/9/26 at 12:30 p.m. in the administration conference room with the ICN, ICN stated, she was a Registered Nurse (RN) who was hired into an educator role. ICN stated she was appointed to the ICN role in 2024 after serving as the Interim ICN since 2023. ICN stated she was not certified but was registered to take the national certification “Certified in Infection Control” (CIC) exam through the Certification Board of Infection Control and Epidemiology, Inc. The ICN stated she followed hospital policies for infection control but did not know what infection control national standards the hospital followed for the Surgical Services Department (SSD - Operating room [a special clean room where doctors perform surgery], preoperative [pre-op- the time and place where nurses and doctors get a patient ready for surgery], Postoperative [post op - the time and place where nurses recover a patient after surgery], Sterile Processing Department [SPD - an area in the hospital used to clean, disinfect, sterilize, store, and maintain the reusable surgical medical instruments], and Endoscopy Department [ED - a procedure area in the hospital where doctors use a thin, flexible tube with a camera and light to look inside a patient’s body, the instruments are cleaned and stored] ). The ICN stated she had no training or experience in SSD. ICN confirmed her role included monitoring the SSD. A review of the CBIC’s “CIC Initial Exam Eligibility Requirements,” (undated; obtained online 8/26/25), indicated the following requirements must be met to be eligible for the exam: “1. Post-secondary education through university, college, or community college in a health-related field such as medicine, nursing, laboratory technology, public health, or biology. 2. Direct responsibility for IPCP in a healthcare setting, reflected in current job description. 3. At least one year of full-time employment OR two years of part-time employment OR 3,000 hours (approximately 18 months) of compensated infection prevention work experience within the last three years. 4. Required practice elements included: a. Identification of infectious disease processes, b. Surveillance and epidemiologic investigation, c. Preventing and controlling the transmission of infectious agents, d. Environment of care, e. Cleaning/sterilization/disinfection/asepsis, and f. At least two of the following three elements must also be accounted for: employee/occupational health, management and communication, and education and research”. During an interview on 3/10/26 at 8:19 a.m. in the administration conference room with Chief Nursing Officer (CNO), CNO stated the ICN reported to the CNO. CNO stated she had shared oversight for the SSD with the Director of Operating Room Operations (DOO) and had no direct experience in SSD. CNO stated she expected the ICN to round in the SSD monitoring infection control processes and to know the national standards the hospital followed for infection control for the SSD. During a concurrent interview and record review on 3/10/26 at 11:11 a.m. in the administration conference room with the Human Resources Manager (HRM), ICN’s personnel file was reviewed. HRM validated that ICN’s file indicated a background in acute rehabilitation, was hired as an educator on 1/24/23 and promoted to interim ICN on 12/12/23. HRM stated the hospital’s expectation is for orientation to new roles to occur within 90 days. HRM confirmed there was no documented evidence ICN was oriented to the current role. During file review there was no documented training for 2025. During an interview on 3/10/26 at 4:30 p.m. in the administration conference room with ICN, ICN stated she was unfamiliar with the SPD and infection control was not her background. During an interview on 3/11/26, at 9:20 a.m. in the administration conference room with ICN, ICN stated she was aware she had access to a hospital contracted quality control consultant with CIC training. ICN stated she was aware she could contact the consultant and stated when she identified infection control issues in the SSD, she did not contact the contracted consultant and “did not think about it”. ICN stated she was not trained in the ICN position and stated, “I don’t know what I don’t know”. ICN stated her contact with the quality consultant focused on JCAHO readiness and did not think to “reach out to her about sterile process, operating room, or endoscopy” services. ICN stated “I should have reached out to learn” how to address SPD issues. ICN stated she performed environment of care rounds and infection control rounds and was not aware of any issues with eyewash station location or endoscope storage. During a concurrent interview and record review on 3/11/26 at 9:45 a.m. in the administration conference room with HRM, ICN’s 2025 education documentation was provided and reviewed. HRM confirmed there was no documented evidence for infection control training specific to high level disinfection (HLD - the process of complete elimination of all microorganisms in or on a device, with the exception of small numbers of bacterial spores for sterile processing) and endoscopy. During an interview on 3/12/26 at 9:26 a.m. in the administration conference room with the CAO, CAO stated the ICN was appointed by the governing body, and he was not aware of the job requirements for the ICN role. CAO stated he “was not aware” the ICN “was not qualified” for the infection control role. During a review of the hospital policy and procedure (P&P), titled “2026 Infection Prevention and Control Plan”, the P&P indicated, “IC-01.01.01 Authority and Responsibility Statement ...Authority Statement: 1. The infection prevention committee members have the overall authority and responsibility for the infection prevention program at [hospital name]. 2. The Infection Preventionist has primary responsibility for the daily management of the infection prevention activities. This includes developing and implementing policies that govern control of infections and communicable disease and developing and implementing policies that govern control of infections and communicable disease and developing a system for identifying, reporting, investigation, and controlling infections and communicable disease. 3. The infection preventionist has authority to institute any surveillance, prevention, and control measures or studies when there is a reason to believe that any patient or personnel may be in danger from a potential or actual outbreak of, or exposure, to infectious disease. 4. All employees have responsibility for adherence to infection prevention and control processes/strategies.””

“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: 40358 Based on observation, interview, and record review, the facility failed to ensure a system was in place for identifying, reporting, investigating, and controlling infections and communicable diseases in accordance with hospital policies, national standards and/or state building codes when: 1. The Infection Prevention and Control Program (IPCP - a system of policies, procedures, and practices designed to prevent/control the spread of infection) failed to ensure the emergency eyewash station was positioned away from the decontamination (the removal of dangerous substances and germs) sink in the high-level disinfection (HLD, a process that kills all microbial organisms but not necessarily large numbers of bacterial spores) decontamination workroom. 2. The IPCP failed to designate a supervisor for the Sterile Processing Department (SPD - an area of a health care facility where devices are decontaminated, cleaned, inspected, assembled into trays, and prepared for high-level disinfection and/or sterilization) and Endoscope Department (ED - a procedure area in the hospital where doctors use a thin, flexible tube with a camera and light to look inside a patient’s body, the instruments are cleaned and stored) that was qualified by training, experience, and certified in accordance with national standards. 3. The IPCP failed to ensure clean gastrointestinal endoscopes (GI scopes - thin flexible tubes with a light and a camera used to examine the inside of the digestive tract) were stored in a clean environment and the storage cabinet was in a space compliant with the manufacturer’s instructions for use (IFU’s) and National Infection Control Standards (American National Standards Institute [ANSI]/Advancement of Medical Instrumentation [AAMI] - a non-profit organization that develops and publishes standards, guidance, and other technical documents to improve patient safety and healthcare outcomes in the medical device industry) which the hospital followed. 4. The IPCP failed to ensure two of two new steam sterilizers were installed in the SPD according to statewide building code standards and Department of Health Care Access (HCAI - a California state agency that checks hospitals to make sure their buildings and equipment are safe for patients and workers) requirements. These failures increased the risk for the spread of communicable diseases (illnesses that can spread from one person to another) and cross-contamination (the transfer of harmful bacteria from one person, object, or place to another) thereby adversely affecting the health and safety of patients and staff in the hospital. Findings: During a concurrent observation and interview with Director of Operations (DOO) on 3/9/26 at 9:55 a.m. in the Surgical Services Department (SSD), DOO stated the hospital followed these national standards: a. AORN - (Association of Perioperative Registered Nurses - evidence -based guidelines which define the standards that help keep healthcare workers and surgical patients safe), b. AAMI - (Association for the Advancement of Medical Instrumentation - an organization for advancing the development, and safe and effective use of medical technology). 1. During a concurrent observation and interview with DOO on 3/9/26 at 9:39 a.m. in the decontamination room, an eyewash station was observed located next to the decontamination sink. DOO validated the observation. During a concurrent observation and interview with Sterile Processing Department technician (SPDT - a person trained specifically to clean, disinfect, and sterilize medical tools so they are safe to use on patients) on 3/9/26 at 10:14 a.m. in the decontamination room, SPDT stated the eyewash station should not be next to the decontamination sink. SPDT stated “if you go to clean your eyes, they could get dirty from the splash back” from the decontamination sink. SPDT stated it was his understanding a work order to fix the eyewash station had been placed prior to his start date three weeks prior. During an interview on 3/9/26 at 12:30 p.m. in the administration conference room with the Infection Control Nurse (ICN), ICN stated she was not aware of AAMI standards for the SPD and did not know the eyewash station was located next to the decontamination sink. ICN stated the eyewash station should “probably not” next to the decontamination sink, the sink was not sanitary and could expose employee eyes to potentially infectious (something can spread from one person to another and make them sick) matter in the sink. During an interview on 3/9/26 at 12:50 p.m. in the administration conference room with the Plant Operations Manager (POM), POM stated he was not aware of an issue with the eyewash station, had never been told about it, and had no work orders to move eyewash station. During a concurrent observation and interview on 3/10/26 at 9:56 a.m. with DOO in the SSD outside the decontamination room, DOO validated the eyewash station near the decontamination sink and stated the eyewash station was “too close” to the decontamination sink. DOO stated the SPDT could contaminate himself with “bioburden when rinsing chemicals” out of his eyes over the decontamination sink. DOO stated she was aware of the eyewash station location and plant services had been notified to move the eyewash station. During an interview on 3/10/26 at 11:11 a.m. with the POM, POM stated he had not been notified regarding the eyewash station and could not find any work orders to move the eyewash station in the hospital’s computerized work order system. During a review of the hospital’s policy and procedure (P&P) titled, “2026 Infection Prevention and Control Plan”, Dated 2026, the P&P indicated, “ ...IC 01.05.01 Infection Control Plan EVIDENCE-BASED NATIONAL GUIDELINES. Infection prevention and control follow guidelines of national, state, and local regulatory agencies, and professional guidance for Standards of Practice which may include, but is not limited to: CMS The Centers for Medicare and Medicaid Services OSHA Occupational Safety and Health Administration CDPH California Department of Public Health ACHC Accreditation Commission for Health Care HICPAC Hospital Infection Control Practices Advisory Committee CDC Center for Disease Control and Prevention APIC Association for Professionals in Infection Control AORN Association of Operating Room Nurses ANSI American National Standards Institute AOA American Osteopathic Association IDSA Infectious Disease Society of America SHEA Society for Hospital Epidemiology of America AWHONN Association of Women’s Health, Obstetrics and Neonatal AAMI Association for the Advancement of Medical Instruments ...” During an interview on 3/12/26 at 8:16 a.m. in the administration conference room a request was made for a copy of the AAMI standards related to SPD and Endoscopy referenced in the hospital’s 2026 infection control plan. During an interview on 3/12/26 at 11:25 a.m. in a hallway outside the administration conference room with QRD, QRD stated the hospital could not locate the AAMI standards. During a review of ANSI/AAMI ST 79 “Comprehensive guide to steam sterilization and sterility assurance in health care facilities” (ANSI/AAMI ST 79) dated 2017, ANSI/AAMI ST 79 indicated, “ ...3.3.7 Emergency eyewash/shower equipment ...Before attempting to implement the ANSI standard, health care personnel should consult the standard to familiarize themselves with all of its provisions. Eyewash station should not be in a location that requires flushing of the eyes in a decontamination sink ...” During a review of the AORN guidelines for Perioperative Practice (2020), Guideline for Instrument Cleaning (GIC), GIC indicated, “...recommendation: 2.3 Do not clean or decontaminate instruments in the sinks where eyewash stations are located... rationale: Cleaning soiled instruments can contaminate the sink and faucet, which can contaminate the person using the sink for clean activities...” 2. During a concurrent observation and interview on 3/9/26 at 10:05 a.m. in the SPD with DOO, DOO stated she supervised the SPD for the past eight months but was not SPD certified. During an interview on 3/10/26 at 8:19 a.m. with the Chief Nursing Officer (CNO), CNO described the leadership structure for the SSD and stated the DOO had “overall responsibility” for surgical services, SPD, and endoscope reprocessing. The CNO stated the CNO leadership role was available for nursing specific issues. CNO stated she did not have operating room or sterile processing experience. During an interview on 3/10/26 at 9:00 a.m., in the administration conference room, with QRD, QRD stated “we do not have a nurse manager” for the SSD. QRD stated the DOO was responsible for day-to-day operations and the CNO provided administrative support for nursing services. During an interview and record review on 3/10/26 at 11:11 a.m. in the administration conference room with the Human Resources Manager (HRM) and the Human Resources Assistant (HRA), personnel files were reviewed. HRM stated the DOO was not a hospital employee, she was a contracted staff member. A review of the DOO contract with the hospital, dated June 2025, indicated, “ ...Surgical Department Oversight ...Oversee day-today-operations across all perioperative phases: pre-operative, intraoperative, post-operative (PACU), and ambulatory surgery ...Provide collaborative oversight to surgery department ...conducts routine performance reviews and work flow assessments to optimize operation efficiency ...Oversee adherence to evidence-based clinical protocols and surgical safety checklists ...Monitor and Ensure Surgery Department Regulatory Compliance Readiness ....Shall prepare for, and participate in, announced and unannounced surveys ...Maintain up-to-date policies and procedures aligned with the latest federal and state requirements ...Resource Planning for Surgery Department to align with Patient and Provider Needs ...Ensure adequate equipment, surgical instruments, and sterile supplies are available through efficient materials management and coordination with central sterile services ...” During an interview and record review on 3/11/26 at 1:55 p.m. in the administration conference room with the CNO, CNO stated she was not aware of DOO job specific competencies required and did not know if the DOO was certified in sterile processing. CNO stated she did not know AAMI standards required SPD supervisors to be certified in SPD. CNO validated the DOO would be considered the SPD supervisor based on the contract and job description. A review of the document titled “Surgery Organization Chart”, undated, indicated the DOO had direct supervision to SPD, Scrub Techs and Endo Techs. CNO validated the Surgery Organizational Chart. During a review of the hospital’s policy and procedure (P&P titled, “2026 Infection Prevention and Control Plan”, dated 2026, the P&P indicated, “ ...IC 01.05.01 Infection Control Plan EVIDENCE-BASED NATIONAL GUIDELINES. Infection prevention and control follows guidelines of national, state, and local regulatory agencies, and professional guidance for Standards of Practice which may include but is not limited to: ...AAMI - Association for the Advancement of Medical Instruments ...”. During a review of ANSI/AAMI “ST79: 2017 - Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities” (ANSI/AAMI “ST79: 2017), ANSI/AAMI “ST79: 2017 indicated, “4.2 Qualifications4.2.1 Supervisory personnel All preparation and sterilization activities, including decontamination, inspection, preparation, packaging, sterilization, storage, and distribution, should be supervised by competent, qualified personnel. Personnel assigned to supervisory functions should be prepared for this responsibility by education, training, and experience. Minimum recommended qualifications include a) successful completion of a sterile processing management certification examination ...” 3. During a concurrent observation and interview on 3/9/26 at 9:48 a.m. in the endoscope storage room with Surgical Technician (ST) 1, ST 1 stated the hospital followed AORN/AAMI guideline standards for the endoscopes. The following concerns were identified: the endoscopes (three) were stored in an endoscope drying cabinet 9a special storage unit used to keep cleaned endoscopes safe and dry) in room without a door. There was no evidence the hospital monitored room humidity according to the Manufacturer’s IFU’s. Additionally, the endoscopes were stored in a room used to perform high level disinfection (HLD - the strongest form of disinfection, effectively killing all microorganisms, making the scopes safe to use) of reusable endoscopes and an automated endoscope reprocessor (AER -a machine that cleans and disinfects endoscopes) was in use adjacent to the endoscope drying cabinet. ST 1 was asked if the room had a temperature and humidity tracking log, ST 1 stated she was not aware of one. A request was made for the endoscope cabinet manufacturer’s instructions for use, the hospital policy for temperature/humidity tracking, tracking logs and AAMI standards the hospital followed for endoscope storage. During a concurrent observation and interview on 3/10/26 at 9:41 a.m. with DOO and QRD in the endoscope storage room, DOO stated the endoscope cabinet was too close to the AER reprocessor that created a cross-contamination risk. DOO stated there should be separation between clean and dirty equipment. QRD validated that there was no door in the room. During a review of the manufacturer’s IFU’s titled, “Scope Cabinets, User’s Manual & Instruction Guide” (IFU) dated 10/16, the IFU indicated, “We recommend the following: 1. Keep carts in a ventilated humidity-controlled environment indoor air-conditioned rooms are ideal.” During a review of hospital P&P titled, “Temperature, Humidity, and Pressure of Surgical Services”, dated 8/22, the P&P indicated, “Procedure: 1. The temperature and humidity are checked daily upon staff arrival 2. Positive pressure will be checked daily prior to surgery in the ‘Pressure Log’. 3. All temperature and humidity is recorded in the “Temperature and Humidity Log”. 4. Out of range compliance is reported through the Chain of Command immediately to Plant Operations, Risk, Infection Control, and Administration, as needed ...” There were no documented humidity tracking logs provided for the endoscope reprocessing and storage room. During a concurrent interview and record review on 3/11/26 at 1:30 p.m. with CNO in the administration conference room, the manufacturer’s IFU’s were reviewed and CNO confirmed the endoscope cabinet must be kept in a humidity-controlled environment. During a review of hospital P&P titled, “2026 Infection Prevention and Control Plan”, Dated 2026, the P&P indicated, “ ...IC 01.05.01 Infection Control Plan EVIDENCE-BASED NATIONAL GUIDELINES. Infection prevention and control follow guidelines of national, state, and local regulatory agencies, and professional guidance for Standards of Practice which may include but is not limited to: CMS The Centers for Medicare and Medicaid Services OSHA Occupational Safety and Health Administration CDPH California Department of Public Health ACHC Accreditation Commission for Health Care HICPAC Hospital Infection Control Practices Advisory Committee CDC Center for Disease Control and Prevention APIC Association for Professionals in Infection Control AORN Association of Operating Room Nurses ANSI American National Standards Institute AOA American Osteopathic Association IDSA Infectious Disease Society of America SHEA Society for Hospital Epidemiology of America AWHONN Association of Women’s Health, Obstetrics and Neonatal AAMI Association for the Advancement of Medical Instruments ...” During an interview on 3/12/26 at 8:16 a.m. in the administration conference room a request was made for a copy of the AAMI standards related to SPD and Endoscopy referenced in the hospital’s 2026 infection control plan. During an interview on 3/12/26 at 11:45 a.m. outside the administration conference room with the QRD, QRD stated leadership was unable to find a copy of the AAMI standards the hospital followed for SPD and endoscope reprocessing. During a review of hospital P&P titled “Endoscope Care”, dated 2/2025, the P&P indicated, “Technique ...5. After the use of disinfectants and detergent, the endoscopes will be thoroughly rinsed and forced air dry. At the end of the day all scopes will be run through the OER PRO (company name AER) machine; then hung in a dry place protected from traffic flow. During a review of the National Standards the hospital followed, “ANSI/AAMI ST91:2021 Flexible and semi-rigid endoscope processing in health care facilities” (ANSI/AAMI ST91:2021), ANSI/AAMI ST91:2021 indicated, “11.2.2 Storage Cabinets, cabinets used for storage of flexible endoscopes should be situated in a secure location such as in the clean workroom of the endoscopy processing room in a two-room design or in a separate clean area close to, but not within, the endoscopy procedure room (AORN, 2018e, IX.a [39]). Situating the storage cabinet in a secure location helps protect inventories of flexible endoscopes and supplies that are vulnerable to misappropriation. Locating the storage cabinet in the clean workroom or in a clean area outside of the procedure room helps prevent contamination of processed endoscopes...”. 4. During an interview on 3/9/26 at 8:39 a.m. in the administration conference room with the Chief Administrative Officer (CAO), and the Administrative Support (AS), CAO stated the hospital had recently installed two new steam sterilizers. During a concurrent observation and interview on 3/9/26 at 10:14 a.m. with SPDT and DOO in the preparation and package area of the SPD, there were two Amsco 400 Series steam sterilizers (Sterilizer 1 and Sterilizer 2). SPDT stated the old sterilizers had issues passing quality tests and new sterilizers had recently been installed. DOO confirmed the 2 new steam sterilizers. During an interview on 3/10/26 at 10:04 a.m. with the Plant Operations Manager (POM), POM stated he had not notified HCAI regarding the steam sterilizer changes because the hospital was swapping “part for part”. POM stated the sterilizers were the same, the old one removed, and the new one filled the spot. Requested a copy of the manufacturer’s instructions for use of the steam sterilizers. Requested the purchase order for the new steam sterilizers. During an interview on 3/12/26 at 9:26 a.m. in the administration conference room with CAO, the CAO explained the steam sterilizer replacement process. CAO stated he understood that if the hospital replaced a sterilizer with the same type, HCAI did not need to be involved, but the POM was responsible for the decision to contact HCAI. A request was made for the manufacturer’s instructions for use for the old steam sterilizers and the new steam sterilizers. During an interview on 3/12/26 at 10:45 a.m. with the AS, AS stated the old steam sterilizer manufacturer’s IFU’s, old photos or any documentation for the old steam sterilizers could not be found. During a review of hospital P&P titled, “2026 Infection Prevention and Control Plan”, dated 2026, the P&P indicated, “HIGH LEVEL DISINFECTING AND STERILIZATION Refer to Sterilization, Disinfection and asepsis-General Review policy. List of High-Level disinfectant and sterilizers ...Central Processing MASCO Eagle Series 3000 Autoclave ...”. During an interview and document review on 3/12/26 at 11:25 a.m., with the QRD, a document titled “Purchase Order”, dated 10/7/25 was reviewed. The purchase order from Steers Corporation included two MASCO 400 Series steam sterilizers, installation labor, reinstallation, and Seismic Anchoring. Additionally, the work order indicated “Trade-In Eagle Sterilizer” The QRD validated the purchase order. There was no documentation indicating the old steam sterilizers and new steam sterilizers were the same steam sterilizers. During an interview on 3/12/26 at 11:27 am. with HCAI Project Architect (HCAI), HCAI stated any project to replace steam sterilizers even exact same equipment, required a field review with HCAI to determine if construction was indicated. HCAI stated a review of the HCAI online system indicated the last request from [name of hospital] was in 2019. The HCAI project manager stated seismic anchoring was considered construction and HCAI must be involved with construction. During a review of document titled “Freer Manual - a guide for Field Review (CFR) Projects, Excluded (E) from HCAI/SPD Plan Review (ER) (Freer Manual) dated August 2025, Freer Manual indicated, “ ...This manual is formatted to assist users in understanding and obtaining necessary clearances, plan approvals and building permits from the Department of Health Care Access and Information (HCAI), Office of statewide Hospital Planning and Development (SPD), for projects that are classified as ‘Field Review’ ...Users should feel free to contact the regional filed staff if they have any questions ...ESQ-16 Equipment - Installing equipment weighing more than 400 lbs. ER=Expedited (office) review ...” During a review of the document linked in the Freer Manual to equipment weighing more than 400 pounds titled “HCAI POLICY INTENT NOTICE, SUBJECT Support and Attachment Requirements for Fixed ...Equipment ...PURPOSE ... (Freer Manual Link), Freer Manual Link indicated, “To maintain sanitary conditions in the hospital and/or for routine service or maintenance some hospital equipment is required to be moved from its usual fixed or stationary position. Other equipment is required to be moved from location to location for operational purposes. To establish which equipment is required to be anchored, restrained, or permitted to be unanchored to meet the operational needs of the hospital, new definitions were added to the 2019 California Building Code (CBIC) and revised in the 2022 CBIC. This PIN clarifies what is needed to be shown on the construction documents to identify which equipment falls in each classification and whether it is required to be anchored or restrained, and if required to be restrained, what constitutes an acceptable restraint ...POLICY ...To facilitate plan review and construction, all construction documents should include an equipment schedule identifying all applicable equipment, its classification (fixed, movable, mobile or other) ...Fixed Equipment Fixed equipment includes but is not limited to: Mechanical, electrical and plumbing equipment, medical, laboratory or other equipment that is intended to be moved for cleaning our use. 1. Design requirements: a Weight>400 lb: Provide support and attachment details on the drawing and submit seismic design calculations ...””

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 48901 Based on interview and record review, the hospital failed to implement its policy and procedure (P&P) titled, “Patient Complaint / Grievance,” for one of two sampled patients (Patient 16). This failure resulted in Patient 16’s complaints and concerns not being addressed during her hospitalization which had the potential to negatively affect Patient 16’s pyschosocial well-being. Findings: During a review of Patient 16’s “Nursing Narrative Note” (NNN), dated 12/11/25 at 6:20 p.m. documented by Registered Nurse (RN) 1, the NNN indicated, “During change of shift, Per patient, ‘other male peer [Patient 17] touch me in butt twice, while I was making phone call [sic].’ per staff no one saw male peer [Patient 17] touching her.” During an interview on 1/6/26 at 11:56 a.m. with Quality and Risk Manager (QRM), QRM stated she did not interview staff, Patient 16, nor Patient 17 regarding Patient 16’s allegations on 12/11/25. During a concurrent interview and record review on 1/7/26 at 9:12 a.m. with QRM, Patient 16’s “BH Progress Note” (BHPN), dated 12/10/25 at 12:45 p.m. was reviewed. The BHPN indicated, “PT [Patient 16] REPORTED ABUSE BY MALE PEER. . . PT CAME TO SPEAK TO THERAPIST. PT REPORTED MALE PEER [Patient 17] TWO NIGHTS AGO, TOUCHED HER INAPPROPRIATELY AS SHE WAS ON THE PT PHONE DURING THE NIGHT SHIFT. PT [Patient 16]ALSO REPORTED THAT MALE PEER [Patient 17], WENT TO HER ROOM THAT NIGHT AND ASKED HER IF SHE WANTED TO HAVE SEX. PT [Patient 16] REPORTED SHE DECLINED MALE PEER [Patient 17]OFFER. PT [Patient 16] ALSO REPORTED THAT MALE PEER [Patient 17] IS TAKING HER FOOD AND TOOK HER JACKET.” QRM stated it was unknown the number of incidences of Patient 17’s inappropriate behavior directed towards Patient 16. QRM stated there was no documentation to provide that Patient 16’s complaints/concerns were investigated. During a concurrent interview and record review on 1/7/26 at 9:41 a.m. with QRM, the hospitals “Patient Grievance Log,” (PGL) dated December 2025 was reviewed. The PGL indicated no grievances for Patient 16 and Patient 17. QRM stated the PGL did not indicate any grievances made for or by Patient 16 and Patient 17 regarding Patient 16’s 12/10/25 allegations of sexual and physical abuse, and harassment. QRM stated the facility’s grievance process was not followed. During a concurrent interview and record review on 1/7/26 at 1:57 p.m. with Case Manager (CM), Resident 16’s “BH Master Treatment Plan” (BHMTP), dated 12/9/25 at 2:33 p.m. was reviewed. The BHMTP indicated, “PT [Patient 16] STATED THAT HER OLD ROOM MATE HAD TAKEN SOMETHING FROM HER, TW [this writer] TRIED TO EXPLAIN TO HER THAT SHE NEEDED TO LOOK FOR IT BETTER BEFORE ACCUSING ANYONE, AND IF YOU DO NOT FIND IT, AND IF IT IS NOT THAT IMPORTANT THEN THERE WILL BE MORE.” CM stated Patient 16 liked to make wrongful accusations. CM stated since Patient 16 did not find her lip gloss [lost item] she could have purchased a new one when she was discharged. CM stated she should have notified her supervisor and escalated Patient 16’s complaint/concerns. CM stated she did not follow the grievance process for Patient 16’s complaint/concerns. During a review of the hospitals P&P titled, “Patient Complaint / Grievance,” dated 7/25/25, the P&P indicated, “PURPOSE: It is the policy of [hospital] to assess patient satisfaction in the hospital in a variety of ways. Issues that arise, including complaints, will be promptly responded to through the appropriate staff. It is every employee’s responsibility to address concerns promptly to the best of their ability and refer matters through the chain of command when initial efforts do not meet the patient’s expectations. . . PROCEDURE. . . 3. Reporting Grievances: Any written Patient Complaint and any verbal Patient Complaint that cannot be promptly resolved by the Staff Member(s) present shall be referred to the Customer Service Representative. The Customer Service Representative will document and route all unresolved complaints, at the time of the call, to the Department Manager to investigate the complaint and provide a plan of correction. The Patient Complaint form and supporting documentation will be forward to the Quality Assurance Department for review, notification to the Grievant, and tracking. 3.1 Options and Time Frame for Referral. . . 3.1. 3. Timeliness: Patient Grievance related to the quality of care or patient safety shall be reported as soon as possible. 4. Receipt, Investigation and Resolution. . . 4.4. Timeliness: Most grievances should be completed within seven days of receipt. . . 4.5. Conclusion of Investigation: At the conclusion of the investigation, the Grievant shall be sent a letter briefly describing the conclusions of the investigation and, when appropriate, the steps taken to resolve the matter.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48901 Based on interview and record review, the hospital failed to implement its policy and procedure (P&P) titled, “Patient Rights and Responsibilities, Parents (or Guardians),” for two of 30 sampled patients (Patient 15 and Patient 16), when: 1. Patient 15 was undergoing a laparoscopic (small incisions in the belly) Cholecystectomy (gallbladder- organ of the body removal) surgery and laparoscopic Stryker scope camera was dropped. This failure resulted in Patient 15 not being provided with a safe environment of care. 2a. Patient 16 was inappropriately touched by Patient 17. This failure had the potential for Patient 16 to experience physical and psychosocial [thoughts emotions and beliefs] harm. 2b. Patient 16 was not provided personal dignity during her hospital stay. This failure had the potential for harm to Patient 16’s emotional and psychosocial health. Findings: 1. During an interview on 1/8/26 at 9:20 a.m. with Operating Room Manager (ORM), ORM stated on 11/4/25 Patient 15 had a laparoscopic (small incisions in the belly) Cholecystectomy (gallbladder- organ of the body removal) surgery. ORM stated the laparoscopic Stryker scope camera was “blurry.” ORM stated the camera’s Coupler (a device that links two things together) was dropped when it was removed from the scopes camera to be cleaned. ORM stated there was not another available laparoscopic Stryker scope camera onsite at the facility for continued use for Patient 15’s surgery. ORM stated Patient 15’s surgical procedure was paused. ORM stated she made the decision to obtain another laparoscopic Stryker scope camera from another facility. ORM stated Patient 15 was in surgery under anesthesia until she returned with the borrowed facility’s laparoscopic Stryker scope camera. ORM stated that when a patient is placed under anesthesia for longer than anticipated there is potential for poor outcomes/risks. During an interview on 1/8/26 at 9:55 a.m. with Surgical Technician (ST) 1, ST 1 stated on 11/4/25, the laparoscopic Stryker scope camera was only visually inspected before Patient 15’s surgery. ST 1 stated a visual inspection cannot determine if the Stryker scope camera view was “foggy.” ST 1 stated during Patient 15’s surgery the camera was “foggy” and upon inspection the seal on the camera was bad. ST 1 stated Patient 15 was under anesthesia and the surgery needed to be completed. ST 1 stated someone made the decision to borrow a camera from another facility. During a review of the “Manufacture Guidelines” (MG) titled, “Stryker”, (undated), the MG indicated, “Operation ...Performing the White Balance Test [a calibration procedure]: Before each surgical procedure, perform the White Balance test to adjust the camera’s perception of white so it can display other colors correctly.” During a concurrent interview and record review on 1/9/26 at 11:51 a.m. with ORM, Patient 15’s “Intraoperative Report,” (IR) dated 11/4/25 at 12:51 p.m. was reviewed. The IR indicated Patient 15 was brought into the operating room at 10:08 a.m. and left at 12:56 p.m. The IR did not indicate when Patient 15’s surgery was paused, restarted, or accounted for the additional laparoscopic Stryker scope camera equipment used (borrowed Stryker scope), and Patient 15 was informed of the delay in her surgery. ORM stated there was no documentation to provide for the additional laparoscopic Stryker scope camera used. During a review of Patient 15’s “Intraoperative Anesthesia Flowsheet” (IAF) dated 11/4/25, the IAF indicated, “Times: Anesthesia Start: 1008 [a.m.], Surgery Start: 1035[a.m.], End: 1251[p.m.], Anesthesia End: 1301[ 1:01 p.m.].” During an interview on 1/9/26 at 1:29 p.m. with Chief Administrative Officer (CAO), CAO stated Patient 15’s surgery on 11/4/25 was planned and non-emergent. During an interview on 1/9/26 at 2:48 p.m. with CAO, CAO stated the facility staff were expected to follow P&P’s. CAO stated patients were to be provided with a safe environment of care. CAO stated the nurse manager was responsible to review the surgical schedule and to ensure the necessary laparoscopic Stryker scope camera was onsite and available for Patient 15. During a review of “Nurse Manager of Surgery Job Description (NMSJD),” (undated), the “NMSJD” indicated, “Makes and implements decisions regarding activities in area of responsibility based on Hospital Administration Standards, Human Resource Standards, Department of Nursing Standards, and Unit Standards and the Chief of Surgery or the Director of Patient care services in unusual situations ...In collaboration with the medical staff, coordinate scheduling of surgical procedures in the Operating Room to ensure that there is available staff, space, equipment and support for provision of required services.” During a review of the hospitals P&P titled, “Patient Rights and Responsibilities, Parents (or Guardians),” dated 7/24/25. The P&P indicated, “Personal Safety: The patient has the right to expect reasonable safety insofar [sic] as the hospital’s practices and environment are concerned.” 1a. During a review of Patient 16’s “Nursing Narrative Note” (NNN), dated 12/11/25 at 6:20 p.m. documented by Registered Nurse (RN) 1, the NNN indicated, “During change of shift, Per patient, ‘other male peer [Patient 17] touch me [Patient 16] in butt twice, while I was making phone call’ [sic] per staff no one saw male peer [Patient 17] touching her.” During a concurrent interview and record review on 1/7/26 at 9:12 a.m. with Quality and Risk Manager (QRM), Patient 16’s “BH Progress Note” (BHPN), dated 12/10/25 at 12:45 p.m. was reviewed. The BHPN indicated, “PT [Patient 16] REPORTED ABUSE BY MALE PEER [Patient 17]. . . PT [Patient 16] CAME TO SPEAK TO THERAPIST. PT REPORTED MALE PEER [Patient 17] TWO NIGHTS AGO, TOUCHED HER INAPPROPRIATELY AS SHE WAS ON THE PT PHONE DURING THE NIGHT SHIFT. PT [Patient 16] ALSO REPORTED THAT MALE PEER [Patient 17], WENT TO HER ROOM THAT NIGHT AND ASKED HER IF SHE WANTED TO HAVE SEX. PT [Patient 16]REPORTED SHE DECLINED MALE PEER [Patient 17] OFFER. PT [Patient 16] ALSO REPORTED THAT MALE PEER [Patient 17] IS TAKING HER FOOD AND TOOK HER JACKET.” QRM stated it was unknown the times and circumstances that Patient 16 was inappropriately touched, harassed, and asked to have sex by Patient 17. QRM stated there was no documentation Patient 16 was offered to make a police report, notification to the Physician, counseling, internal and external report of abuse allegations for further investigation to provide. During an interview on 1/7/26 at 2:24 p.m. with QRM, QRM stated on 12/17/25 she was made aware of the inappropriate touching incident that happened on 12/11/25. QRM stated the facility’s abuse reporting process included Physician notification, offering the patient to notify and file a police report, counseling, increased monitoring and observation, be provided a room change, and an internal grievance and external mandated report made to the State Agency for investigation. QRM stated patient rights included Patient 16 to be provided with a safe environment. QRM stated Patient 16 and Patient 17 were discharged on 12/18/25. During an interview on 1/7/26 at 2:56 p.m. with QRM, QRM stated the incident on 12/10/25 was a missed opportunity to investigate, protect Patient 16 from repeated abuse (12/11/25) and potential abuse towards other patients. During an interview on 1/9/26 at 8:40 a.m. with Interim Chief Nursing Officer (ICNO), ICNO stated Patient 16 and patient 17 should have been separated, with increased observational monitoring. ICNO stated the appropriate staff should have been notified and facility procedures should have been followed. ICNO stated Patient 16 should have had emotional and psychosocial support provided. ICNO stated Patient 16 and Patient 17’s physician(s) should have been notified and have their treatment plans updated. ICNO stated the facility did not follow its patient rights P&P. 1b. During a concurrent interview and record review on 1/7/26 at 1:57 p.m. with Case Manager (CM), Resident 16’s “BH Master Treatment Plan” (BHMTP), dated 12/9/25 at 2:33 p.m. was reviewed. The BHMTP indicated, “PT [Patient 16] STATED THAT HER OLD ROOM MATE HAD TAKEN SOMETHING FROM HER, TW [this writer] TRIED TO EXPLAIN TO HER THAT SHE NEEDED TO LOOK FOR IT BETTER BEFORE ACCUSING ANYONE, AND IF YOU DO NOT FIND IT, AND IF IT IS NOT THAT IMPORTANT THEN THERE WILL BE MORE.” CM stated Patient 16 liked to make wrongful accusations. CM stated since Patient 16 did not find her lip gloss [lost item] she could have purchased a new one when she was discharged. CM stated she should have notified her supervisor and escalated Patient 16’s complaint/concerns. CM stated she did not follow the facility’s patient rights P&P. CM stated Patient 16 was not treated with dignity and respect. During a review of the hospitals P&P titled, “Patient Rights and Responsibilities, Parents (or Guardians),” dated 7/24/25, the P&P indicated, “PURPOSE: To clarify Patient Rights. . . POLICY/PROCEDURE: PATIENT RIGHTS: The rights and responsibilities delineated below apply to patients. . . All hospital personnel should observe these patient rights. . . Respect and Dignity: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition of personal dignity. . . Personal Safety: The patient has the right to expect reasonable safety insofar [sic] as the hospital’s practices and environment are concerned. . . Complaints: Patients are entitled to information about the hospital’s mechanism for initiation, review and resolution of patient complaints.””

“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: 48901 Based on interview and record review, the hospital failed to follow its policy and procedure (P&P) titled, “Abuse Identifying and Reporting,” for one of 11 sampled patients (Patient 16), in the behavioral health unit, when staff did not report Patient 16’s allegation of abuse to the State Agency. This failure resulted in a delay in an investigation and the potential to prevent abuse. Findings: During a review of Patient 16’s “Nursing Narrative Note” (NNN), dated 12/11/25 at 6:20 p.m. documented by Registered Nurse (RN) 1, the NNN indicated, “During change of shift, Per patient, ‘other male peer [Patient 17] touch me in butt twice, while I was making phone call [sic].’ per staff no one saw male peer [Patient 17] touching her.” During a concurrent interview and record review on 1/6/26 at 11:38 a.m. with Quality and Risk Manager (QRM), the facility video record titled, “Common Area” (CA), dated 12/11/25, was reviewed. The CA indicated at 6:14:16 (hour/minutes/seconds) p.m. Patient 17 walked from the adult hallway (hallway of Patient 17’s room) towards the common area (where nursing station is located), Patient 16 was facing the wall and using the phone in the common area. Patient 17 stopped next to Patient 16, turned his back towards Patient 16. Patient 16 and Patient 17 were back-to-back when Patient 17 reached outward with his right hand, palm side up, touched and rubbed Patient 16’s buttocks. Patient 17 then walked away immediately and stood near the restroom in the patient common area. In response to being touched, Patient 16 turned around. At 6:14:33 p.m. Patient 17 waved at Patient 16 as he walked back to the adult hallway. At 6:14:50 p.m. Patient 16 was observed talking to staff and pointing towards the adult hallway. QRM stated Patient 16 was inappropriately touched by Patient 17. During an interview on 1/6/26 at 11:56 a.m. with Quality and Risk Manager (QRM), QRM stated she did not interview staff, Patient 16, nor Patient 17 regarding Patient 16’s allegations on 12/11/25. During a concurrent interview and record review on 1/7/26 at 9:12 a.m. with QRM, Patient 16’s “BH Progress Note” (BHPN), dated 12/10/25 at 12:45 p.m. was reviewed. The BHPN indicated, “PT [Patient 16] REPORTED ABUSE BY MALE PEER. . . PT CAME TO SPEAK TO THERAPIST. PT REPORTED MALE PEER [Patient 17] TWO NIGHTS AGO, TOUCHED HER INAPPROPRIATELY AS SHE WAS ON THE PT PHONE DURING THE NIGHT SHIFT. PT [Patient 16]ALSO REPORTED THAT MALE PEER [Patient 17], WENT TO HER ROOM THAT NIGHT AND ASKED HER IF SHE WANTED TO HAVE SEX. PT [Patient 16] REPORTED SHE DECLINED MALE PEER [Patient 17]OFFER. PT [Patient 16] ALSO REPORTED THAT MALE PEER [Patient 17] IS TAKING HER FOOD AND TOOK HER JACKET.” QRM stated it was unknown the number of incidences of inappropriate behavior. QRM stated there was no documentation to provide that Patient 16’s complaints/concerns were investigated. During an interview on 1/7/26 at 2:24 p.m. with QRM, QRM stated on 12/17/25 she was made aware of the inappropriate touching incident that happened on 12/11/25. QRM stated the facility’s abuse reporting process included Physician notification, offering the patient to notify and file a police report, counseling, increased monitoring and observation, be provided a room change, and an internal grievance and external mandated report made to the State Agency for investigation. QRM stated patient rights included Patient 16 to be provided with a safe environment. QRM stated Patient 16 and Patient 17 were discharged on 12/18/25. During an interview on 1/7/26 at 2:56 p.m. with QRM, QRM stated the incident on 12/10/25 was a missed opportunity to investigate, protect Patient 16 from repeated abuse (12/11/25) and potential abuse towards other patients. QRM stated the incident was not reported within 24 hours to California Department of Public Health (CDPH). QRM stated the “Abuse Identifying and Reporting,” policy was not followed. During an interview on 1/7/25 at 3:28 p.m. with Medical Doctor (MD) 1, MD 1 stated he was not aware of Patient 16 being inappropriately touched and asked to have sex by Patient 17. MD 1 stated if he was made aware he would have evaluated the patients (Patient 16 and Patient 17), updated their treatment plans, increased observational monitoring from every 15 minutes to every 5 minutes, or 1:1 (one mental health worker to one patient observation), and offered Patient 16 to file a police report. MD 1 stated he expects staff to notify him and follow the facility’s P&Ps. MD 1 stated after Patient 17’s medical evaluation he could have added danger to others to his treatment plan. MD 1 stated Patient 16 was at risk for victimization and trauma. During an interview on 1/8/26 at 2:53 p.m. with Psychiatric Program Manager (PPM), PPM stated she was aware of Patient 16’s allegations of abuse and harassment on 12/10/26. PPM stated there was no documentation to provide the facility investigated and reported to CDPH for Patient 16’s allegations of abuse and harassment. PPM stated the facility’s P&P for abuse was followed. During an interview on 1/8/26 at 3:29 p.m. with Therapist, Therapist stated there was no documentation to provide that Patient 16 received the support and therapeutic counseling after Patient 16 notified him on 12/10/25 of allegations of abuse and harassment from Patient 17 . During an interview on 1/9/26 at 8:40 a.m. with Interim Chief Nursing Officer (ICNO), ICNO stated Patient 16 and patient 17 should have been separated, with increased observational monitoring. ICNO stated the appropriate staff should have been notified and facility procedures should have been followed. ICNO stated Patient 16 should have had emotional and psychosocial support provided. ICNO stated Patient 16 and Patient 17’s physician(s) should have been notified and have their treatment plans updated. ICNO stated the facility did not follow its abuse P&P. During a review of the hospitals P&P titled, “Abuse Identifying and Reporting,” dated 9/24/24, the P&P indicated, “PURPOSE: To provide procedures for investigating, reporting, and following up when an allegation of patient abuse or neglect may have occurred in our facilities. To provide for notifying external agencies of allegations of abuse, as required. . . POLICY Patients have the right to be free from abuse or neglect as well as the fear of being abused or neglected. Allegations or information indicating the abuse or neglect may have occurred will be thoroughly and promptly investigated with appropriate follow-up action taken. . . Hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may have occurred and to report any and all information concerning where abuse or neglect may have occurred. . . The hospital also recognizes that persons with mental illness are vulnerable and are at risk for abuse or neglect. . . Patients who are victims of abuse or neglect will be provided counseling and support directed at re-establishing therapeutic relationships and addressing the impact of the abuse or neglect on the individual. PROCEDURE B. Employees who witness or have knowledge of suspected patient abuse during admission shall immediately report it to the Charge Nurse. . . Documentation in the form of an occurrence report is to be completed and provided to a Charge Nurse by employees reporting allegations of abuse or neglect. C. The Charge Nurse will gather initial facts and include the findings in the occurrence report. . . The charge nurse will ensure a physical assessment is completed. . . D. The Charge Nurse serves as initial investigator and reports immediately to the Risk Manager. . . E. The Risk Manager or their Designee will initiate a Patient Complaint/Grievance Form to document the findings and obtain additional information if needed to determine a conclusion. . . Reporting I. . . If, after investigation, allegations are found to be true the California Department of Public Health will be notified of abuse or neglect. m. The Risk Manager or their designee will report suspicions of abuse or neglect to the police department. n. an Unusual Occurrence Report will be completed by the Risk Manager.””

“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: 51540 Based on observation, interview, and record review the hospital failed to follow its policy and procedure (P&P) titled, “Clean Equipment Storage Room,” when: 1a. Stored equipment was not covered in one of one clean utility room. 1b. Broken Equipment was stored in one of one clean utility room. These failures resulted in cross contamination with the potential to spread infection throughout the hospital. Findings: 1a. During a concurrent observation and interview on 1/6/26 at 10:52 a.m. with Nurse Manager (NM), in the clean utility room, the following were noted: a folded walker, two uncovered black chairs, one uncovered blue chair, five uncovered IV poles, two wheelchairs, and a training cart were stored in the clean utility room. NM stated everything should be covered inside the clean utility room to indicate it was clean. NM stated there are multiple items in the closet that are not covered and should be. 1b. During a concurrent observation and interview on 1/6/26 at 10:54 a.m. with NM, in the clean utility room, the following were noted: a gray bedside table that had a bend in the leg with a black fan on top which was missing the front cover (exposing the blades),and a vital sign machine with a red tag indicated “Defective. Dated 6/27/25. Problem: vital machine charger no good. So the machine not charges [sic] ...also not working,” were stored in the clean utility room. NM stated no broken items should be placed in this clean utility room. During a review of the hospitals P&P titled, “Clean equipment storage room,” dated 11/20/25, the P&P indicated, “PURPOSE: To define what items may be stored in Clean Utility Rooms and ensure only clean, functional, and appropriately prepared patient care equipment is stored ...POLICY: Non-critical items are those items which come in contact with intact skin ...Examples” bedpans, blood pressure cuffs ...bedside table. . . The Clean Utility Room is designated only for the storage of clean, non-critical patient care equipment and supplies. Storage Requirements-Permitted Items ...Equipment cleaned, disinfected, dried, and wrapped with a clean plastic cover. Equipment ready for patient use. Storage Requirements-Prohibited Items: soiled or used equipment ...Equipment awaiting repair or disposal.””

“Progress Notes Recommendations and Revisions CFR(s): ...and must contain recommendations for revisions in the treatment plan as indicated as well as This Standard is not met as evidenced by: 48901 Based on interview and record review, the hospital failed to follow its policy and procedure (P&P) titled, “Psychiatric Master Treatment Plan [A summary of information derived from sources, such as the psychosocial assessment, nurse and provider assessments, patient perception, and history],” for two of 11 sampled patients (Patient 16 and Patient 17). This failure had the potential to negatively impact Patient 16 and Patient 17’s continuity of care. Findings: During a review of Patient 16’s “Nursing Narrative Note” (NNN), dated 12/11/25 at 6:20 p.m. documented by Registered Nurse (RN) 1, the NNN indicated, “During change of shift, Per patient, ‘other male peer [Patient 17] touch me in butt twice, while I was making phone call [sic].’ per staff no one saw male peer [Patient 17] touching her.” During a concurrent interview and record review on 1/7/26 at 9:12 a.m. with QRM, Patient 16’s “BH Progress Note” (BHPN), dated 12/10/25 at 12:45 p.m. was reviewed. The BHPN indicated, “PT [Patient 16] REPORTED ABUSE BY MALE PEER. . . PT CAME TO SPEAK TO THERAPIST. PT REPORTED MALE PEER [Patient 17] TWO NIGHTS AGO, TOUCHED HER INAPPROPRIATELY AS SHE WAS ON THE PT PHONE DURING THE NIGHT SHIFT. PT [Patient 16]ALSO REPORTED THAT MALE PEER [Patient 17], WENT TO HER ROOM THAT NIGHT AND ASKED HER IF SHE WANTED TO HAVE SEX. PT [Patient 16] REPORTED SHE DECLINED MALE PEER [Patient 17]OFFER. PT [Patient 16] ALSO REPORTED THAT MALE PEER [Patient 17] IS TAKING HER FOOD AND TOOK HER JACKET.” QRM stated it was unknown the number of incidences of inappropriate behavior. QRM stated there was no documentation to provide that Patient 16’s complaints/concerns were investigated. During an interview on 1/7/25 at 3:28 p.m. with Medical Doctor (MD) 1, MD 1 stated he was not aware of Patient 16 being inappropriately touched and asked to have sex by Patient 17. MD 1 stated if he was made aware he would have evaluated the patients (Patient 16 and Patient 17), updated their treatment plans, increased observational monitoring from every 15 minutes to every 5 minutes, or 1:1 (one mental health worker to one patient observation), and offered Patient 16 to file a police report. MD 1 stated he expects staff to notify him and follow the facility’s P&Ps. MD 1 stated after Patient 17’s medical evaluation he could have added danger to others to his treatment plan. MD 1 stated Patient 16 was at risk for victimization and trauma. During an interview on 1/8/26 at 3:29 p.m. with Therapist, Therapist stated there was no documentation to provide that Patient 16 and Patient 17’s Master Treatment Plans was updated. During a review of the hospitals P&P titled, “Psychiatric Master Treatment Plan,” dated 9/19/25, the P&P indicated, “PURPOSE: Ensure a multi-disciplinary plan for each patient based on needs. . . POLICY: The patient’s individualized treatment plan shall be formulated by the multidisciplinary professional staff following thorough assessments of the patient, and approved by the treating physician. PROCEDURE. . . CLINICAL DOCUMENTATION 1. Psychiatrists shall dictate reports that describe the treatment. Staff members (nursing, social services, therapists) shall document daily the treatment provided in the progress notes. . . Treatment Plan Update: 1. A formal update of the master treatment plan shall be conducted by the team as frequently as the patient’s condition requires. . . 2. Reassessment is based on the scope and intensity of services required as well; as on the patient’s functioning and preferences for care, treatment, and services. 3. Reassessment will include (but not limited to) the following. . . b. Change of Observation Need (e.g Q5, 1:1) c. Response to a significant change in status. . . 4. Target problems shall be summarized, progress towards goals shall be reviewed, new goals and interventions defined, as well as discharge considerations shall be updated.””

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 47734 Based on interview and record review the hospital failed to follow their Policy and Procedures (P&P) to complete a care plan for one of 30 sampled patients (Patient 21) when Patient 21 did not have a care plan for pain management. Findings: During a concurrent interview and record review on 9/24/24 at 3:18 p.m. with Health Information Manager (HIM), Patient 21’s “Pain Assessment (PA) and Medication Administration Record (MAR),” dated 9/23/24, the PA indicated, Patient 21 had lower abdominal pain. The MAR indicated Patient 21 was given pain medication at 11:24 a.m. During a concurrent interview and record review on 9/24/24 at 3:18 p.m. with HIM, Patient 21’s “Medical Records (MR),” undated, the MR indicated Patient 21 did not have a care plan for pain management. During an interview on 9/25/24 at 12:53 p.m. with Registered Nurse (RN), RN stated for a patient who complains of pain, she would assess the pain score and check if the was an order for pain medication. RN stated she would start the pain care plan right away when a patient complains of pain. During a review of the hospital’s policy and procedure (P&P) titled, “Pain Assessment and Management Standards,” dated 10/27/22, the P&P indicated, “Educate patient and family on discharge plans related to pain management including: plan of care, side effect of pain management treatment.” During a review of the hospital’s P&P titled, “Nursing Diagnosis/Patient Problems/Care Plan,” dated 4/27/23, the P&P indicated, “c. A written patient care plan is developed for each hospitalized patient by use of the nursing process: a problem-solving method consisting of assessment, planning, intervention, and evaluation. The care plan includes physiological, psychological, and environmental factors.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48901 Based on interview, and record review the hospital failed to protect and promote the rights of patients in the behavioral health unit as evidenced by: 1. Quality Risk Manager (QRM) did not follow hospital policy and procedures (P&P) titled “Patient Elopement [leave a medical facility without permission]” and “Occurrence Reporting & Adverse Event Determination,” when one of one sampled patient (Patient 2), with a legal hold due to high risk of self-harm, eloped through the exit doors. This failure resulted in a delay in the investigation of a safe environment in the behavioral health unit. (Refer to A-142) 2. A safe environment for three of four sampled patients (Patient 2, Patient 3 and Patient 4) when: a. Therapist were not informed of:a. one of four sampled patients’ (Patient 1) need for counseling due to staff to patient abuse b. one of four sampled patients’ (Patient 4) need for counseling due to patient-to-patient altercation. These failures had the potential for Patient 1 and Patient 4 to not have appropriate emotional support.(Refer to A-144) b. Pharmacy Technician (PT) exited the security door of the behavioral health unit without an escort as required by policy. This failure resulted in Patient 2, with known high risk for suicide, to push PT away from the security doors of the behavioral health unit, elope (run away) from the hospital and the potential to commit self-harm. (Refer to A-144) 3.The hospital policy and procedure (P&P) titled, “Abuse Identifying and Reporting,” for two of four sampled patients (Patient 1 and Patient 4), in the behavioral health unit, who experienced abuse when: a. Mental Health Worker (MHW 1) choked one of four patients (Patient 4) in the behavioral health unit. This failure resulted in Patient 4 experiencing pain and had the potential to result in Patient 4 experiencing mental distress and/or physical injury. (Refer to A-145) b. MHW 3 continued working with one of four patients (Patient 1) in the behavioral health unit after being accused of committing abuse towards Patient 1. This failure had the potential to cause Patient 1 to experience severe emotional distress and the potential to not receive timely medical treatment and continued abuse. (Refer to A-145) c. Staff did not report the allegation (accusation) MHW 3 went into Patient 1’s room, struck and choked Patient 1 to the hospital’s abuse coordinator. This failure resulted in the hospital unable to conduct a timely investigation and protect Patient 1’s right to receive care in a safe environment. (Refer to A-145) d. The hospital Policy and Procedure (P&P) titled “Abuse Identifying and Reporting” did not indicate to report all allegations of abuse. This failure resulted in a delay in an investigation and the potential to prevent abuse. (Refer to A-145) 4. 15 of 20 sampled staff (Registered Nurse [RN] 2, RN 3, RN 4, RN 5, RN 6, RN 7, RN 8, RN 9, RN 10, RN 11, RN 12, RN 13, Certified Nurse Assistant [CNA] 1, CNA 2, and Mental Healthcare Worker [MHW] 8) were not current with required training when: a. 11 of 20 sampled staff (Registered Nurse [RN] 5, RN 6, RN 7, RN 8, RN 9, RN 10, RN 11, RN 12, RN 13, Certified Nurse Assistant [CNA] 2, and Mental Healthcare Worker [MHW] 8) completed required training for Handle with Care (HWC- verbal and physical de-escalation training). This failure had the potential to result in staff unable to de-escalate unstable situations and the potential to result in unsafe patient care. (Refer A-199) b. Four of 20 sampled staff (Registered Nurse [RN] 2, RN 3, RN 4, CNA 1), completed their annual competency. This failure had the potential to result in unsafe patient care. (Refer A-199) 5. Four of 20 sampled staff (Mental Health Worker [MHW] 5, MHW 6, Clinical Therapist [CT] 1 and Registered Nurse [RN] 1) Basic Life Support (BLS and Advanced Cardiac Life Support (ACLS) certificates were not current a. MHW 5, MHW 6 and CT 1 did not have current BLS certification. b. RN 1 did not have current ACLS certification. These failures had the potential to result in a delay in patient care, and patient safety during a life threatening event. (Refer to A-206) The cumulative effect of these systemic problems resulted in the facility’s failure to monitor and deliver care in a safe environment in the behavioral health unit and in compliance with the Condition of Participation for Patient Rights.”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 48901 Based on interview and record review, the hospital failed follow their policy and procedures (P&P) titled “Patient Elopement [leave a medical facility without permission]” and “Occurrence Reporting & Adverse Event Determination,” when one of one sampled patient (Patient 2), with a legal hold due to high risk of self-harm, eloped (leave a medical facility without permission) through the exit doors. This failure resulted in a delay in the investigation of a safe environment in the behavioral health unit. Findings: During a review of Patient 2’s “Provider Progress Note [PPN],” dated 7/30/24 at 8:16 a.m., the “PPN” indicated, “[Patient 2]...with unknown past psychiatric [mental health] history who was admitted to [Hospital] on a 5250 hold [involuntary 14 day hold] for danger to self after he cut his throat with glass to end his life and stated, “God told me to do it.” The patient [Patient 2] was given a preliminary diagnosis of brief psychotic disorder [disconnection from reality], with suspicion of schizoaffective disorder [mental health disease] or schizophrenia [mental health disease] . . .REASONS FOR CONTINUED STAY: AWOLED [Absent Without Leave] from the unit last night. . .The patient’s 5250 hold expires today and a 5260 [additional involuntary 14 day hold] hold will be submitted as he remains a danger to himself. The patient has high acute [time-limit] suicide risk assessment. . .The patient has high imminent (ready to happen) risk of suicide and self-harm. Patient is unable to verbalize a viable [workable] plan for self-care and current presentation is evidence that the patient cannot care for himself in a less restrictive setting.” During a review of Patient 2’s “Nursing Narrative Note [NNN],” dated 7/29/24 at 18:15 (6:15 p.m.), the “NNN” indicated, “patient [2] follow the pharmacy staff [PT] when staff push numbers on door key pad to open the door and patient kick the door and push the staff away and run in hallway towards dietary department and staff try to hold patient, patient swing on the staff and patient run through dietary exit door.” During a review of Patient 2’s “NNN,” dated 7/29/24 at 20:54 (8:54 p.m.), the “NNN” indicated, “Pt [Patient 2] came back in the unit @ [at] 20:25 [8:25 p.m.] and pt states ‘He ran away because he feel [sic] anxious and he went to his home...” During an interview on 8/7/24 at 9:03 a.m. with Quality and Risk Manager (QRM), QRM stated when Patient 2 eloped (outside of facility for about 2 hours), she did not report to the Department because Patient 2 returned back to the facility on the same day. During a review of the facility’s policy & procedures (P&P) titled, “Patient Elopement,” dated 10/28/22, the P&P indicated, “Patients who leave without informing a member of the healthcare staff; or patients who breach the inpatient unit exit doors...without consent or cause to do so, are considered to have eloped. . .PURPOSE: To ensure that patients held for any combination of Danger to Self, Danger to Others, Grave Disability, or patients retained in the inpatient setting on administration days pending acceptable housing due to conservatorship (“involuntary patient”) are returned to appropriate and compelled care as quickly and safety as possible ... “ During a review of the facility’s policy & procedure (P&P) titled, “Occurrence Reporting & Adverse Event Determination,” dated 5/16/23, the P&P indicated, “PURPOSE: An effective Quality and Patient Safety Program requires optimal reporting of medical/health care occurrences. . .California Department of Public Health: When an event meets the self-reporting provision in Title 22 and California Health and Safety Code Section 1279.1, the Risk Manager or designee will report no later than 5 days after the event has been detected. . .California Code of Federal Regulation (CCR) Title 22 Section 70737: Unusual Occurrences may include but is not limited to. . .unusual occurrence which threatens the welfare, safety, or health of patients, personnel, or visitors.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47734 Based on interview and record review the hospital failed to follow their Policy and Procedures (P&P) to provide a safe environment for three of four sampled patients (Patient 1, Patient 2 and Patient 4) when: 1. The hospital did not inform the therapists of a. one of four sampled patients’ (Patient 1) need for counseling due to staff to patient abuse b. one of four sampled patients’ (Patient 4) need for counseling due to patient-to-patient altercation. These failures had the potential for Patient 1 and Patient 4 to not have appropriate emotional support. 2. Pharmacy Technician (PT) exited the security door of the behavioral health unit without an escort as required by policy. This failure resulted in Patient 2, with known high risk for suicide, to push PT away from the security doors of the behavioral health unit, elope (run away) from the hospital and the potential to commit self-harm. Findings: 1a. During a review of an anonymous complaint dated 7/31/24 received by the California Department of Public Health (Dept), the complaint indicated on 7/30/24, Mental Health Worker (MHW) 3 went into Patient 1’ room, struck Patient 1 and then MHW 3 returned to Patient 1’s room and choked Patient 1. 1b. During a review of a facility reported incident (FRI) dated 7/31/24 received by the California Department of Public Health (Dept), the FRI indicated on 7/1/24, Patient 3 suddenly and unprovoked hit Patient 4. The FRI indicated on 7/1/24, MHW 2 pushed Patient 4 away from the nurses station. The FRI also indicated Patient 4 was standing near the activity room, when uprovoked MHW 1 ran toward Patient 4 and grabbed him by the throat. During an interview on 8/5/24 at 1:21 p.m. with Clinical Therapist (CT) 1, CT 1 stated she was not aware of any abuse allegation from the staff. CT 1 stated patients who experienced abuse would benefit from speaking with a therapist. During an interview on 8/5/24 at 1:38 p.m. with CT 2, CT 2 stated the hospital staff had not asked her to speak with any patient that was a victim of staff to patient alleged abuse. During an interview on 8/6/24 at 4:19 p.m. with Psych (psychological, mental or emotional state) Program Manager (PPM), PPM stated the hospital did not inform therapists about abuse incidents in order to provide counseling to patients. During a review of the hospital’s P&P titled, “Patient to Patient Altercation,” dated 5/23/24, the P&P indicated, “Assess the physical and emotional well-being of the patients involved and provide appropriate medical care or support as needed.” During a review of the hospital’s Policy and Procedure (P&P) titled, “Abuse Identifying and Reporting,” dated 4/23/24, the P&P indicated, “Patients who are victims of abuse or neglect will be provided counseling and support ...appropriate counseling and treatment should be given as part of the individual’s individualized plan of care.” 48901 2. During a review of Patient 2’s “Provider Progress Note [PPN],” dated 7/30/24 at 8:16 a.m., the “PPN” indicated, “[Patient 2]...with unknown past psychiatric history who was admitted to [Hospital] on a 5250 hold [involuntary 14 day hold] for danger to self after he cut his throat with glass to end his life and stated, “God told me to do it.” The patient [Patient 2] was given a preliminary diagnosis of brief psychotic disorder [disconnection from reality], with suspicion of schizoaffective disorder [mental health disease] or schizophrenia [mental health disease] . . .REASONS FOR CONTINUED STAY: AWOLED [Absent Without Leave] from the unit last night. . .The patient’s 5250 hold expires today and a 5260 [additional involuntary 14 day hold] hold will be submitted as he remains a danger to himself. The patient has high acute [time-limit] suicide risk assessment. . .The patient has high imminent (ready to happen) risk of suicide and self-harm. Patient is unable to verbalize a viable [workable] plan for self-care and current presentation is evidence that the patient cannot care for himself in a less restrictive setting.” During a review of Patient 2’s “Nursing Narrative Note [NNN],” dated 7/29/24 at 18:15 (6:15 p.m.), the “NNN” indicated, “patient [2] follow the pharmacy staff [PT] when staff push numbers on door key pad to open the door and patient kick the door and push the staff away and run in hallway towards dietary department and staff try to hold patient, patient swing on the staff and patient run through dietary exit door.” During an interview on 8/7/24 at 3:44 p.m. with QRM, QRM stated Pharmacy Technician (PT) did not follow the psychiatric (psych) unit rules that indicate that staff need to be companied in the psych unit for out of safety. QRM stated the PT did not look back to see if Patient 2 was following her, PT put in the code to unlock the door, opened door, and Patient 2 pushed her and left the unit and hospital. During an interview on 8/7/24 at 4:17 p.m. with PT, PT stated on 7/29/24 she was going out of the psych unit, she pushed the code to unlock door. PT stated Patient 2 came so quickly that she did not have time to close the door. PT stated she was not being escorted in the psych unit. PT stated she goes in and out of the unit. PT stated the facility had not provided her any training. During an interview on 8/7/24 at 4:20 p.m. with Chief Nursing Officer (CNO), CNO stated PT should not have had the code to the psych unit. During a video record review on 8/7/24 with QRM and CNO, the surveillance video record dated 7/29/24 at 6 p.m. was reviewed. Patient 2 sat cross-legged on the floor next to the door on the right side of the nursing station. PT, without an escort, walked towards the door on the right side of the nursing station, PT did not ask any staff to escort her through the door. PT entered the code for the door to unlock, Patient 2 got up fast, pushed PT out of the way. MHW 10 attempted to stop Patient 2 from exiting the unit. During a review of the Hospital wide memo (HWM) dated 2/22/24, at 3:32 pm, the HWM indicated “TEAM! If you ever need to go to the Psych [psychiatric, mental health] Unit (i.e. lab, pharmacy, housekeeping, dietary) Please make sure you go accompanied with a MHW, and as soon as you are done taking care of the patients’ needs you are to leave the unit.” During a review of the hospital’s P&P titled “Patient Elopement [unauthorized leaving of a medical facility]” dated 10/27/2022, the P&P indicated “Purpose: To ensure that patients held for any combination of Danger to Self, Danger to Others, Grave Disability ...This police shall instruct staff on how to respond when a patient leaves the inpatient unit without authorization ...If an involuntary patient has eloped and is not observed on the hospital grounds the nursing staff shall call local law enforcement to report ...” During a review of the hospital’s Policy and Procedure (P&P) titled, “Abuse Identifying and Reporting,” dated 4/23/24, the P&P indicated, “Hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring.””

“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: 47734 Based on interview and record review, the hospital failed to follow their policy and procedure (P&P) titled, “Abuse Identifying and Reporting,” for two of four sampled patients (Patient 1 and Patient 4), in the behavioral health unit, who experienced abuse when: 1. Mental Health Worker (MHW 1) choked a one of four patients (Patient 4) in the behavioral health unit. This failure resulted in Patient 4 experiencing pain and had the potential to result in Patient 4 experiencing mental distress and/or physical injury. 2. MHW 3 continued working with one of four patients (Patient 1) in the behavioral health unit after being accused of committing abuse towards Patient 1. This failure had the potential to cause Patient 1 to experience severe emotional distress and the potential to not receive timely medical treatment and continued abuse. 3. Staff did not report the allegation (accusation) MHW 3 went into Patient 1’s room, struck and choked Patient 1 to the hospital’s abuse coordinator. This failure resulted in the hospital unable to conduct a timely investigation and protect Patient 1’s right to receive care in a safe environment. 4. The hospital Policy and Procedure (P&P) titled “Abuse Identifying and Reporting” did not indicate to report all allegations of abuse. This failure resulted in a delay in an investigation and the potential to prevent abuse. Findings: 1. During an interview on 8/7/24 at 2:49 p.m. with MHW 4, MHW 4 stated she was in the hallway in the behavioral health unit and saw MHW 1 running down the hallway towards a patient that was yelling. When she (MHW 4) entered the lobby area, she (MHW 4) saw Patient 4 on the floor. MHW 4 stated she spoke to Patient 4 in his native language, to calm down. MHW 4 stated Patient 4 told her he was in pain because MHW 1 was holding him down. During a record review on 8/7/24 at 3:56 p.m. with Quality and Risk Manager (QRM), Patient 4’s Security Footage (SF) in the behavioral health unit, dated 7/1/24, was viewed. The SF showed the following: Patient 4 standing in front of the nurses’ station in the behavioral health unit, talking to the nurses on the other side of the counter. MHW 2 came towards Patient 4, wrapped her arms around Patient 4 and moved him outside the yellow and black lines. MHW 1 ran from the hallway towards the lobby area of the behavioral health unit and placed his pointed finger on Patient 4’s chest. When Patient 4 put his hand on MHW 1’s arm, MHW 1 moved his hand to Patient 4’s neck in a choke-like grip Patient 4 then swung his other arm towards MHW 1’s face. MHW 1 tackled Patient 4 to the floor. During a review of the hospital document titled “Patient Rights-Hospital Wide” the document indicated “A patient’s rights shall include but not be limited to ...12. Receive care in a safe setting, free from verbal or physical abuse or harassment ...” During a review of the hospital’s policy and procedure (P&P) titled, “Abuse Identifying and Reporting,” dated 4/8/24, the P&P indicated, “Patients have the right to be free from abuse or neglect as well as the fear of being abused or neglected.” 48901 2. During a review of an anonymous complaint received by the department, dated 7/31/24, the complaint indicated on 7/30/24, “[MHW 3] went into room and struck [Patient 1] and then went back into the room and choked [Patient 1] because he [MHW 3] was annoyed with him [Patient 1]. He [MHW 3] is a danger and should not work patient care.” During an interview on 8/1/24, at 10 a.m. with QRM, QRM stated the hospital was not aware of this abuse accusation and the hospital would start an investigation. QRM stated if a patient was annoying an MHW, the MHW needed to switch off with another MHW. During an interview on 8/7/24 at 10:36 a.m. with MHW 10, MHW 10 stated on 7/30/24, Patient 1 was trying to get past MHW 4 to reach the exit of the behavioral health unit; MHW 3 sat in a chair in the hallway, MHW 3 jumped up from the chair several times and redirected Patient 1 with a stern voice. MHW 10 stated she thought MHW 3 was getting fed-up from constantly redirecting Patient 1. MHW 10 stated she thought MHW 3 was a little irritated that Patient 1 did not listen to him. During an interview on 8/7/24 at 12:56 p.m. with QRM , QRM stated MHW 3 continued to work in the behavioral health unit during the investigation. During a review of MHW 3’s Working Schedule Spreadsheet (WSS) for the behavioral health unit, dated August 2024, the “WSS” indicated on 8/1/24 “Sick” 8/2/24, 8/3/24, and 8/4/24 “Night”, 8/5/24 blank (not scheduled) and MHW 3 worked Day shift on 8/6/24. During a review of Patient 1’s “Provider [doctor] Progress Note [PPN],” dated 7/30/24 at 8:46 a.m. the “PPN” indicated Patient 1 was a conserved (legally appointed responsible party) 53-year old male, with intellectual disabilities (below average ability in reasoning, social skills and self-care), and schizoaffective disorder bipolar type (mental health disease). Reasons for stay included: Due to psychosis (mental health illness), unpredictable behavior, labile (rapid, exaggerated changes) mood, intermittent behavioral agitation, the patient remains a danger to himself and others. Due to psychosis, the patient remains a gravely (disabling psychiatric condition), disabled adult.” During a review of the hospital’s policy and procedure (P&P) titled, “Abuse Identifying and Reporting,” dated 4/8/24, the P&P indicated, “PURPOSE: To provide procedures for investigating, reporting, and following up when an allegation of patient abuse of neglect is made, or when other information is received indicating that patient abuse or neglect may have occurred in our facilities. To provide procedures for notifying external agencies of allegation of abuse, as required. . .POLICY. . .Hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may have occurred.” 3. During a review of an anonymous complaint received by the department, dated 7/31/24, the complaint indicated on 7/30/24, “[MHW 3] went into room and struck [Patient 1] and then went back into the room and choked [Patient 1] because he [MHW 3] was annoyed with him [Patient 1]. He [MHW 3] is a danger and should not work patient care.” During an interview on 8/1/24 at 10 a.m. QRM stated she was not aware of an allegation that on 7/30/24, MHW 1 abused Patient 1 in the behavioral health unit until the Department informed her on 8/1/24. During a review of the hospital P&P titled “Abuse Identifying and Reporting” dated 4/8/24, the P&P indicated “Patients have the right to be free from abuse or neglect as well as the fear of being abused or neglected. Allegations or information indicating abuse or neglect may have occurred will be thoroughly and promptly investigated with appropriate follow-up action taken ...The hospital also recognizes that persons with mental illness are vulnerable and are at risk for abuse or neglect ...Employees who witness or have knowledge of suspected patient abuse during admission shall immediately report it to the Charge Nurse. If for some reason, the employee believes they cannot or should not inform the charge Nurse, the employee may contact the Director of Nursing, Risk Management, Quality, Risk or their designee or the Medical Director or their designee directly ...The Charge Nurse will gather initial facts and include the findings in an occurrence report ...” The P&P does not provide a procedure for reporting abuse after admission. 4. During a review of an anonymous complaint received by the department, dated 7/31/24, the complaint indicated on 7/30/24, “[MHW 3] went into room and struck [Patient 1] and then went back into the room and choked [Patient 1] because he [MHW 3] was annoyed with him [Patient 1]. He [MHW 3] is a danger and should not work patient care.” During an interview on 8/5/24 at 9:47 a.m. with QRM, QRM stated she did not do a self-report to the Department because the SF in the behavioral health unit, dated 7/30/24, did not show anything regarding the alleged abuse between MHW 1 and Patient 1. During an interview on 8/7/24 at 9:21 a.m. with QRM, QRM stated the hospital’s policy and procedure on reporting alleged abuse indicates that if it was an actual event then they will report it to the Department, other than that it will not be reported to CDPH. QRM stated she needed MHW 9 to tell her she saw MHW 3 hit Patient 4. During an interview on 8/7/24 at 12:56 p.m. with QRM, QRM stated she viewed the behavioral health unit SF, dated 7/30/24, on 8/1/24. QRM stated she did not speak with Patient 1 because he was developmentally delayed, and Patient 1 needed to be more stable before being spoken with. QRM stated she notified CNO and reviewed the behavioral health unit footage. QRM stated she did not inform anyone other than the CNO. During a review of the hospital P&P titled “Abuse Identifying and Reporting” dated 4/8/24, the P&P indicated “Patients have the right to be free from abuse or neglect as well as the fear of being abused or neglected. Allegations or information indicating abuse or neglect may have occurred will be thoroughly and promptly investigated with appropriate follow-up action taken ...The hospital also recognizes that persons with mental illness are vulnerable and are at risk for abuse or neglect ...Immediate actions that may be necessary to protect patients ...” During a review of the hospital document titled, “Patient Rights-Hospital Wide,” undated, the document indicated, “A patient’s right shall include...12. Receive care in a safe setting, free from verbal or physical abuse or harassment.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2) Training content. The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following: (i) Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion. This Standard is not met as evidenced by: 48901 Based on interview, and record review, the hospital failed to ensure 15 of 20 sampled staff (Registered Nurse [RN] 2, RN 3, RN 4, RN 5, RN 6, RN 7, RN 8, RN 9, RN 10, RN 11, RN 12, RN 13, Certified Nurse Assistant [CNA] 1, CNA 2, and Mental Healthcare Worker [MHW] 8) were current with required training when: 1. Eleven of 20 sampled staff (Registered Nurse [RN] 5, RN 6, RN 7, RN 8, RN 9, RN 10, RN 11, RN 12, RN 13, Certified Nurse Assistant [CNA] 2, and Mental Healthcare Worker [MHW] 8) completed required training for Handle with Care (HWC- verbal and physical de-escalation training). This failure had the potential to result in staff unable to de-escalate unstable situations and the potential to result in unsafe patient care. 2. Four of 20 sampled staff (Registered Nurse [RN] 2, RN 3, RN 4, CNA 1 MHW 7), completed their annual competency (required skills). This failure had the potential to result in unsafe patient care. Findings: 1. During an interview on 8/5/24 at 3:18 p.m. with Human Resource Assistant [HRA], HRA stated staff need to be current with required training as per policy. During an interview on 8/6/24 at 11:20 a.m. with Chief Nursing Officer (CNO), CNO stated he was responsible for ensuring staff were current with critical dates, such as Handle with Care. CNO stated he had not recently reviewed if there were any overdue critical dates for active staff. During an interview on 8/6/24 at 1:40 p.m. with CNO, CNO stated the facility scheduled HWC training every other Thursday. CNO stated either Human Resources (HR) or he looked at whoever was on the schedule (those pending re-certification or new hires) All those employees would stay for the eight or nine hours for the training. During an interview on 8/6/24 at 1:53 p.m. with Human Resource Manager (HRM), HRM stated if any staff are actively working on the floor and have critical dates that are expired, the staff should be removed from the floor according to policy. During a review of the facility’s critical dates spreadsheet [CDS], undated, the “CDS” indicated the following: RN 5’s did not have HWC training; RN 6’s HWC expiration date 1/24/24; RN 7’s HWC expiration date 6/7/23; RN 8’s HWC expiration date 6/21/23; RN 9’s HWC expiration date “DUE”; (need to be renewed) RN 10’s HWC expiration date 5/4/24; RN 11’s HWC expiration date 11/23/23; RN 12’s HWC expiration date “DUE”; RN 13’s HWC expiration date 6/27/24; CNA 2’s HWC expiration date “DUE”; MHW 8’s HWC expiration date 12/1/23. During a review of the facility’s policy & procedure (P&P) titled, “PROACT/Handle with Care/CPI Training,” dated 11/02/2022, the P&P indicated, “PURPOSE: To ensure the safety of employee and patients. . .SCOPE: All Hospital Staff. . .COMPLIANCE RESPONSIBILITY: Managers. . .POLICY: Employees assigned in departments that have potential safety risks are required to have. . .Handle with Care (HWC). . .Training. These departments are: 1. Psychiatric [mental or behavioral health] Unit 2. Medical Surgical Unit.” 2. During an interview on 8/5/24 at 3:18 p.m. with Human Resource Assistant [HRA], HRA stated staff need to be current with required training as per policy. During an interview on 8/6/24 at 11:20 a.m. with Chief Nursing Officer (CNO), CNO stated he was responsible for ensuring staff were current with critical dates, such as competencies [required skills]. CNO stated he had not recently reviewed if there were any overdue critical dates for active staff. During an interview on 8/6/24 at 1:53 p.m. with Human Resource Manager (HRM), HRM stated if any staff are actively working on the floor and have critical dates that are expired, the staff should be removed from the floor if according to policy. During a review of the facility’s critical dates spreadsheet [CDS], undated, the “CDS” indicated the following: RN 2’s annual department (dept) competency due 10/31/23; RN 3’s annual dept competency due 7/9/24; RN 4’s annual dept competency due 10/31/23; CNA 1’s annual dept competency due 10/31/23; MHW 7’s annual dept competency due 10/31/23; During a review of the hospital’s P&P titled, “Assessment of Competency,” dated 10/21, the P&P indicated, “POLICY: It is the responsibility of [NAME of Hospital] to assure the competence of each staff member. . .PROCEDURE: Annual competency assessment. . .a. Successful completion of unit/department specific critical competency skills assessment. 2. Staff members. . .they may not provide patient care identified as requiring unit/department specific critical competency skills unless they successfully completed competency requirements for those skills.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(vii) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (vii) The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification. This Standard is not met as evidenced by: 48901 Based on interview, and record review the facility failed to ensure four of 20 sampled staff (Mental Health Worker [MHW] 5, MHW 6, Clinical Therapist [CT] 1 and Registered Nurse [RN] 1) had the ability to respond to life saving emergencies for when MHW 5, MHW 6 and CT 1 did not have current Basic Life Support (BLS-life support training) and RN 1 did not have current Advanced Cardiac Life Support (ACLS-advanced life support training). This failure had the potential to result in a delay in patient care, and patient safety during a life threatening event. Findings: During an interview on 8/5/24 at 3:18 p.m. with Human Resource Assistant (HRA), HRA stated staff need to be current with BLS, and ACLS required training as per policy. During an interview on 8/6/24 at 11:20 a.m. with Chief Nursing Officer (CNO), CNO stated he was responsible for ensuring staff were current with critical dates, such as BLS, annual competencies [required skills], and Handle with Care (technique to safely manage disruptive, aggressive and self-destructive behaviors). CNO stated he had not recently reviewed if there were any overdue critical [important] dates for active staff. CNO stated the facility had a code [emergency response/lifesaving team] team. CNO stated he does not know if someone who had an expired BLS could be working on the floor. During an interview on 8/6/24 at 1:53 p.m. with Human Resource Manager (HRM), HRM stated according to policy, if any staff were actively working on the floor with expired critical dates, the facility should remove the employee from the floor. During a review of the facility’s critical dates spreadsheet [CDS], undated, the “CDS” indicated the following: MHW 5’s BLS expiration date is 4/30/24; MHW 6’s BLS expiration date is 3/31/24; CT 1 did not have a BLS; RN 1’s ACLS expiration date is Not applicable “NA”; During an interview on 8/6/24 at 1:50 p.m. with CNO, CNO stated MHW 5 and MHW 6 were still working with expired BLS. CNO stated MHW 5’s BLS expired on 4/30/24 and MHW 6’s BLS expired 3/31/24. During a review of the facility’s P&P titled, “BLS/ACLS Requirements,” dated 12/02/2022, the P&P indicated, “PURPOSE: In order to ensure maximum safe, efficient and effective patient care, all employees involved in direct patient care are required to become proficient in cardiopulmonary resuscitation (CPR, life support training) in the event resuscitation measures need to be initiated. . .SCOPE: All Personnel. . .COMPLIANCE RESPONSIBILITY: HR, Managers. . .POLICY. . .Delinquency of CPR cards can result in temporary suspension of the employee without pay and the use of PTO. The employee will not be scheduled to work until proof of current certification is provided to the department manager. . .PROCEDURE. . .BCLS Recertification: Each direct patient contact employee shall recertify his/her BCLS card every two (2) years, at least 30 days before expiration. . .ACLS Certification: All RNs who are hired into departments that require ACLS shall be ACLS certified prior to employment. . .medsurg/tele [general hospital unit]. . .ACLS Recertification: All RNs shall recertify their ACLS care every two (2) years, at least 30 days before expiration.” During a review of the facility’s P&P titled, “Assessment of Competency,” dated 10/21, the P&P indicated, “POLICY: It is the responsibility of [Hospital] to assure the competence of each staff member. . .PROCEDURE: Annual competency assessment. . .a. Successful completion of unit/department specific critical competency skills assessment. 2. Staff members. . .they may not provide patient care identified as requiring unit/department specific critical competency skills unless they successfully completed competency requirements for those skills.””