L A Downtown Medical Center

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Governing Body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) was met, as evidenced by: 1. The facility’s Governing Body failed to ensure oversight on the Nursing Department to ensure that staff (RNs, LVNs [Licensed Vocational Nurses], MHWs [Mental Health Workers]) working in the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders), accurately and consistently performed Q15 minutes (every 15 minutes) patient rounding (a proactive nursing practice where staff check on patients at regular intervals to anticipate and address their needs. This strategy aims to improve patient safety )/and monitoring, in accordance with the facility’s policy regarding patient rounding for 25 of 76 involuntary (5150 hold; 72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) and voluntary hold (when a patient agrees to be admitted to a psychiatric unit for treatment, a decision they make on their own or with their guardian’s consent) sampled patients (Patients 1, 2, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 42, 43, 44). On 6/5/2025 (at 2:20 p.m.), an altercation occurred between two patients: Patient 1 and Patient 2, in the locked Behavioral Health Unit (BHU), 5th floor (Campus 1). The incident was unwitnessed by both licensed (RN, LVN) and unlicensed healthcare personnel (MHW) assigned to the unit and tasked to conduct Q15-minute patient rounding at the time. This deficient practice resulted in inadequate monitoring and created a significant safety risk for all patients in the Behavioral Health Unit (BHU) at Campus 1 for several hours by placing them in an unsafe environment, thereby increasing the risk of self-harm, harm to others, or even death. In addition, this deficient practice potentially resulted in Patient 1 and Patient 2 not being adequately monitored, which led to an unwitnessed altercation. During the incident, Patient 1 sustained a neurological deficit (a possible subdural hematoma, a form of traumatic brain injury involving bleeding) and a confirmed displaced fracture of the right femoral neck, which is a break in the upper part of the thigh bone, just below the ball of the hip joint. (Refer to A-0063) 2. The facility’s Governing Body failed to Ensure oversight over the Nursing Department to ensure that there was a process for nursing staff to escalate and advocate for one (1) of 76 sampled patients (Patient 18) to receive proper medical attention in a timely manner, when Patient 18 reported swallowing a foreign object (a non-food item is ingested and gets lodged in the gastrointestinal [GI, includes mouth, esophagus- a passage from throat to stomach, stomach and intestines] tract) on 9/6/2025. Patient 18 was sent out to emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) on 9/8/2025 ( 2 days later) and had esophagogastroduodenoscopy (EGD, a medical procedure using a thin, lighted tube [endoscope] to examine the lining of the esophagus, stomach, and the first part of the small intestine) to retrieve the foreign object. This deficient practice resulted in Patient 18 suffering from having a foreign object lodged in Patient 18’s throat for two (2) days. This deficient practice also had the potential to put other patients with similar symptoms at risk for not receiving care in a timely fashion thus compromising patient care and safety. (Refer to A-0063) 3. The facility’s Governing Body failed to ensure oversight over the Nursing Department to ensure alleged abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) cases were investigated and reported to the healthcare regulatory agencies (establishes and enforces standards and guidelines to ensure the safety, quality, and efficacy of healthcare services and products) in a timely manner, in accordance with the facility’s policy and procedure regarding abuse reporting, for one of 76 patients (Patient 19), when Patient 19 reported an alleged physical abuse to Registered Nurse 1 (RN 1) on 4/23/2025. This deficient practice compromised the safety of Patient 19 when the facility failed to initiate an investigation, did not remove the alleged staff members from duty, and potentially placed Patient 19 at further risk of abuse. Additionally, it compromised the safety of other patients who may have been at risk for further abuse. (refer to A-0063) 4. The facility’s Governing Body failed to ensure that the facility’s policy and procedure (P&P) regarding face-to-face assessments (an in person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]), conducted after initiation of restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) or seclusion (a secure, private room used to involuntarily confine an individual alone to de-escalate a situation or modify behavior) in the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders), was in alignment with Federal regulatory requirements, when the P&P did not indicate that a Registered Nurse must consult a physician after face-to-face assessment was completed. The physician was not consulted after a face-to- face assessment was completed for two (2) of 76 sampled patients (Patients 7 and 12). This deficient practice had the potential for inconsistent practices, non-compliance with laws and regulations, and patient harm due to the P&P not reflecting up to date best practices. (Refer to A-0063) 5. The facility’s Governing Body (GB, the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital’s overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) failed to ensure oversight on its contracted services in relation to their performance measures, when the facility’s Quality Assessment and Performance Improvement committee (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital), under the direction of the Governing Body failed to identify quality and performance issues for contracted services, implement corrective or improvement actions, and ensure ongoing monitoring and sustainability of implemented corrective actions, when there was a delay in obtaining a head computed tomography scan (CT scan, a medical imaging procedure that creates detailed cross-sectional images of the body), performed by a contracted company, for one of 76 sampled patients (Patient 1). On 6/5/2025, Patient 1 was involved in a patient-to-patient altercation with Patient 2. As a result, Patient 1 sustained a hip fracture and exhibited neurological deficits (impairment in the function of the nervous system) as was manifested by trembling (shaking) of arms and legs, right pupil sluggish response, right upper eyelid drooping (sagging), and left-hand grip weakness. thus, requiring a STAT (immediately) CT scan, but was not carried out by the contracted radiology company as ordered by the physician. This deficient practice resulted in a delay in obtaining a head (CT) scan for Patient 1. The delay in diagnostic imaging potentially contributed to a delay in diagnosis for Patient 1. Furthermore, the facility’s failure to assess and monitor the performance of contracted services, such as CT imaging, through its QAPI program, presented a missed opportunity to identify, analyze, correct, and monitor systemic issues related to delayed diagnostic performance times, placing all patients requiring contracted imaging services at risk. (Refer to A-0083) 6. The facility’s Governing Body failed to ensure appropriate oversight on its contracted services (refer to specialized tasks performed by external, independent providers for a specific fee, outlined in a formal agreement that details the scope, timeline, and payment terms) staff in order to provide safe patient care, in accordance with the facility’s contract agreement and the policy on Patient Rights, for one of 76 sampled patients (Patient 7), when a security guard (SG 1), from a contracted company, hit Patient 7 on 10/13/2024. This deficient practice resulted in Patient 7 being physically abused (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by SG 1 and resulted in bruises on the cheek. This deficient practice also had the potential for psychological trauma for Patient 7. (Refer to A-0084) 7. The facility’s Governing Body failed to ensure oversight over its contracted services by failing to maintain a current contract, in accordance with the facility’s policy titled, “Vendor Agreements,” for one of three sampled contracted services (CS 1, refer to specialized tasks performed by external, independent providers for a specific fee, outlined in a formal agreement that details the scope, timeline, and payment terms) when the contract expired since June 2024. This deficient practice resulted in CS 1 providing services to the facility’s patients without a current contract which may lead to the provision of services outside the contract agreement and substandard quality of care to patients that may result in patient harm and/or death. (Refer to A-0085) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient Rights was met, as evidenced by: 1. The facility failed to ensure that patients received care in a safe environment when Q 15-minute (every fifteen-minute) observation patient rounding (a proactive nursing practice where staff check on patients at regular intervals to anticipate and address their needs. This strategy aims to improve patient safety)/monitoring, was not correctly and consistently performed for 56 of 76 sampled 5150 (involuntary hold/involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) patients (Patient 1, Patient 2, Patient 14, Patient 15, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 42, Patient 43, Patient 44, Patient 45, Patient 46, Patient 47, Patient 48, Patient 49, Patient 50, Patient 51, Patient 52, Patient 54, Patient 55, Patient 56, Patient 57, Patient 58, Patient 59, Patient 60, Patient 61, Patient 62, Patient 63, Patient 64, Patient 65, Patient 66, Patient 67, Patient 68, Patient 72, Patient 73, Patient 74, Patient 75, Patient 76), in accordance with the facility’s policy on patient rounding for both 5150 and voluntary hold (when a patient agrees to be admitted to a psychiatric unit for treatment, a decision they make on their own or with their guardian’s consent) patients. This deficient practice resulted in 5150 patients in the BHU (Behavioral health Unit, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) unit in Campus 1 and Campus 2 inadequately monitored for hours and had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, and potentially can result to death. Patient 1 and Patient 2 had an unwitnessed altercation in which Patient 1 sustained a subdural hematoma (a form of traumatic brain injury involving bleeding) and a displaced fracture (broken bone) of the right femoral neck (the narrow, connecting part of the femur (thigh bone) that links the ball-shaped head of the femur to the long shaft of the bone) thus needed to be transferred out for higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]). (Refer to A-0144) 2. The facility failed to protect one of 76 sampled patients (Patient 19) from alleged abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), failed to investigate the abuse allegations, and to identify or remove the alleged perpetrator (a staff member) from the environment, in accordance with the facility’s policy regarding abuse reporting, when Patient 19 reported to the Registered Nurse (RN) 1 that the night shift staff choked and placed Patient 19 in 4-point (both wrists and ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) on 4/23/2025. This deficient practice resulted in the facility not conducting an investigation and removing the alleged staff members from working duties and potentially placing Patient 19 and other patients at risk for further abuse. (Refer to A-0145) 3. The facility failed to investigate thoroughly and report to the appropriate regulatory agencies an incident of alleged physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by the facility’s security guard (SG 1) which occurred on 10/13/2024, for one of 76 sampled patients (Patient 7), in accordance with the facility’s policy regarding abuse investigation and reporting. This deficient practice resulted in a delay in involving regulatory agencies in investigating the abuse allegation and could potentially put other patients in an unsafe environment and be at risk of being abused. (Refer to A-0145) 4. The facility failed to report to appropriate regulatory agencies an allegation of sexual abuse (sexual conduct or a sexual act forced upon a woman, man or child without their consent), in accordance with the facility’s policy regarding abuse reporting, for one of 76 sampled patients (Patient 8), after Patient 8 reported an alleged sexual abuse on 8/29/2024. This deficient practice resulted in a delay in involving regulatory agencies in investigating the abuse allegation and could potentially put other patients in an unsafe environment and be at risk of being abused. (Refer to A-0145) 5. The facility failed to ensure nursing staff consulted the physician after a face to face assessment (an in person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) was performed by Registered Nurses (RNs) for two of 76 sample patients (Patient 7 and 12), in accordance with the federal regulation regarding physician notification after the completion of the face-to-face assessment. This deficient practice had the potential to result in Patient 7 and Patient 12 not receiving evaluation from physicians to determine appropriate treatment, care and intervention. (Refer to A-0182) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Quality Assessment and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) was met, as evidenced by: 1. The facility failed to ensure its Quality Assessment and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) team collected, tracked and trend data on critical patient safety indicators, implement comprehensive action plan, and measure the success of actions taken and track performance to ensure improvements are sustained, when the QAPI team failed to collect data on all patient abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) incidents and report the data to the QAPI quarterly meeting, in accordance with the facility’s performance improvement plan. The facility did not retain any abuse data for 2024 including two (2) of 76 sampled patients’ (Patient 7 and Patient 8) abuse allegation incidents and did not report abuse data to QAPI committee in 2024 and 2025. The facility also failed to capture an alleged physical abuse incident for one of 76 sampled patients (Patient 19) which happened on 4/23/2025, when Patient 19 reported being choked and restrained (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) by staff. This deficient practice resulted in the facility’s QAPI team’s inability to analyze abuse data, identify and address potential problems which had the potential to affect quality of patient care and safety. This deficient practice also resulted in the facility’s QAPI team’s inability to monitor state regulatory compliance with reporting patient abuse to regulatory agencies as required. (Refer to A-0273) 2. The facility’s Quality Assurance and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) program team failed to ensure that an ongoing program showed measurable improvements in indicators for patient safety and/or adverse events, when the facility’s QAPI team failed to thoroughly investigate, report to the regulatory agencies, measure, analyze, and track adverse patient events (any unintended or undesirable occurrence, symptom, or condition that arises during medical treatment and may result in harm) such as incidents of alleged abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), for three (3) of 76 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 19), in accordance with the facility’s performance improvement plan, when: 2.a. The facility failed to ensure that a thorough internal investigation was conducted following the reported patient-to-patient altercation involving Patient 1 and Patient 2 that took place on 6/5/2025. The Quality Assurance and Performance Improvement (QAPI) team did not review available video footage and was unable to provide proof demonstrating that a structured method was used to identify the underlying causes of the adverse event and to implement measures to prevent recurrence, as required by the hospital’s Performance Improvement Plan. This deficient practice had the potential to result in a missed opportunity to identify and correct systemic failures, such as staff possibly not performing Q15-minute safety checks (routine observations conducted every 15 minutes to monitor and document each patient’s condition and behavior, with the goal of identifying risks and intervening early to ensure safety) and failing to recognize and intervene to prevent Patient 1 from striking Patient 2. As a result of the altercation, Patient 1 sustained a hip fracture (break in the bone) and exhibited neurological changes, including trembling (shaking) of the arms and legs, sluggish (reduced or delayed) response of the right pupil, right upper eyelid drooping (sagging), and left-hand grip weakness. The facility’s failure to address these issues potentially created an ongoing risk for other patients in the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders). (Refer to A-0286) 2.b. The facility failed to ensure that abuse allegations (any suspected or alleged incident of physical abuse, abandonment, abduction, deprivation, financial abuse, mental suffering, neglect, exploitation, or mistreatment of an elder or dependent adult by a person responsible for their care) involving Patient 3 and nursing staff (Licensed Vocational Nurse - LVN 1), was promptly reported to the California Department of Public Health (CDPH, the department that works to protect the public’s health), within 24 hours, in accordance with the facility’s policy and procedure (P&P) regarding “Abuse Mandated Reporting,” when abuse allegations were made regarding LVN 1, who was witnessed slapping Patient 3 twice during medication pass on 1/19/2024. This deficient practice had the potential to result in continued risk of harm to Patient 3. In addition, it delayed external regulatory review and the opportunity for oversight, which may compromise patient safety when an investigation is not immediately undertaken to ensure that corrective action plans are implemented and that the facility is taking adequate steps to reduce the risk of a similar future event. (Refer to A-0286) 2.c. The facility failed to ensure that allegations of abuse (suspected or alleged incidents of physical abuse, abandonment, abduction, deprivation, financial abuse, mental suffering, neglect, exploitation, or mistreatment of an elder or dependent adult-must be reported immediately or as soon as practically possible by phone and followed by a written report (SOC 341) within 24 hours) involving Patient 19 was promptly investigated and reported to the California Department of Public Health (CDPH), in accordance with the facility’s policy and procedure titled “Abuse Mandated Reporting.” The allegation involved Patient 19 reporting to Registered Nurse (RN) 1 that night shift staff had choked and placed Patient 19 in four-point restraints (involve securing all four of a patient’s limbs-both arms and both legs-to a bed or stretcher using soft or leather straps). This deficient practice resulted in a delay in recognizing and responding to abuse allegations involving Patient 19, which compromised the patient’s safety and well-being. In addition, it reflected the facility’s failure to demonstrate an effective internal reporting system and oversight mechanisms intended to protect patients from the harm of abuse. (Refer to A-0286) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by: 1. The facility failed to promptly evaluate and provide immediate medical intervention and treatment, in accordance with the facility’s policy and procedure regarding plan for provision of care pertaining to safe, effective, timely care and treatment, when one of 76 sampled patient (Patient 18), a Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) patient (Patient 18), swallowed a foreign object (any item that does not belong in the body). This deficient practice resulted in Patient 18’s claim of swallowing a razor (sharp blade instrument) not validated and evaluated by nursing staff until two days later (on 9/8/2025) after Patient 18’s initial claim (9/6/2025) of having swallowed a razor, which led to Patient 18 being transferred to another facility and undergoing a procedure for removal of the foreign object. This deficient practice also had the potential of Patient 18 losing a large amount of blood and damage to his esophagus (canal that connect the throat to the stomach), which may result in further serious injury or even death. (Refer to A-0395) 2. The facility failed to ensure nursing staff adhered to the facility’s policy and procedure regarding “Every 15 Min (minute) Rounds, Patient,” and the facility’s charting/documentation policy, when staff did not consistently perform and accurately document the Q (every) 15?minute rounding (observing patient location and behavior), for 62 of 76 sampled patients (Patient 1, Patient 2, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 41, Patient 42, Patient 43, Patient 44, Patient 14, Patient 15, Patient 16, Patient 45, Patient 46, Patient 47, Patient 48, Patient 49, Patient 50, Patient 51, Patient 52, Patient 53, Patient 54, Patient 55, Patient 56, Patient 57, Patient 58, Patient 59, Patient 60, Patient 61, Patient 62, Patient 63, Patient 64, Patient 65, Patient 66, Patient 67, Patient 68, Patient 69, Patient 70, Patient 71, Patient 72, Patient 73, Patient 74, Patient 75 and Patient 76), on 9/19/2025 from 1:00 a.m. to 2:30 a.m. in Campus 1, on 9/13/2025 from time period 1:20 a.m. to 4:58 a.m. in Campus 2, and on 9/19/2025 from time period of 1:00 a.m. to 2:15 a.m. in Campus 2. This deficient practice had potentially placed the patients in an unsafe environment, at risk of self?harm, or harm to others, psychological trauma and/or death. (Refer to A-0398) 3. The facility failed to ensure implementation of a safe transfer to a higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]), in accordance with the facility’s policy regarding Higher level of care transfer of patients to another facility, when one of 76 sampled patients (Patient 18), was transferred to another hospital for evaluation and treatment, in a hospital van which was not equipped with lifesaving equipment or a licensed staff capable of providing emergency service, after Patient 18 swallowed a foreign object (any item that does not belong in the body). This deficient practice had the potential for inadequate medical support and compromised monitoring of Patient 18 who was at risk of losing a large amount of blood and damage to his esophagus (canal that connect throat to stomach), which had the potential to result in harm, serious injury or even death. (Refer to A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 46238 Based on observation, interview and record review, the facility’s Governing Body (the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital’s overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) failed to: 1. Ensure oversight on the Nursing Department to ensure that staff (RNs, LVNs [Licensed Vocational Nurses], MHWs [Mental Health Workers]) working in the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders), accurately and consistently performed Q15 minutes (every 15 minutes) patient rounding (a proactive nursing practice where staff check on patients at regular intervals to anticipate and address their needs. This strategy aims to improve patient safety )/and monitoring, in accordance with the facility’s policy regarding patient rounding for 25 of 76 involuntary (5150 hold; 72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) and voluntary hold (when a patient agrees to be admitted to a psychiatric unit for treatment, a decision they make on their own or with their guardian’s consent) sampled patients (Patients 1, 2, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 42, 43, 44). On 6/5/2025 (at 2:20 p.m.), an altercation occurred between two patients: Patient 1 and Patient 2, in the locked Behavioral Health Unit (BHU), 5th floor (Campus 1). The incident was unwitnessed by both licensed (RN, LVN) and unlicensed healthcare personnel (MHW) assigned to the unit and tasked to conduct Q15-minute patient rounding at the time. This deficient practice resulted in inadequate monitoring and created a significant safety risk for all patients in the Behavioral Health Unit (BHU) at Campus 1 for several hours, by placing them in an unsafe environment, thereby increasing the risk of self-harm, harm to others, or even death. In addition, this deficient practice potentially resulted in Patient 1 and Patient 2 not being adequately monitored, which led to an unwitnessed altercation. During the incident, Patient 1 sustained a neurological deficit (a possible subdural hematoma, a form of traumatic brain injury involving bleeding) and a confirmed displaced fracture of the right femoral neck, which is a break in the upper part of the thigh bone, just below the ball of the hip joint. 2. Ensure oversight over the Nursing Department to ensure that there was a process for nursing staff to escalate and advocate for one (1) of 76 sampled patients (Patient 18) to receive proper medical attention in a timely manner, when Patient 18 reported swallowing a foreign object (a non-food item is ingested and gets lodged in the gastrointestinal [GI, includes mouth, esophagus- a passage from throat to stomach, stomach and intestines] tract) on 9/6/2025. Patient 18 was sent out to emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) on 9/8/2025 ( 2 days later) and had esophagogastroduodenoscopy (EGD, a medical procedure using a thin, lighted tube [endoscope] to examine the lining of the esophagus, stomach, and the first part of the small intestine) to retrieve the foreign object. This deficient practice resulted in Patient 18 suffering from having a foreign object lodged in Patient 18’s throat for two (2) days. This deficient practice also had the potential to put other patients with similar symptoms at risk for not receiving care in a timely fashion thus compromising patient care and safety. 3. Ensure oversight over the Nursing Department to ensure alleged abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) cases were investigated and reported to the healthcare regulatory agencies (establishes and enforces standards and guidelines to ensure the safety, quality, and efficacy of healthcare services and products) in a timely manner, in accordance with the facility’s policy and procedure regarding abuse reporting, for one of 76 patients (Patient 19), when Patient 19 reported an alleged physical abuse to Registered Nurse 1 (RN 1) on 4/23/2025. This deficient practice compromised the safety of Patient 19 when the facility failed to initiate an investigation, did not remove the alleged staff members from duty, and potentially placed Patient 19 at further risk of abuse. Additionally, it compromised the safety of other patients who may have been at risk for further abuse. 4. Ensure that the facility’s policy and procedure (P&P) regarding face-to-face assessments (an in person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]), conducted after initiation of restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) or seclusion (a secure, private room used to involuntarily confine an individual alone to de-escalate a situation or modify behavior) in the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders), was in alignment with Federal regulatory requirements, when the P&P did not indicate that a Registered Nurse must consult a physician after face-to-face assessment was completed. The physician was not consulted after a face-to- face assessment was completed for two (2) of 76 sampled patients (Patients 7 and 12). This deficient practice had the potential for inconsistent practices, non-compliance with laws and regulations, and patient harm due to the P&P not reflecting up to date best practices. Findings: 1. During a review of Patient 1’s History and Physical (H&P, a comprehensive clinical document that includes a patient’s medical history and findings from a physical examination), dated 6/4/2025, the H&P indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) due to being “agitated (feeling of uneasiness and severe restlessness) and aggressive.” The H&P also indicated that Patient 1 was placed on assaultive (safety measures implemented for patients who exhibit or are at risk of exhibiting violent or aggressive behavior) and homicidal precautions (safety interventions used when a patient expresses or demonstrates thoughts, intentions, or behaviors indicating a risk of harming others). During a review of Patient 1’s “Behavioral Admission Assessment,” dated 6/4/2025, the record indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU) at 2:45 p.m. on a 5150 Hold (involuntary hold/involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to others and being gravely disabled (GD, a condition in which a person, due to a mental health disorder, is unable to provide for their basic personal needs such as food, clothing, or shelter).” The record also stated that Patient 1 required “line of sight observation,” meaning continuous visual monitoring by staff to ensure immediate intervention if needed, and was placed on 15-minute Close Observation Level II, which involved staff checking on the patient every 15 minutes due to a history of threatening and/or assaultive behavior within the past 30 days. During a review of Patient 1’s “Behavioral Health Daily Nursing Assessment,” dated 6/5/2025, the record indicated that on 6/5/2025 Patient 1 continued to remain on 15-minute Close Observation Level II (patient was monitored every 15 minutes due to concerns about potential harm to self or others) and also had assault/aggression precautions in place (implemented due to the patient exhibiting, or being at risk of exhibiting, aggressive or violent behavior; includes increased supervision, environmental safety measures, and use of de-escalation techniques [methods used to reduce the intensity of a conflict or agitation in a person through calm, verbal, and non-verbal communication]). During a review of Patient 2’s History and Physical (H&P), dated 6/3/2025, The H&P indicated that Patient 2 was admitted to the Behavioral Health Unit (BHU) on 6/3/2025 for agitation and aggressive behavior. During a review of Patient 2’s Psychiatric Evaluation, dated 6/3/2025, the record indicated that Patient 2 was admitted on a 5150 Involuntary Hold. The record also indicated that the Hold was initiated due to danger to others after Patient 2 became “increasingly aggressive at the nursing home (a residential facility that provides 24-hour medical and personal care for individuals, who are unable to live independently due to illness, disability, or cognitive decline).” During a review of Patient 2’s “Nursing Progress Note,” dated 6/5/2025 at 3:43 p.m., the note indicated that Patient 2 was involved in an altercation with another patient (Patient 1) and stated that he (Patient 2) was defending himself after Patient 1 struck him in the face, specifically on the left cheek and/or jaw. During a review of Patient 2’s “Rounds Sheet, dated 6/5/2025, the sheet indicated that Patient 2 was documented as either lying or sitting in his “BR” (bedroom) for the entire time from 7:00 a.m. to 7:00 p.m. During a concurrent interview and record review on 9/30/2025 at 3:02 p.m. with the Chief Nursing Officer (CNO), Patient 1’s medical record titled, “Nursing Progress Notes,” dated 6/5/2025, was reviewed. The CNO stated that, according to the documentation, Patient 1 attempted to strike Patient 2, who was sitting at the door in the hallway. Patient 2 defended himself, stood up, and pushed Patient 1, who then fell backwards. The CNO confirmed that the fall was unwitnessed (as per nursing notes documentation), and that Rapid Response Team (RRT, a team of healthcare professionals, often including a critical care nurse and a respiratory therapist, who are quickly dispatched to provide immediate care to a patient who shows signs of acute deterioration within a hospital) was called at 2:20 p.m. on 6/5/2025 after Patient 1 was assessed to have weakness in the lower extremities (both legs), drooping (excessive sagging) on the left side of face, and left arm weakness. During a review of Patient 1’s “Nursing Progress Notes,” dated 6/5/2025 at 2:20 p.m., the note indicated the following: on 6/5/2025, Patient 1 was actually witnessed by an EVS (Environmental Services- trained cleaning support staff) worker who witnessed Patient 1 walking in the hallway, attempting to strike another patient (Patient 2). In response, Patient 2 pushed Patient 1, causing Patient 1 to fall backwards and sit down on the floor. A Rapid Response Team (RRT) was called, and Patient 1 was assessed to have bilateral (both) lower extremity weakness and was noted to be losing balance while standing. The note also stated that Patient 1 was transferred to a medical-surgical floor (a general hospital unit for adult patients who need care for a variety of illnesses and surgical recovery, but do not require intensive or highly specialized care) for further evaluation). During a review of Patient 1’s nursing note, dated 6/5/2025 at 2:20 p.m., the note indicated that Patient 1 sustained an unwitnessed fall (meaning the patient had experienced a fall that was not observed by staff or others, and the exact circumstances were unknown). During further review of Patient 1’s nursing notes documentation, dated 6/5/2025 at 2:35 p.m. (late entry), the note indicated that Patient 1 was status post (after) unwitnessed fall, and that Patient 1 began showing signs of facial drooping (sagging) on the left side, along with bilateral (both sides) leg tremors (involuntary, rhythmic shaking or trembling movements in the legs). During a review of Patient 1’s “Nursing Progress Note,” dated 6/5/2025 at 4:30 p.m., the note indicated that on 6/5/2025 at 4:00 p.m., Patient 1 was observed with increasing shaking of the left leg and bilateral lower extremities. The note also indicated that during the physician’s bedside assessment, Patient 1 was noted to have a bump on the right side of the head, with no bleeding. The note also indicated the following at 4;30 p.m. on 6/5/2025: the family was informed that, due to the fall, Patient 1 had possible fracture of the right hip ... and the physician recommended transferring Patient 1 to a higher level of care, as the patient continued to experience shaking and had a head injury with a possible subdural hematoma (a type of brain bleed that occurs when blood collects in the brain, often caused by head trauma and potentially life-threatening if not treated promptly). During an interview on 10/1/2025 at 1:31 p.m. with the House Supervisor (HS 1), HS 1 stated that typically the facility conducted daily audit for the completeness of Q 15-Minute rounding sheets (a clinical documentation tool used by healthcare staff to record patient observations at regular intervals [every 15 minutes], designed to monitor patient location, behavior, and safety status, and to ensure staff accountability and timely intervention when needed) to verify staff compliance with patient rounding. However, the HS 1 also said that the paper documentation for patient rounding was not reviewed concurrently with video footage to determine whether the documented patient rounding matched what was observed through the facility’s video surveillance cameras. During a concurrent interview and record review on 10/1/2025 at 2:06 p.m. with the Chief Nursing Officer (CNO), Patient 1’s “Patient Rounding Sheet, dated 6/5/2025 (covering the time from 7:00 a.m. to 4:30 p.m.), was reviewed. The rounding sheet indicated that Patient 1 was not agitated during this time frame (7 a.m. to 4;30 p.m.) and was consistently documented as either lying or sitting in their (Patient 1) bedroom. Specifically: -At 1:00 p.m., Patient 1 was documented as either lying or sitting -At 2:15 p.m., Patient 1 was again documented as either lying or sitting -This same documentation pattern continued through 2:45 p.m. -The Chief Nursing Officer (CNO) verified that this documentation was possibly inaccurate, noting that the Rapid Response Team was called at 2:20 p.m., and Patient 1 was found in the hallway by Patient 2’s room, yet no deviation or incident was reflected in the rounding sheet during that time. During further interview on 10/1/2025 at 3:37 p.m. with the Hospital Administrator (ADM), the ADM stated that the administration was no longer certain whether the entire incident (between Patient 1 and Patient 2) had been witnessed by the Environmental Service (EVS) worker. The ADM confirmed that nursing staff and mental health workers did not witness the altercation between the two patients (Patient 1 and Patient 2). The ADM also stated that he (ADM) could not verify whether staff were conducting Q15-minute patient rounding on that day (6/5/2025). The ADM said, “They (referring to the facility staff) should have done it (referring to the Q 15-minute rounding)- this is the expectation,” and noted that staff verbally confirmed they were conducting their rounds. However, the ADM also confirmed that the video footage, on 6/5/2025, was never reviewed to verify whether staff actions aligned with what was documented and reported on the day of the incident between Patient 1 and Patient 2. During a concurrent observation, interview and video footage review on 10/1/2025 at 11:00 a.m. with Nurse Manager (NM 1) of BHU and Medical-Surgical (Med/Surg), the video footage dated 9/19/2025, from 1:00 a.m. to 2:30 a.m., was reviewed. The following events were observed at the indicated timestamp in the video: 9/19/2025 at 1:00 a.m. -No staff seen conducting patient rounding in any of the video angles. 9/19/2025 at 1:15 a.m. -No staff seen conducting patient rounding, in any video of the angles. 9/19/2025 at 1:30 a.m. -No staff seen conducting patient rounding in any of the video angles 9/19/2025 at 1:45 a.m. -no staff seen doing rounding, one patient seen in wheelchair going down hallway with no staff present (camera angle 6) 9/19/2025 at 2:00 a.m. -two staff members seen rounding patient rooms 1, 2, 3 and 4 (camera angle 4) but not seen checking other rooms. Confirmed with NM1 that one was licensed staff (RN) and the other individual was the resource nurse. 9/19/2025 at 2:15 a.m. -two staff members sitting in chairs in BHU hallway on Camera angles 6 and 7. Not getting up to conduct rounding on patients. NM 1 was unable to identify the two staff members. 9/19/2025 at 2:30 a.m. -Same two staff members sitting in chairs in BHU hallway, not getting up to conduct rounding as seen in camera angles 6 and 7. NM 1 was unable to identify the two staff members During an interview on 10/1/2025 at 11:47 a.m. with NM 1, NM 1 stated the expectation was for staff to do Q 15-minute rounding to check on the patients, ensure safety and known location. Purpose of rounding was to know the location of the patients and make sure the patient was safe. “It allows us to notice any changes in behaviors, so that staff can address them accordingly.” NM 1 verified that rounding was only completed once for 4 rooms (rooms 1,2, 3, and 4) but not the whole unit within the 1.5 hour of video reviewed for Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 41, Patient 42, Patient 43, Patient 44. During a concurrent interview and record review on 10/1/2025 at 2:02 p.m. with NM 1, Patient 20’s “Patient Rounds Sheet” dated 9/18/2025, was reviewed. NM 1 stated that the rounding sheet began on 9/18/2025 at 7:00 a.m. and ended on 9/19/2025 at 6:45 a.m. NM 1 stated that all patient rounding sheets being reviewed started around the same time (7 a.m. to 6:45 a.m.), which captures the entire 24 hours. During an interview on 10/3/2025 at 3:44 p.m. with NM 1, NM 1 stated that, after reviewing the video footage and discussing the matter with the Chief Nursing Officer (CNO), it appeared that staff were documenting Q15-minute checks as completed, despite not actually performing them. NM 1 emphasized the importance of holding staff accountable and acknowledged that this practice falls under the category of falsification of records. During an interview on 9/30/2025 at 11:35 a.m. with the Charge Nurse (CN) 4, CN 4 stated that licensed nurses were required to conduct patient rounds every hour and document on the patient’s rounding sheet. CN 4 stated that licensed nurses could also help the MHW (Mental health Worker) with conducting Q15-minute rounding. During an interview on 10/1/2025 at 2:12 p.m. with the Chief Nursing Officer (CNO), the CNO confirmed that Q15 (every 15 minutes) patient safety checks should be conducted to: -Ensure patient safety, -Confirm responsiveness, -Assess patient behavior, -Document patient activity. During an interview on 10/1/2025 at 3:17 p.m. with the Chief Nursing Officer (CNO) and the Hospital Administrator (ADM), the CNO stated that the incident (involving Patients and 2) was investigated internally and that all key team members were interviewed, including the Environmental Services (EVS) worker who witnessed the altercation between Patient 1 and Patient 2 in the hallway. The ADM confirmed that, because of the EVS worker’s statement regarding the witnessed fall and the altercation between the two patients (Patient 1 and Patient 2), the facility had no reason to review the video footage to verify what happened during the incident. During an interview on 10/3/2025 at 3:34 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following regarding Q-15 Minutes rounding: “Q15-minute safety checks are conducted to monitor each patient’s condition and behavior at regular 15-minute intervals. The purpose is to identify any signs of agitation, frustration, or behaviors that may indicate a risk to the patient or others. These checks are preventive in nature and allow staff to intervene early and provide therapeutic support as needed. We use this time to assess whether patients are escalating and to respond in a way that promotes safety and de-escalation. While staff are expected to document these checks accurately, it’s also important to verify that the documentation aligns with actual observations, such as through video review when available.” During an interview on 10/6/2025 at 10:55 a.m. with the Chief Executive Officer (CEO), Hospital Administrator (ADM), and the Chief Nursing Officer (CNO), the CEO stated that he (CEO) was a voting member of the Governing Body (GB), responsible for participating in decisions regarding hospital operations and quality oversight. The Hospital Administrator and the CNO stated that they were non-voting members of the GB, attending meetings and contributing to discussions but not participating in formal decision-making or voting processes. During an interview on 10/6/2025 at 10:56 a.m. with the Chief Executive Officer (CEO), the CEO stated that the Governing Board (GB) serves as the ultimate resource, responsible for overseeing operations, ensuring that policies and procedures were properly implemented, and maintaining compliance with regulatory agencies. The CEO also emphasized that the responsibility for ensuring overall patient quality of care and safety lies with the Governing Board. During an interview on 10/6/2025 at 11:42 a.m. with the Chief Executive Officer (CEO), the CEO stated that Q15-minute rounding was something that must be done thoroughly and consistently, emphasizing its importance in maintaining visual monitoring for the patients served, particularly due to the volatility of behavioral health patients. The CEO was not aware that Q15-minute rounding was not being conducted in the Behavioral Health Unit (BHU) and acknowledged that it was something that needed to be implemented. During an interview on 10/6/2025 at 11:44 a.m. with the Chief Nursing Officer (CNO), the CNO stated that Q15-minute rounding was considered “a given” in the Behavioral Health Unit (BHU). The CNO described the Q15-minutes rounding as an automatic process and a standard practice for BHU nurses. The CNO said that leadership had been focused on quality improvement projects on the medical-surgical floors and expressed trust in staff to perform the rounding as expected. However, the CNO acknowledged that there was no audit process in place to ensure that the rounding was actually being completed. During a review of the facility’s Bylaws (formal documents that establish the operational framework, governance structure, and strategic direction of a hospital and its medical staff. They define the hospital’s purpose, set policies, ensure compliance with laws and accreditation standards, and outline the relationship between the governing body and the medical staff. Key functions include managing hospital finances and resources, selecting and evaluating leadership, and ensuring quality and patient safety ), dated 5/2019, the Bylaws indicated the following: “Governing Board is a committee appointed by the Facility. As the hospital’s Governing Body, it is responsible for setting policy, ensuring quality patient care, and supporting institutional planning and management. Its actions align with the hospital’s mission to deliver safe, compassionate, and cost-effective care that upholds patient dignity. The Governing Board reports directly to the Board of Directors, which retains ultimate oversight.” During a review of the facility’s Bylaws, dated 5/2019, the Bylaws indicated the following: “The Governing Board, through the Administrator, shall provide whatever administrative assistance is reasonably necessary to support and facilitate the implementation and ongoing operations of these quality review and evaluation activities. These quality review and evaluation activities shall ensure that the same level of overall quality and appropriateness of care is provided to all patients of the Hospital.Monitoring and evaluating the quality and appropriateness of patient care through a valid and reliable quality assessment program.” During a review of the facility’s policy and procedure (P&P) titled, “Every 15 Min Rounds, Patient,” last revised 3/2025, the P&P indicated the following: “It is the policy of [the facility] Behavioral Health Services to monitor the safety/locations of all patients on a continuing basis. Such rounds will be conducted at 15-minute intervals. Patients requiring additional observation will be evaluated individually, and physician orders will be generated to address the safety/needs of the patient ...Floor staff will conduct patient rounds at 15-minute intervals, including the location of the patient and his/her condition, and will verify completion of such rounds by their initial and signature. In order to accurately monitor safety and condition of patients at night and/or during non-wakeful times, staff will visually observe chest movement of the patient to ascertain respiratory effort.” During a review of the Facility’s policy and procedure (P&P) titled, “Observation Levels System,” dated 3/2025, the P&P indicated, “It is the policy of [the facility] to initiate and provide the appropriate observation level of patient’s behaviors exhibited and also the information provided at the time of admission, and throughout hospitalization. All patients will be routinely observed in compliance with physician/psychologist orders and prescribed protocols. Purpose: to provide the most appropriate patient observation level is maintained throughout hospitalization. To provide patient safety at all times ... Types of Observation Level A. Level I: every 15-minute checks, routine observation. Minimal level of observation for all patients. Staff will observe patient and document on the Patient’s Observation Rounds Sheet Q15 minutes. Assigned staff will make direct contact with patients and confirm they are in no danger or distress .... Observation may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping. It is expected that the staff conducting the 15 minutes observation will enter the room, approach the patient and check their identify, respirations, and to ensure that they are not in any distress.” B. Level II: every 15 minutes checks, routine observations with precautions and taking note of precautions ordered as well ...staff will observe patient and document on the Patient’s Observation Rounds sheet every 15 minutes ...” 2. During a review of Patient 18’s Behavioral Health History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 9/6/2025 at 1445 (2:45 p.m.), the H&P indicated, Patient 18 was admitted to the facility’s Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) on 5150-hold (involuntary hold/involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to self (DTS) stating he (Patient 18) wanted to run into traffic and a danger to others (DTO) for wanting to hurt people in Mexico. During a review of Patient 18’s “Nursing Progress Notes,” dated 9/6/2025 at 1808 (6:08 p.m.), the Nursing Progress Notes indicated Patient 18 reported to nurse (RN 1) he swallowed a razor, Nurse Practitioner (NP 1) was notified, and order was given to monitor Patient 18 and send to emergency department if with symptoms. During a review of Patient 18’s “Nursing Progress Notes,” dated 9/7/2025 at 1608 (4:08 p.m.), the Nursing Progress Notes indicated Patient 18 stated, “you never did anything about the razor I swallowed yesterday.” There was no record of a nurse notifying the physician regarding Patient 18’s statement on 9/7/2025. During a review of Patient 18’s “Nursing Progress Notes,” dated 9/8/2025 at 7:46 a.m., the Nursing Progress Notes indicated Patient 18 stated he (Patient 18) swallowed a razor that he hid inside his “butt.” During a review of Patient 18’s “Nursing Progress Notes,” dated 9/8/2025 at 1828 (6:28 p.m.), the Nursing Progress Notes indicated Patient 18 stated he (Patient 18) was going to swallow a razor and also stated he swallowed a razor “send me to ER (emergency room/emergency department) now.” The notes also indicated that Patient 18 was observed spitting out small amount of serosanguinous drainage (pink or light red color) from mouth. During a review of Patient 18’s” Discharge Summary (a comprehensive medical document created when a patient leaves a hospital or other care setting, detailing the reason for admission, the care received, key findings, and post [after]-discharge instructions),” dated 9/9/2025, the discharge summary indicated Patient 18 was transferred to another facility (on 9/8/2025) for swallowing a foreign object and was later admitted at the receiving facility. During an interview on 10/2/2025 at 11:00 a.m. with RN 1, RN 1 stated Patient 18 reported swallowing a razor on 9/6/2025. RN 1 stated she (RN 1) reported it to NP 1 on the floor and was told to monitor Patient 18 and send Patient 18 to ER if something was abnormal. RN 1 further stated no order for x-ray (a diagnostic imaging procedure that uses a small dose of high-energy radiation to create pictures of the inside of the body) was given on 9/6/2025. During an interview on 10/1/2025 at 10:48 a.m. with Registered Nurse 3 (RN 3), RN 3 stated that on 9/8/2025, Patient 18 went to the nursing station and reported he (Patient 18) swallowed something, “we (staff) were not sure if he (Patient 18) did, later he (Patient 18) started spitting out blood and we (staff) called the Nurse Practitioner (NP 2) and patient was sent to Emergency Department via facility van.” During a review of Patient 18’s “Operative Report,” dated 9/9/2025, the Operative Report indicated, Patient 18 underwent Esophagogastroduodenoscopy (EGD, medical procedure that allows doctors to examine throat, stomach and small intestine) on 9/9/2025 with “a huge metallic foreign body ... very thick metal ... measured about 6 cm in length, 2 cm in width,” removed from the esophagus (canal connecting the throat to the stomach). During an interview on 10/1/2025 at 12:24 p.m. with the Behavioral Health Unit Manager (NM 3), NM 3 stated that for a patient who reports they swallowed a razor, staff should have called 911 because “we (staff) do not know what is going on with patient internally.” During an interview on 10/1/2025 at 1:33 p.m. with BHU manager (NM 3), NM 3 stated Charge Nurse or primary nurse should assess patient, call the doctor, and send patient to ER for evaluation to verify patient did not swallow anything. “We (staff) cannot ignore what patients say, in this case patient (Patient 18) should have been sent to higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]) to verify what he (Patient 18) was saying.” During an interview on 10/1/2025 at 3:13 p.m. with house supervisor (HS 3), HS 3 stated she (HS 3) was doing rounds on 9/8/2025 and overheard Patient 18 report to Charge Nurse (CN) 6 that he (Patient 18) swallowed a razor. During an interview on 10/1/2025 at 3:56 p.m. with the Chief Nursing Officer (CNO), CNO stated the following: when a patient reported to a nurse that he or she had swallowed a foreign object, the nurse should assess and notify the physician right away. Depending on the symptoms, the nurse may call 911 for emergency (patient’s bleeding or unstable vital signs) or send the patient to emergency department for higher level of care. The CNO stated, “Nurse should take the report seriously and not to make any assumption.” During an interview on 10/1/2025 at 4:27 p.m. with Chief of Staff (COS, head of all medical staff), COS stated the following: when a patient reported he or she swallowed a foreign object (a non-food item is ingested and gets lodged in the gastrointestinal [GI, includes mouth, esophagus, stomach and intestines] tract), we need to believe the patient even though they have poor insight and judgement. When a patient reported he or she swallowed a foreign object, the provider needed to be notified and perform examination on the patient. There should be a STAT (a medical abbreviation for immediately or without delay) chest X ray (an imaging procedure to create detailed image of the body’s internal structure such as bones, tissues and organs) and abdomen X ray to rule out the foreign object and to determine the next step for treatment. Once the foreign object was confirmed, the patient should be sent out to emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) for medical intervention. During an interview on 10/1/2025 at 4:38 p.m. with COS, COS stated medical staff (physicians, nurse practitioners and physician assistants) were expected to follow the facility’s Medical Staff Bylaws (governing document that establishes the framework for the self-governance of medical practitioners within a hospital) to provide examination and interventions to assess patient’s condition and complaints. During an interview on 10/1/2025 at 4:45 p.m. with COS, COS stated the following: Patient 18’s medical complaint (of swallowing a razor) was not properly prioritized when it was first reported on 9/6/2025. Patient 18 was seen by another provider (NP 2) and sent out to an emergency department for EGD 48 hours later on 9/8/2025 (from the first time [9/6/2025] of Patient 18 reporting swallowing a foreign object). There would be an extensive discussion of this incident in the next Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issues within the hospital) meeting this month on the 22nd (10/22/2025). COS also stated, “We are trying to recognize this better so we can put a stop to this.” During an interview on 10/3/2025 at 4:57 a.m. with the Chief Executive Officer (CEO), CEO stated the following: medical staff reported to facility’s governing board (GB, the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital’s overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health). GB provided oversight to medical staff. During an interview on 10/6/2025 at 10:55 a.m. with the Chief Executive Officer (CEO), Hospital Administrator (ADM), and the Chief Nursing Officer (CNO), the CEO stated that he (CEO) was a voting member of the Governing Body (GB), responsible for participating in decisions regarding hospital operations and quality oversight. The Hospital Administrator and the CNO stated that they were non-voting members of the GB, attending meetings and contributing to discussions but not participating in formal decision-making or voting processes. During an interview on 10/6/2025 at 10:56 a.m. with CEO, CEO stated the following: the GB was the ultimate resource for the facility and overseeing the operation. GB was responsible for overall patient quality of care and safety. During an interview on 10/6/2025 at 11:41 a.m. with the Hospital Administrator (ADM), ADM stated all medical staff were required to follow Medical Staff Bylaws and all facility’s policies and procedures. During an interview on 10/6/2025 at 11:48 a.m. with the Chief Nursing Officer (CNO), CNO stated the following: RN 1 should not have settled and followed the provider’s (NP 1’s) recommendation even if Patient 18 was not in distress. RN 1 should have escalated the incident to CNO so CNO could talk to the provider. Also, the treating physician did not provide oversight for NP 1 to ensure appropriate care was provided for Patient 18. Medical Executive Committee (MEC) meeting was planning to discuss Patient 18’s incident this month on the 22nd (10/22/2025). During an interview on 10/6/2025 at 11:55 a.m. with the Hospital Administrator (ADM), ADM stated the Governing Board relied on MEC to set expectation with all the providers (physicians, physician assistants and nurse practitioners). During a review of the facility’s Governing Board Bylaws (GB Bylaws, internal rules that govern an organization’s management, outlining the powers, duties and procedures for its board of directors and officers), dated 5/2019, the GB Bylaws indicated, “the Governing Board is responsible for establishing policy, maintaining quality patient care ... provide individualized patient care emphasizing quality of the life in a way that is caring, safe, cost effective and supportive ... enhance the dignity of each individual ... the Medical Staff shall be responsible to the Governing Board for the general quality of medical care provided in the Hospital and the ethical and professional standards of the members of the Medical Staff.” During a review of the facility’s policy and procedure (P&P) titled, “Patient’s Rights,” dated 3/2025, the P&P indicated, “Basic Rights. 1. The patient has a basic right to treatment. Provision of treatment is the physician’s and hospital’s fundamental responsibility to the patient ... B. Rights which May not Be Limited. 3. To humane care and treatment.” During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for Provision of Care,” dated 2022, the P&P indicated, “[the facility] is committed to assuring a single standard of culturally competent care to patients. Patient Services at [the facility] are delivered through organized and systemic process designed to ensure the delivery of safe, effective, timely care and treatment. Patients have access to the appropriate level of care based on their individual condition and needs.” During a review of the facility’s “Medical Staff Bylaws,” dated 10/2024, the Medical Staff Bylaws indicated, “Basic Responsibilities of Medical Staff Membership ... (a) providing patients with quality of care meeting the professional standards of the medical staff of this hospital.” During a review of the facility’s policy and procedure (P&P) titled, “Higher level of care transfer of patient to another facility,” revised 3/2023, the P&P indicated, “If a patient has an emergency medical condition, (facility name) will provide the necessary stabilizing examination and treatment with its capabilities if and when the hospital does not have the necessary capability to treat the patient, the hospital will make all required arrangement for transfer, including but not limited to: stabilizing, treating and monitoring the patient condition, performing any and all life saving measures that may be needed and are within our capabilities... Clinical Situations based on. 3. Or any other clinical diagnosis requiring specialty services not offered at [the facility] will be stabilized and transferred expeditiously to higher level of care receiving facility, based on Emergency Medical Services. 3. During a review of Patient 19’s History & Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/21/2025, the H&P indicated that Patient 19 was admitted to the facility’s Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) on a 5150 (72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) hold due to increased aggression and at risk for assaultive behavior (actions likely to cause physical harm or danger to another person). During a review of Patient 19’s “Nursing Progress Notes,” dated 4/23/2025 and timed at 14:58 (2:58 p.m.), the Nursing Progress Notes indicated that according to the patient (Patient 19), he (Patient 19) was awakened around the morning of (4/23/2025) 0100 (1:00 a.m.) by noises from his (Patient 19) roommate. When he (Patent 19) got up to check on the situation, he (Patient 19) was instructed by the night shift staff to return to his bed immediately. The patient (Patient 19) stated while he (Patient 19) was preparing his bed, staff members approached him (Patient 19), choked him (Patient 19), and escorted him to the seclusion room (a secure, private room used to involuntarily confine an individual alone to de-escalate a situation or modify behavior). He (Patient 19) further reported he (Patient 19) was choked again and placed in 4-point (both wrists and ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) for approximately four (4) to five (5) hours around 0100 (1:00 a.m.). He (Patient 19) was reported released from the restraints around 0600 (6:00 a.m.) that morning (4/23/2025). The Nursing Progress notes also indicated that the house supervisor and nursing manager were both informed of the incident. During a review of Patient 19’s “Nursing Progress Notes” dated 5/11/2025, the notes indicated Patient 19 was discharged to an Independent Living facility. During concurrent interview and record review on 10/2/2025 at 10:47 a.m. with Registered Nurse (RN) 1, Patient 19’s “Nursing Progress Notes,” dated 4/23/2025 and timed at 14:58 (2:58 p.m.), was reviewed. RN 1 confirmed she (RN 1) wrote the progress note and notified the house supervisor and nurse manager (NM 3) regarding the incident involving Patient 19. RN 1 stated that everyone was a mandated reporter, and an alleged abuse must be escalated appropriately. During an interview on 10/2/2025 at 1:59 p.m. with the Nurse Manager (NM) 3 of BHU and the Director (DIR 1) of BHU, NM 3 stated this was the first time of the administrative team hearing of Patient 19’s alleged abuse. NM 3 stated that RN 1 “never reported this to me (NM 3) and if it was, I (NM 3) would have started an investigation.” DIR 1 stated when an alleged abuse incident occurred and involved staff, “we put the alleged staff member on suspension while an investigation is being conducted.” DIR 1 stated since “we (the facility) did not know about the incident regarding the patient (Patient 19), there was no investigation conducted and was never reported to the proper authorities.” DIR 1 stated since the allegation was not reported to the facility administrative team, “we (facility) were unable to identify the perpetrator.” During an interview on 10/3/2025 at 10:19 a.m. with House Supervisor 4 (HS 4), HS 4 stated that she (HS 4) was unaware of the alleged abuse incident. HS 4 stated when RN 1 became aware of the alleged abuse, RN 1 “should have notified myself (HS 4) and I (HS 4) should file an incident report. The incident report then will go to the nurse manager and performance improvement team for them to investigate.” During an interview on 10/6/2025 at 10:55 a.m. with the Chief Executive Officer (CEO), Hospital Administrator (ADM), and the Chief Nursing Officer (CNO), the CEO stated that he (CEO) was a voting member of the Governing Body (GB), responsible for participating in decisions regarding hospital operations and quality oversight. The Hospital Administrator and the CNO stated that they were non-voting members of the GB, attending meetings and contributing to discussions but not participating in formal decision-making or voting processes. During an interview on 10/6/2025 at 10:56 a.m. with the CEO, the CEO stated the following: the GB was the ultimate resource for the facility and oversees the hospital operation. GB was responsible for overall patient quality of care and safety. The GB was also responsible for ensuring the facility was compliant with the local, state, and federal regulations. During an interview on 10/6/2025 at 11:20 a.m. with ADM, ADM stated he (ADM) was not aware of the alleged abuse case that happened on 4/23/2025 involving Patient 19 until 10/3/2025 (during the Federal survey and the abuse incident was brough to the facility’s attention by the surveyors). ADM stated the case (involving Patient 19) was currently under investigation. ADM stated, “no, we are not 100% compliant (referring to the timely investigation and reporting of abuse allegations to regulatory agencies).” ADM stated the facility was required to investigate any alleged abuse case immediately and report the abuse to regulatory agencies. ADM further stated failure to report could cause safety issues and concern. During a review of the facility’s Governing Board Bylaws (GB Bylaws, internal rules that govern an organization’s management, outlining the powers, duties and procedures for its board of directors and officers), dated 5/2019, the GB Bylaws indicated, “the Governing Board is responsible for establishing policy, maintaining quality patient care ... provide individualized patient care emphasizing quality of the life in a way that is caring, safe, cost effective and supportive ... enhance the dignity of each individual ... the Administrator has overall responsibility for the operation and development of the Hospital is accordance with the policies of Board of Directors and Governing Board, and shall take reasonable steps to assure that the hospital complies with all statues, ordinances, and regulations of local, state, and national government.” During a review of the facility’s policy and procedure (P&P) titled, “Abuse/Mandated Reporting,” dated 03/2025, the P&P indicated that: Under applicable laws, the facility requires any person with reasonable cause to suspect abuse, neglect, or exploitation to report it to the appropriate regulatory agency. Key Procedures: Prioritize cases of suspected sexual assault, physical abuse, or neglect. Immediate investigation is required for all suspected cases. Reports must be made within 24 hours to Administration. Law enforcement must be notified when applicable. Who Must Report: All healthcare practitioners and facility employees are mandated reporters. Staff must notify their immediate supervisor and department manager, who will coordinate with the CNO or Administrator (Abuse Coordinator). Reporting Process: Document the incident in the patient’s progress notes (include date, time, source, and quotes). Generate an incident report. Notify supervisor and Quality & Risk Department. Report to authorities via phone and written report within required timeframes. Administrative Responsibilities: Leadership (CEO, CNO, Administrator, etc.) will review and determine reportability. Investigation results must be reported to management and regulatory agencies within 5 working days. 4.a. During a review of Patient 7’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 10/12/2024, the Psych Eval indicated Patient 7 was admitted to the facility on 10/11/2024 due to increased agitation (feeling of irritability or severe restlessness) with diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), paranoid type (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During a review of Patient 7’s “Emergency Medication Intervention (EMI) Assessment and Re-assessment (EMI form),” dated 10/11/2024, the EMI form indicated Patient 7 received Haldol (medication to treat schizophrenia [a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions] and acute [new onset] agitation [feeling of irritability or severe restlessness]) 5 milligrams (mg, unit of measure), Ativan (medication used to anxiety and produce drowsiness and has sedation [a state of calmness or drowsiness induced by drugs] effect) 1 mg, and Benadryl (medication usually used for allergic reaction, can cause drowsiness) 50 mg intramuscular (IM, delivering medication directly into the muscle tissue) injections on 10/11/2024 at 2:15 p.m. due to being combative and agitated toward staff by throwing punches on the floor. During an interview on 10/2/2025 at 8:44 a.m. with Nurse Manager (NM) 2, NM 2 stated it was not indicated in the facility’s policy to notify the physician after a face-to-face assessment was completed by a Registered Nurse (as required by the Federal regulation). During a concurrent interview and record review 10/2/2025 at 1:40 p.m. with the Nurse Manager (NM) 1 of Behavioral Health Unit (BHU, (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) and Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery), Patient 7’s EMI form, dated 10/11/2024, was reviewed. The EMI form indicated a face-to-face assessment was completed on 10/11/2024 at 3:15 p.m. and there was no notification made to physician after face-to-face assessment was completed. NM 1 stated the Registered Nurses (RN) did not call Patient 7’s physician after the completion of the face-to-face assessment on 10/11/2024. During an interview on 10/2/2025 at 1:46 p.m. with NM 1, NM 1 stated the following: emergency medication were injections given to patients when patients’ behavior was imminent danger (a situation where a hazard exists that could reasonably be expected to cause death or serious physical harm immediately or before the danger can be eliminated) to self and/or others. The purpose of the medications was to control the patient’s behavior and maintain patient’s safety. It was a type of behavioral restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body). Trained RN must perform face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) within an hour after medication administration to evaluate the patient. Nurses would notify physicians only if there was change of condition such as the patient being not arousable or medications were ineffective. It was not the facility’s policy to notify the physician every time a face-to-face assessment was completed. During a concurrent interview and record review with NM 1 on 10/2/2025 at 1:55 p.m., the Code of Federal Regulation Title 42 (federal regulations), “Condition of Participation: Patient’s Rights,” dated 2/2020, was reviewed. The federal regulations indicated, “§482.13(e)(14) - - If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient soon as possible after the completion of the 1 hour face-to-face evaluation.” NM 1 stated she (NM 1) was not aware of this regulation. NM 1 further stated physicians should be updated on patient’s response to the emergency medication injections so the physician could determine how the medication improved the patient’s behavior and adjust the treatment plan for patients as needed. During a concurrent interview and record review on 10/6/2025 at 2:53 p.m. with the Chief Nursing Officer (CNO), Hospital Administrator (ADM), and the Nurse Manager (NM) 1, the facility’s policy and procedure (P&P) pertaining to “Restraint and Seclusion Policy,” effective 3/2019, was reviewed. The CNO and NM 1 verified that the facility’s P&P did not align with the federal regulations (regarding the notification of a physician after a RN completes a face-to-face assessment). ADM stated it was the governing body’s responsibility to oversee the facility’s policy implementation and compliance of staff. During a review of the facility’s Governing Board Bylaws (GB Bylaws, internal rules that govern an organization’s management, outlining the powers, duties and procedures for its board of directors and officers), dated 5/2019, the GB Bylaws indicated, “the Governing Board is responsible for establishing policy, maintaining quality patient care ... provide individualized patient care emphasizing quality of the life in a way that is caring, safe, cost effective and supportive ... enhance the dignity of each individual ... the Administrator has overall responsibility for the operation and development of the Hospital is accordance with the policies of Board of Directors and Governing Board, and shall take reasonable steps to assure that the hospital complies with all statues, ordinances, and regulations of local, state, and national government.” During a review of the facility’s policy and procedure (P&P) titled, “Psychotropic Medications (drugs that affect the brain and central nervous system [the body’s main processing center, consisting of the brain and spinal cord] to treat mental health disorders),” dated 10/2024, the P&P indicated, “Emergency Medication Intervention (EMI) injections shall be assessed and reassessed by nursing staff in eHR (electronic health record, digital version of paper charting) including initial assessment, vital signs, conclusion assessment, and patient behavior face to face interview.” During a review of the facility’s policy and procedure (P&P) titled, “Restraint and Seclusion Policy,” dated 4/2025, the P&P indicated, “Assessment and Monitoring of Restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body)/Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) ... a. Restraint used for the management of violent behavior: One-hour face-to-face assessment: A responsible licensed independent practitioner, qualified registered nurse or physician assistant shall perform a face-to-face assessment of the patient’s physical and psychological status within 1 hour of the initiation of restraint or seclusion. Registered nurses or physician assistants who perform such assessment shall be trained and have demonstrated competence in the management of violent behavior ...” 4.b. During a review of Patient 12’s, “Psychiatric Initial Evaluation, dated 9/20/2025, the psychiatric eval indicated Patient 12 was admitted to the facility’s behavioral health unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) on 9/20/2025 on 5150-hold (72 hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) for danger to others (DTO, a person who poses a substantial likelihood of inflicting serious bodily harm on another person) increased aggression, threats, and instigating fight with staff. During a review of Patient 12’s “Emergency Medication and Restraint Order Sheet,” dated 9/25/2025, the emergency medication and restraint order sheet indicated Patient 12 had physician’s order for the following: -Restraint order -hard restraints (physical or mechanical devices that are rigid and difficult to remove, designed to immobilize a person’s body or limbs. They are typically made of durable materials like padded leather or heavy-duty plastic with locking mechanisms and are used in situations where soft restraints are insufficient to prevent self-harm or escape) -not to exceed four hours, 4 point (both wrists and ankles) and seclusion - not to exceed four hours. -Medication order - Ativan 2 milligrams via IM (intramuscular, into the muscle), Haldol 10 milligrams via IM, and Benadryl 50 milligrams via IM. During a concurrent interview and record review on 10/1/2025 at 11:08 a.m. with the Medical Records Management (MRM) 1 and the Nurse Manager (NM) 2, Patient 12’s “Emergency Medication Intervention (EMI, involve the use of sedative medication [drug that slows brain activity to calm a person] to quickly calm and manage patient experiencing acute agitation) notes,” dated 9/25/2025, was reviewed. NM 2 stated Patient 12 was placed in seclusion room and placed on 4-point (both arms and legs) restraint (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) at 7:30 p.m. NM 2 also said Patient 12 received, via IM route, Haldol 10 milligrams, Ativan 2 milligrams and Benadryl 50 milligrams at 7:55 p.m. on 9/25/2025. During a concurrent interview and record review on 10/2/2025 at 8:44 a.m. with Nurse Manager (NM) 2, Patient 12’s “Seclusion/Restraint face to face assessment by L.I.P/H.S. (Licensed Independent Practitioner/House Supervisor),” was reviewed. NM 2 stated face to face assessment, dated 9/25/2025, was signed by House Supervisor (HS) 6, a Registered Nurse. NM 2 verified the physician was not notified by the RN after face-to-face assessment was completed because the date and time of physician notification was left blank in the seclusion/restraint face to face assessment form. NM 2 also stated it was not indicated in the facility’s policy to notify the physician after a face-to-face assessment was completed by a Registered Nurse (as required by the Federal regulation). During the same concurrent interview and record review on 10/2/2025 at 8:44 a.m. with NM 2, the Code of Federal Regulation Title 42 (federal regulations), “Condition of Participation: Patient’s Rights,” dated 2/2020, was reviewed. The federal regulations indicated, “§482.13(e)(14) - - If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient soon as possible after the completion of the 1 hour face-to-face evaluation.” NM 2 stated the facility’s policy did not reflect the federal regulations, and it was important for their (the facility’s) policy to match the regulations. NM 2 stated it was important for the nurse to inform the physician that face-to-face assessment was conducted, to report any abnormal findings, ensure patient safety, determine if restraint use was tolerated well or whether restraint should be continued. NM 2 stated there should always be a coordination among healthcare disciplines (such as between the physician and the Registered Nurse) regarding the plan of care, change in plan of care or in making adjustments in treatment plan. During a concurrent interview and record review on 10/6/2025 at 2:53 p.m. with the Chief Nursing Officer (CNO), Hospital Administrator (ADM), and the Nurse Manager (NM) 1, the facility’s policy and procedure (P&P) pertaining to “Restraint and Seclusion Policy,” effective 3/2019, was reviewed. The CNO and NM 1 verified that the facility’s P&P did not align with the federal regulations (regarding the notification of a physician after a RN completes a face-to-face assessment). ADM stated it was the governing body’s responsibility to oversee the facility’s policy implementation and compliance of staff. During a review of the facility’s Governing Board Bylaws (GB Bylaws, internal rules that govern an organization’s management, outlining the powers, duties and procedures for its board of directors and officers), dated 5/2019, the GB Bylaws indicated, “the Governing Board is responsible for establishing policy, maintaining quality patient care ... provide individualized patient care emphasizing quality of the life in a way that is caring, safe, cost effective and supportive ... enhance the dignity of each individual ... the Administrator has overall responsibility for the operation and development of the Hospital is accordance with the policies of Board of Directors and Governing Board, and shall take reasonable steps to assure that the hospital complies with all statues, ordinances, and regulations of local, state, and national government.” During a review of the facility’s policy and procedure (P&P) titled, “Psychotropic Medications,” dated 10/2024, the P&P indicated, “Emergency Medication Intervention (EMI) injections shall be assessed and reassessed by nursing staff in eHR (electronic health record) including initial assessment, vital signs, conclusion assessment, and patient behavior face to face interview.” During a review of the facility’s policy and procedure (P&P) titled, “Restraint and Seclusion Policy,” dated 4/2025, the P&P indicated, “Assessment and Monitoring of Restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body)/Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) ... a. Restraint used for the management of violent behavior: One-hour face-to-face assessment: A responsible licensed independent practitioner, qualified registered nurse or physician assistant shall perform a face-to-face assessment of the patient’s physical and psychological status within 1 hour of the initiation of restraint or seclusion. Registered nurses or physician assistants who perform such assessment shall be trained and have demonstrated competence in the management of violent behavior ...””

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility’s Governing Body (GB, the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital’s overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) failed to ensure oversight on its contracted services in relation to their performance measures, when the facility’s Quality Assessment and Performance Improvement committee (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital), under the direction of the Governing Body failed to identify quality and performance issues for contracted services, implement corrective or improvement actions, and ensure ongoing monitoring and sustainability of implemented corrective actions, when there was a delay in obtaining a head computed tomography scan (CT scan, a medical imaging procedure that creates detailed cross-sectional images of the body), performed by a contracted company, for one of 76 sampled patients (Patient 1). On 6/5/2025, Patient 1, was involved in a patient-to-patient altercation with Patient 2. As a result, Patient 1 sustained a hip fracture and exhibited neurological deficits (impairment in the function of the nervous system) as was manifested by trembling (shaking) of arms and legs, right pupil sluggish response, right upper eyelid drooping (sagging), and left-hand grip weakness. thus, requiring a STAT (immediately) CT scan, but was not carried out by the contracted radiology company as ordered by the physician. This deficient practice resulted in a delay in obtaining a head (CT) scan for Patient 1. The delay in diagnostic imaging potentially contributed to a delay in diagnosis for Patient 1. Furthermore, the facility’s failure to assess and monitor the performance of contracted services, such as CT imaging, through its QAPI program, presented a missed opportunity to identify, analyze, correct, and monitor systemic issues related to delayed diagnostic performance times, placing all patients requiring contracted imaging services at risk. Findings: During a review of Patient 1’s History and Physical (H&P, a comprehensive clinical document that includes a patient’s medical history and findings from a physical examination), dated 6/4/2025, the H&P indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU) due to being “agitated (a feeling of uneasiness and severe restlessness) and aggressive.” The H&P also indicated that Patient 1 was placed on assaultive (safety measures implemented for patients who exhibit or are at risk of exhibiting violent or aggressive behavior) and homicidal precautions (safety interventions used when a patient expresses or demonstrates thoughts, intentions, or behaviors indicating a risk of harming others). During a review of Patient 2’s Psychiatric Evaluation, dated 6/3/2025, the record indicated that Patient 2 was admitted on a 5150 Involuntary Hold (a legal provision under the State law, that allows for the involuntary detention of an individual for up to 72 hours when they are deemed a danger to themselves, others, or are gravely disabled [a condition in which a person, due to a mental health disorder, is unable to provide for their basic personal needs such as food, clothing, or shelter ] due to a mental health disorder). The record also indicated that the 5150 Hold was initiated due to danger to others after Patient 2 became “increasingly aggressive at the nursing home (a residential facility that provides 24-hour medical and personal care for individuals, who are unable to live independently due to illness, disability, or cognitive decline),” from which Patient 2 was transferred from. During a concurrent interview and record review on 9/30/2025 at 3:02 p.m. with the Chief Nursing Officer (CNO), Patient 1’s medical record titled, “Nursing Progress Notes,” dated 6/5/2025, was reviewed. The CNO stated that, according to the documentation, Patient 1 attempted to strike Patient 2, who was sitting at the door in the hallway. Patient 2 defended himself, stood up, and pushed Patient 1, who then fell backwards. The CNO confirmed that the fall was unwitnessed (as per nursing notes documentation), and that Rapid Response Team (RRT, a team of healthcare professionals, often including a critical care nurse and a respiratory therapist, who are quickly dispatched to provide immediate care to a patient who shows signs of acute deterioration within a hospital) was called at 2:20 p.m. after Patient 1 was assessed to have weakness in the lower extremities (both legs), drooping (excessive sagging) on the left side of face, and left arm weakness. During a concurrent interview and record review on 10/1/2025 at 2:34 p.m. with the Nurse Manager of the Behavioral Health Unit (NM 2), Patient 1’s physician orders dated 6/4/2025 and 6/5/2025 were reviewed. The records indicated that Patient 1 had two (2) Computed Tomography (CT, a medical imaging procedure that creates detailed cross-sectional images of the body) orders placed, specifically: -6/4/2025 at 5:21 p.m. - Order for CT head to rule out injury (due to a possible self-inflicted injury to the head) -6/5/2025 at 3:32 p.m. - STAT CT head due to fall (unwitnessed fall after a patient-to-patient altercation between Patient 1 and Patient 2) -The NM 2 said she (NM 2) was unaware of the timeframe for performing CT diagnostic imaging and would need to refer to the policy. NM 2 also stated that the CT head ordered on 6/4/2025 resulted on 6/5/2025 at 2:01 p.m., and the STAT (immediately) CT head ordered on 6/5/2025, was never completed. The NM 2 also said, that according to documentation in Patient 1’s nursing notes, dated 6/5/2025, Patient 1 was transferred to a higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]) on 6/5/2025 at 4:46 p.m. via 9-1-1 to rule out (r/o) stroke (brain attack) or subdural hematoma (a collection of blood that accumulates in the brain). During an interview on 10/2/2025 at 3:37 p.m. with the Hospital Administrator (ADM), the ADM stated that during the internal investigation of the incident between Patient 1 and Patient 2, the team did not identify delays in CT scan imaging. The ADM said that CT was a contracted third-party provider and there was no actual timeframe for CT order timeliness. The ADM said that typically the facility was not going to wait for a CT scan if the patient was showing signs of worsening, and the patient (Patient 1) was transferred to a higher level of care. During an interview on 10/2/2025 at 3:37 p.m. with the Chief Nursing Officer (CNO), the CNO said that CT scan orders (a third-party, contracted service) must be called in by the staff to schedule, and the CT provider would typically inform the nurses of the earliest time they are available to perform the CT. The CNO also said that timeframe was not specified in the contract. During the interview on 10/3/2025, at 1:59 p.m. with the Vice President of Operations (VPO), the VPO confirmed that the contract titled, “Hospital Diagnostic Services Agreement,” was current and valid. The VPO further verified that this agreement represented the formal arrangement between the hospital and the diagnostic imaging service provider responsible for delivering on-site Computed Tomography (CT) services at the hospital. The VPO also confirmed that the hospital’s governing board was the final approving authority for this contract (the governing board holds the ultimate decision-making power to authorize and execute the contract). During an interview on 10/3/2025 at 2:01 p.m. with the Vice President of Operations (VPO), the VPO said that each contracted service should have its own performance improvement process and report data to the Quality Council (part of the QAPI program), then to the Medical Executive Committee (MEC, a body of physicians responsible for governing the hospital’s medical staff, focusing on quality of care, professional conduct, and the effectiveness of medical activities), and finally to the Governing Body (GB). During an interview on 10/3/2025 at 3:36 p.m. with the Vice President of Operations (VPO), the Hospital Administrator (ADM), Chief Nursing Officer (CNO), and both Nurse Managers of the Behavioral Health Unit (NM 1 and NM 2), the CNO and the ADM stated the following regarding QAPI and performance monitoring for CT diagnostic imaging contracted services: - The facility did not have a formal QAPI program specifically for CT imaging turnaround times. No issues had been ever reported or identified regarding CT order delays. Monitoring is limited to CT requests and result reporting. -The VPO said that performance improvement for CT diagnostic procedures included identifying delays and notifying physicians. The CNO and NM 1 then also said that since CT imaging was contracted out, STAT (done immediately, without delay) orders may not always be fulfilled immediately, and physicians must be informed when a CT cannot be performed as requested, so the physician can transfer out the patient, instead. The CNO then said that delays in both STAT and routine CT orders could impact patient care, particularly in time-sensitive cases like stroke (brain attack). In such situations, timely imaging was critical for diagnosis and treatment decisions. During a follow-up interview on 10/3/2025 at 4:20 p.m. with Hospital Administrator (ADM), Chief Nursing Officer (CNO), Nurse Managers (NM 1 and NM 2) of Behavioral Health Unit (BHU), the CNO and NM 1 said that there had been past instances where physicians ordered CT scans and experienced delays in timely monitoring. The CNO said that these delays prompted discussions focused on improving communication between nursing staff and the radiology department. The NM 1 also confirmed that no formal tracking data or measurable outcomes were available to assess improvement, although stated that improvement in turn-around times for radiology tests, had been achieved. The CNO said that since nursing staff was responsible for bedside care, nursing staff faced challenges in monitoring QAPI measures addressing any possible performance issues with CT imaging. The NM 1 and CNO both said that in the past nursing staff achieved improved timeliness of CT orders by instructing nurses to directly communicate with the radiology department and notify physicians when a STAT order might be delayed due to the involvement of a third-party radiology contractor to allow physicians to make timely decisions, including transferring the patient if necessary, rather than waiting for CT scan completions. During an interview on 10/6/2025 at 10:55 a.m. with the Chief Executive Officer (CEO), Hospital Administrator (ADM), and Chief Nursing Officer (CNO), the CEO stated that he (CEO) was a voting member of the Governing Body (GB), responsible for participating in decisions regarding hospital operations and quality oversight. The Hospital Administrator and the CNO stated that they were non-voting members of the GB, attending meetings and contributing to discussions but not participating in formal decision-making or voting processes. During an interview on 10/6/2025 at 11:30 a.m. with the Chief Executive Officer (CEO), the CEO stated the following: the facility’s governing body (GB, the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital’s overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) ultimately provided oversight for all contracted services. The contracted services were required to follow the facility’s policies and procedures. During a review of the agreement titled, “Hospital Diagnostic Service Agreement,” dated 2/2024, the agreement indicated that “the CT diagnostic [Brand] company does not provide emergency services. It is willing to make accommodations to the Facility and to provide services within 6 hours of the time of the request of said service, and at additional cost (STAT) service fee.” During a review of the facility’s policy and procedure (P&P) titled, “Contract Services,” dated 3/2022, the P&P indicated the following, “The Governing Board must approve all contractual agreements that involve provision of care, treatment, and services. The contracts clearly describe the type and scope of the contractor’s services, and performance measure expectations are included. Leaders monitor contracted services by evaluating these services in relation to their performance measures. The governing body reviews the performance of contract services on an annual basis.” During a review of the facility’s Bylaws (foundational documents that outline the hospital’s structure, purposes, and the medical staff’s organization and responsibilities ), dated 5/2019, the Bylaws indicated the Governing Board is a committee appointed by the Facility. As the hospital’s Governing Body, it is responsible for setting policy, ensuring quality patient care, and supporting institutional planning and management. Its actions align with the hospital’s mission to deliver safe, compassionate, and cost-effective care that upholds patient dignity. The Governing Board reports directly to the Board of Directors, which retains ultimate oversight. During a review of the facility’s Bylaws, dated 5/2019, the Bylaws indicated the following: “The Governing Board, through the Administrator, shall provide whatever administrative assistance is reasonably necessary to support and facilitate the implementation and ongoing operations of these quality review and evaluation activities. These quality review and evaluation activities shall ensure that the same level of overall quality and appropriateness of care is provided to all patients of the Hospital. Monitoring and evaluating the quality and appropriateness of patient care through a valid and reliable quality assessment program.””

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility’s governing body (GB, the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital’s overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) failed to ensure appropriate oversight on its contracted services (refer to specialized tasks performed by external, independent providers for a specific fee, outlined in a formal agreement that details the scope, timeline, and payment terms) staff in order to provide safe patient care, in accordance with the facility’s contract agreement and the policy on Patient Rights, for one of 76 sampled patients (Patient 7), when a security guard (SG 1), from a contracted company, hit Patient 7 on 10/13/2024. This deficient practice resulted in Patient 7 being physically abused (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by SG 1 and resulted in bruises on the cheek. This deficient practice also had the potential for psychological trauma for Patient 7. Findings: During a review of Patient 7’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 10/12/2024, the Psych Eval indicated Patient 7 was admitted to the facility on 10/11/2024 due to increased agitation (feeling of irritability or severe restlessness) with diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), paranoid type (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During a review of Patient 7’s “Interdisciplinary Team Progress Notes Nursing (nursing notes),” dated 10/13/2024, the notes indicated, on 10/13/2024 at 10:40 p.m., Patient 7 had increased aggressive (behavior that is forceful, assertive, and potentially hostile or threatening) behavior verbally and physically towards staff ... called other staff member to help intervene with patient (Patient 7) behavior ... Patient (Patient 7) stayed in bed still irritable and continue to be aggressive towards staff. Patient (Patient 7) attempted to swing at staff ...” During an interview on 10/3/2025 at 11:09 a.m. with the House Supervisor (HS 5), HS 5 stated the following: on 10/13/2024 at night, she (HS 5) received a report involving Patient 7 being physically abused (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by a security guard (SG 1). HS 5 spoke with SG 1. SG 1 tried to intervene as Patient 7 was being aggressive. SG 1 admitted to HS 5 that he (SG 1) hit Patient 7 because he (SG 1) got mad (at Patient 7) and retaliated. HS 5 assessed Patient 7 and noted Patient 7 had bruises on his (Patient 7’s) cheek. The incident was also witnessed by other staff (Patient 7’s primary nurse and two other Mental Health Workers). SG 1 was sent home immediately. The incident was reported to department nurse manager (NM 1) and the Chief Nursing Officer (CNO) for investigation and report. HS 5 also stated she (HS 5) did not see SG 1 working anymore since then. During a review of SG 1’s termination letter issued by facility’s security guard contracted services (CS 3), dated 10/17/2024, the termination letter indicated SG 1 was terminated on 10/17/2024 due to a serious incident that occurred involving a patient (Patient 7) on 10/13/2024. The termination letter also indicated, “this type of conduct is unacceptable and goes against the values and policies of [the organization] ... it has been determined that immediate termination is the appropriate course of action.” During an interview on 10/3/2025 at 2:07 p.m. with the Chief Executive Officer (CEO 2) for facility’s security guard contracted services (CS 3), CEO 2 stated SG 1 was terminated after confirming the incident with Patient 7 for physical abuse. CEO 2 stated all contracted staff should follow facility’s policies and procedures. During an interview on 10/6/2025 at 11:30 a.m. with the Chief Executive Officer (CEO), the CEO stated the following: the facility’s governing body (GB, the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital’s overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) ultimately provided oversight for all contracted services. The contracted services were required to follow the facility’s policies and procedures. During a review of the facility’s contract with CS 3 titled, “Cardio-Pulmonary Ancillary Services,” dated 8/1/2022, the “Cardio-Pulmonary Ancillary Services” indicated, “Compliance ... 4.1. Cooperation with Compliance Efforts of Hospital. [CS 3] agrees to cooperate with [the facility] as necessary so that [the facility] and [CS 3] meet all requirements imposed by law or ordinance or established by the rules and regulations of any federal state or local agency ...to set standards governing the operation of [the facility] and the activities of [CS3] ... 4.2 Compliance with Law. In the performance of their respective responsibilities and obligations hereunder, [the facility] and [CS 3] shall comply with the requirements of all federal, state and local laws, regulations and ordinances and policies and procedures and Governing Bylaws applicable to their respective organizations and activities.” During a review of the facility’s policy and procedure (P&P) titled, “Patient’s Rights,” dated 5/2025, the P&P indicated, “This policy applies to all employees, medical staff, volunteers, contractors and students providing care or services within [the facility] ... Patient Rights ... All patients receiving care at [the facility] have the rights to ... 6. Safety ... Receive care in a safe environment, free from all forms of abuse, harassment, or restraints that are not medically necessary.””

“CONTRACTED SERVICES CFR(s): 482.12(e)(2) The hospital must maintain a list of all contracted services, including the scope and nature of the services provided. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility’s governing body (GB, the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital’s overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) failed to ensure oversight over its contracted services by failing to maintain a current contract, in accordance with the facility’s policy titled, “Vendor Agreements,” for one of three sampled contracted services (CS 1, refer to specialized tasks performed by external, independent providers for a specific fee, outlined in a formal agreement that details the scope, timeline, and payment terms) when the contract expired since June 2024. This deficient practice resulted in CS 1 providing services to the facility’s patients without a current contract which may lead to the provision of services outside the contract agreement and substandard quality of care to patients that may result in patient harm and/or death. Findings: During a concurrent observation and interview on 10/1/2025 at 8:33 a.m. with the facility’s contracted service (CS 1) clinic physician (MD 1) at the CS 1 clinic, CS 1 clinic was open with clinic staff presently working. MD 1 stated he (MD 1) provided medical screening for patients at the clinic and determined if the patients were medically cleared to be admitted to the facility as inpatients. During an interview on 10/1/2025 at 10:45 a.m. with the House Supervisor (HS 2), HS 2 stated the following: the facility was contracted with CS 1. The facility would receive admissions from CS 1 clinic after patients were medically cleared by the CS 1 physicians. During an interview on 10/3/2025 at 1:54 p.m. with the Vice President of Operation (VPO), VPO stated she (VPO) was responsible for reviewing all facility’s contracts on an annual basis to ensure contracts were current (up to date) and all contract requirements were met. VPO stated she (VPO) reported to the facility’s Chief Executive Officer (CEO) directly and would get CEO’s approval if there were any changes or updates in contract agreement that needed to be made. During a concurrent interview and record review on 10/3/2025 at 2:08 p.m. with VPO, the facility’s contract with CS 1 titled, “Service Agreement,” dated 10/20/2023, was reviewed. The “Service Agreement” indicated, “Term and Termination: a. Term. The initial term of this Agreement (“Initial Term”) shall be 12 MONTHS commencing on the Effective Date 6/1/2023. At the end of the Initial Term, the Agreement may be renewed or extended for any period upon the mutual written agreement of the Parties.” VPO stated the following: She (VPO) thought the contract agreement was “auto-renew (automatic renewal).” The VPO also said the contract expired in June 2024 and was no longer active. There was no written renewal statement with CS 1. VPO also stated the governing body oversaw all contract services. During an interview on 10/6/2025 at 11:33 a.m. with the Chief Executive Officer (CEO), the CEO stated the following: he (CEO) was part of the Governing Body (GB, the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital’s overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health). The GB was responsible for providing oversight for all contract services. Contract must be current, or it was not relevant. There would be areas of service oversight and not accounted for, should the contract be not reviewed appropriately by the facility. All services must be reviewed, communicated, clearly spelled out, and updated in the contract agreement by the controller (GB’s designee) and with the GB’s approval. The GB was under the assumption that the contract with CS 1 was on auto-renew. GB was not aware the contract with CS 1 had expired (since June 2024). During a review of the facility’s policy and procedure (P&P) titled, “Vendor Agreements,” dated 3/2025, the P&P indicated, “All agreements entered into on behalf of the organization must be properly authorized, reviewed, documented, and maintained in accordance with applicable laws, regulations, and organizational procedures.””

“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: 45743 Based on observation, interview and record review, the facility failed to ensure that patients received care in a safe environment when Q 15-minute (every fifteen-minute) observation patient rounding (a proactive nursing practice where staff check on patients at regular intervals to anticipate and address their needs. This strategy aims to improve patient safety)/monitoring, was not correctly and consistently performed for 56 of 76 sampled 5150 (involuntary hold/involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) patients (Patient 1, Patient 2, Patient 14, Patient 15, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 42, Patient 43, Patient 44, Patient 45, Patient 46, Patient 47, Patient 48, Patient 49, Patient 50, Patient 51, Patient 52, Patient 54, Patient 55, Patient 56, Patient 57, Patient 58, Patient 59, Patient 60, Patient 61, Patient 62, Patient 63, Patient 64, Patient 65, Patient 66, Patient 67, Patient 68, Patient 72, Patient 73, Patient 74, Patient 75, Patient 76), in accordance with the facility’s policy on patient rounding for both 5150 and voluntary hold (when a patient agrees to be admitted to a psychiatric unit for treatment, a decision they make on their own or with their guardian’s consent) patients. This deficient practice resulted in 5150 patients in the BHU (Behavioral health Unit, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) unit in Campus 1 and Campus 2 inadequately monitored for hours and had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, and potentially can result to death. Patient 1 and Patient 2 had an unwitnessed altercation in which Patient 1 sustained a subdural hematoma (a form of traumatic brain injury involving bleeding) and a displaced fracture (broken bone) of the right femoral neck (the narrow, connecting part of the femur (thigh bone) that links the ball-shaped head of the femur to the long shaft of the bone) thus needed to be transferred out for higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]). On 10/2/2025 at 2:31 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the Chief Nursing Officer (CNO), Manager of Medical-Surgical and Behavioral Health Unit (NM 1), Hospital Administrator (ADM), Manager of Behavioral Health Unit (NM 2 [from Campus 2]), Director of Behavioral Health Unit (DIR 1 [from Campus 2]), and Manager of Behavioral Health Unit (NM 3 [from Campus 2]). The facility failed to ensure that Q-15 (every fifteen-minute) observation patient rounding (a proactive nursing practice where staff check on patients at regular intervals to anticipate and address their needs. This strategy aims to improve patient safety )/monitoring, was correctly and consistently performed for 56 of 76 sampled 5150 (involuntary hold/involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) patients (Patient 1, Patient 2, Patient 14, Patient 15, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 42, Patient 43, Patient 44, Patient 45, Patient 46, Patient 47, Patient 48, Patient 49, Patient 50, Patient 51, Patient 52, Patient 54, Patient 55, Patient 56, Patient 57, Patient 58, Patient 59, Patient 60, Patient 61, Patient 62, Patient 63, Patient 64, Patient 65, Patient 66, Patient 67, Patient 68, Patient 72, Patient 73, Patient 74, Patient 75, Patient 76), in accordance with the facility’s policy on patient rounding for both 5150 and voluntary hold patients. This deficient practice resulted in 5150 patients in the BHU (Behavioral health Unit, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) unit in Campus 1 and Campus 2 being inadequately monitored for hours and had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, and potentially can result to death. Patient 1 and Patient 2 had an unwitnessed altercation in which Patient 1 sustained a subdural hematoma (a form of traumatic brain injury involving bleeding) and a displaced fracture (broken bone) of the right femoral neck (the narrow, connecting part of the femur (thigh bone) that links the ball-shaped head of the femur to the long shaft of the bone) thus needed to be transferred out for higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]). Patient 1 was admitted to the BHU (locked) unit on 6/4/2025 due to “agitated (feeling of uneasiness and severe restlessness), aggressive” behavior and for increasing and assaultive behavior (actions likely to cause physical harm or danger to another person) towards staff, and was placed on a 5150 hold for DTO (danger to self)/GD (Grave Disability [a situation where a person is unable to provide for their basic needs due to a mental health disorder]). Patient 2 was admitted to the BHU unit on 6/3/2025 due to agitation and increasingly aggressive behavior, and was placed on a 5150 involuntary hold for danger to others. During a review of Patient 1’s “Nursing Progress Note,” dated 6/5/2025 at 4:30 p.m., the note indicated that a physician who was at Patient 1’s bedside noted a head bump on Patient 1’s right head on 6/5/2025. There was no other documented evidence that Patient 1 was admitted already with a head bump on 6/4/2025 On 6/5/2025 at 2:20 p.m., an altercation occurred between Patient 1 and Patient 2 in the locked Behavioral Health Unit (BHU), 5th floor (Campus 1). Patient 1 attempted to strike Patient 2, who was sitting at the door in the hallway. Patient 2 defended himself, stood up, and pushed Patient 1, who then fell backwards and later was confirmed that Patient 1 sustained a right hip fracture (a break in the upper portion of the right femur (thighbone, specifically where it connects to the hip joint on the right side of the body). Patient 1 was also later assessed to show signs and symptoms of neurological deficit (an impairment or loss of function in the nervous system): weakness in the lower extremities (refers to a reduction in muscle strength in the legs, which can affect a person’s ability to stand, walk, maintain balance, or perform daily activities), drooping on the left side of face (a unilateral sagging or weakness of the facial muscles, typically on one side of the face), and left arm weakness and was transferred to a higher level of care. There was also no video footage available for review of the incident that happened on 6/5/2025 because the facility only kept the video footages for 10 days in Campus 1. The incident was unwitnessed (as documented in the nursing progress notes) by both licensed (RN [Registered nurse], LVN [licensed Vocational Nurse]) and unlicensed (MHW [Mental Health Worker]) healthcare personnel assigned to the unit at the time. During the time frame of the incident (on 6/5/2025 between Patients 1 and 2), the Q15-minute observation log on 6/5/2025, indicated that Patient 1 was not agitated (feeling of uneasiness and severe restlessness) and was consistently documented as either lying or sitting in his (Patient 1) room. The Chief Nursing Officer (CNO) verified that this documentation was possibly inaccurate, noting that the altercation occurred at 2:20 p.m. on 6/5/2025, yet no deviation or incident was reflected in the rounding sheet during that time. The CNO also confirmed that the video footage of the incident involving Patient 1 and Patient 2 was not reviewed by the facility during the internal investigation to verify whether the Q15-minute observation documentation accurately reflected the patients’ actual activity and behavior at the time of the incident. During a concurrent observation, interview and video footage review on 10/1/2025 at 11:00 a.m. with Nurse Manager (NM 1) of BHU and Medical-Surgical (Med/Surg) Unit, the video footage, dated 9/19/2025 from 1:00 a.m. to 2:30 a.m., was reviewed. The following events were observed at the indicated timestamp in the video: 9/19/2025 at 1:00 a.m. -No staff seen conducting patient rounding in any of the video angles. 9/19/2025 at 1:15 a.m. -No staff seen conducting patient rounding, in any video of the angles. 9/19/2025 at 1:30 a.m. -No staff seen conducting patient rounding in any of the video angles 9/19/2025 at 1:45 a.m. -no staff seen doing rounding, one patient seen in wheelchair going down hallway without staff presence (camera angle 6) 9/19/2025 at 2:00 a.m. -two staff members seen rounding in Patient rooms 1, 2, 3 and 4 (camera angle 4) but not seen checking other patient rooms. Confirmed with NM 1 that one was a licensed staff (RN) and the other individual was the resource nurse. 9/19/2025 at 2:15 a.m. -two staff members sitting in chairs in the BHU hallway on Camera angles 6 and 7. Not getting up to conduct rounding on patients. NM 1 was unable to identify the two staff members. 9/19/2025 at 2:30 a.m. -Same two staff members sitting in chairs in BHU hallway, not getting up to conduct patient rounding seen in camera angles 6 and 7, NM 1 was unable to identify the two staff members During a concurrent observation, interview, and record review on 10/1/2025 at 12:40 p.m. with the Nurse Manager (NM) 2 of Behavioral Health Unit (BHU) and the Security Supervisor (SS)1, the facility’s security footage of Campus 2 BHU unit (Unit C) on 9/13/2025, from time period 1:20 a.m. to 4:58 a.m., was observed and reviewed. It was observed and was confirmed by NM 2 that there was no patient rounding by facility staff between the hours of 1:20 a.m. to 4:58 a.m. on 9/13/2025. During a concurrent observation, interview, and record review on 10/1/2025 at 1:10 p.m. with the Nurse Manager (NM) 2 of Behavioral Health Unit (BHU) and the Security Supervisor (SS)1, the facility’s security footage of Campus 2 BHU unit (Unit S) on 9/19/2025, from time period of 1:00 a.m. to 2:15 a.m., was observed and reviewed. It was observed and verified by NM 2 that facility staff were not entering the patient rooms during patient rounding to check on patients. During an interview on 10/1/2025 at 11:47 a.m. with NM 1, NM 1 stated the expectation was for staff to do Q 15-minute rounding to check on the patients, ensure safety and known location. Purpose of rounding was to know the location of the patients and make sure the patient was safe. “It allows us to notice any changes in behaviors, so that staff can address them accordingly.” NM 1 verified that rounding was only completed once for 4 rooms (rooms 1,2, 3, and 4) but not the whole unit within the 1.5 hour of video reviewed for Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 41, Patient 42, Patient 43, Patient 44. During an interview on 10/1/2025 at 2:12 p.m. with the Chief Nursing Officer (CNO), the CNO confirmed that Q15 (every 15 minutes) patient safety checks should be conducted to: ensure patient safety, confirm responsiveness, assess patient behavior, and document patient activity. During an interview on 10/1/2025, at 1:31 p.m. with House Supervisor (HS 1), HS 1 stated they do daily audit for the completeness of the Q 15-minute rounding sheet to verify staff compliance with rounding. However, the paper documentation for rounding was not done concurrently with a review of the video footages to determine if the paper documentation matches what was observed on the rounding being done as seen through the video surveillance cameras. During an interview on 10/2/2025 at 9:13 a.m. with the Nurse Manager (NM 2) of BHU and Med/Surg, NM 2 stated she (NM 2) never did any concurrent security video review to compare what the BHU staff did and what was documented for the behavioral health unit (BHU). NM 2 stated, “We wanted to believe the employees that what they wrote was what they did (referring to the documented Q 15-minute rounding by staff).” During a review of the Facility’s policy and procedure (P&P) titled, “Observation Levels System,” dated 3/2025, the P&P indicated, “It is the policy of [the facility] to initiate and provide the appropriate observation level of patient’s behaviors exhibited and also the information provided at the time of admission, and throughout hospitalization. All patients will be routinely observed in compliance with physician/psychologist orders and prescribed protocols. Purpose: to provide the most appropriate patient observation level is maintained throughout hospitalization. To provide patient safety at all times ... Types of Observation Level A. Level I: every 15-minute checks, routine observation. Minimal level of observation for all patients. Staff will observe patient and document on the Patient’s Observation Rounds Sheet Q15 minutes. Assigned staff will make direct contact with patients and confirm they are in no danger or distress ... Observation may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping. It is expected that the staff conducting the 15 minutes observation will enter the room, approach the patient and check their identify, respirations, and to ensure that they are not in any distress.” B. Level II: every 15 minutes checks, routine observations with precautions and taking note of precautions ordered as well ...staff will observe patient and document on the Patient’s Observation Rounds sheet every 15 minutes ...” On 10/6/2025 at 2:50 p.m., the IJ was removed in the presence of the Chief Executive Officer (CEO), ADM, CNO, NM 1, NM 3 and DIR 1, after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed by the survey team while onsite through observation, interview, and record review. The acceptable IJ Removal plan included the following: On 10/2/2025 the facility added additional MHW staffing to the BHU units at both campuses (Campus 1 and Campus 2) to assist with the provision of alternate rounding schedules, monitoring patients’ behavior and condition, staffing will be based on acuity (the severity and complexity of a patient’s medical condition. It is a measure of the patient’s healthcare needs and the intensity of nursing care required). On 10/2/2025, new staff workflow interventions were implemented, a ‘Buddy System’ where staff pairings were assigned and designed to overlap coverage and ensure accountability for staff to complete rounds, the buddy system will be indicated on the staff assignment sheet. On 10/2/2025 re-education began for licensed nurses, Certified Nurse Assistants (CNA) and MHWs regarding the facility’s policy on Q 15-minute rounding, emphasis on awareness of the patients location, behavior and safety, in order to provide a safe environment for all patients away from any harm, any non-compliance would result in disciplinary action. Leadership oversight included: the house supervisor/designee will make unannounced visits to each unit, every shift to ensure staff are conducting observational rounds every 15 minutes and audit the document titled, “Patient Observation Rounds Sheet Q15 minutes” focusing on accuracy and completion of the documents in accordance with the facility’s policy. The House Supervisor/Designees will address any findings immediately for corrective actions. The house supervisor/designee will perform random video review at least every 4 hours around the clock to ensure licensed nurses, CNAs, MHWs are rounding every 15 minutes for patient’s locations, behavior and safety, a log will be maintained by Nurse Managers. The Quality Risk Coordinator created a Performance Improvement Indicator in the Quality Assessment and Performance Improvement (QAPI) dashboard to incorporate every 15-minute rounds data to present at the quality meetings. Hospital Administration will review data monthly, and present to the quality meeting for any further recommendations if necessary Findings: 1.a. During a review of Patient 1’s History and Physical (H&P, a comprehensive clinical document that includes a patient’s medical history and findings from a physical examination), dated 6/4/2025, the H&P indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) due to being “agitated (feeling of uneasiness and severe restlessness) and aggressive.” The H&P also indicated that Patient 1 was placed on assaultive (safety measures implemented for patients who exhibit or are at risk of exhibiting violent or aggressive behavior) and homicidal precautions (safety interventions used when a patient expresses or demonstrates thoughts, intentions, or behaviors indicating a risk of harming others). During a review of Patient 1’s “Behavioral Admission Assessment,” dated 6/4/2025, the record indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU) at 2:45 p.m. on a 5150 Hold (involuntary hold/involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to others and being gravely disabled (GD, a condition in which a person, due to a mental health disorder, is unable to provide for their basic personal needs such as food, clothing, or shelter).” The record also stated that Patient 1 required “line of sight observation,” meaning continuous visual monitoring by staff to ensure immediate intervention if needed, and was placed on 15-minute Close Observation Level II, which involved staff checking on the patient every 15 minutes due to a history of threatening and/or assaultive behavior within the past 30 days. During a review of Patient 1’s “Behavioral Health Daily Nursing Assessment,” dated 6/5/2025, the record indicated that on 6/5/2025 Patient 1 continued to remain on 15-minute Close Observation Level II (patient was monitored every 15 minutes due to concerns about potential harm to self or others) and also had assault/aggression precautions in place (implemented due to the patient exhibiting, or being at risk of exhibiting, aggressive or violent behavior; includes increased supervision, environmental safety measures, and use of de-escalation techniques [methods used to reduce the intensity of a conflict or agitation in a person through calm, verbal, and non-verbal communication]). During a review of Patient 2’s History and Physical (H&P), dated 6/3/2025, The H&P indicated that Patient 2 was admitted to the Behavioral Health Unit (BHU) on 6/3/2025 for agitation and aggressive behavior. During a review of Patient 2’s Psychiatric Evaluation, dated 6/3/2025, the record indicated that Patient 2 was admitted on a 5150 Involuntary Hold. The record also indicated that the Hold was initiated due to danger to others after Patient 2 became “increasingly aggressive at the nursing home (a residential facility that provides 24-hour medical and personal care for individuals, who are unable to live independently due to illness, disability, or cognitive decline).” During a review of Patient 2’s “Nursing Progress Note,” dated 6/5/2025 at 3:43 p.m., the note indicated that Patient 2 was involved in an altercation with another patient (Patient 1) and stated that he (Patient 2) was defending himself after Patient 1 struck him in the face, specifically on the left cheek and/or jaw. During a review of Patient 2’s “Rounds Sheet, dated 6/5/2025, the sheet indicated that Patient 2 was documented as either lying or sitting in his “BR” (bedroom) for the entire time from 7:00 a.m. to 7:00 p.m. During a concurrent interview and record review on 9/30/2025 at 3:02 p.m. with the Chief Nursing Officer (CNO), Patient 1’s medical record titled, “Nursing Progress Notes,” dated 6/5/2025, was reviewed. The CNO stated that, according to the documentation, Patient 1 attempted to strike Patient 2, who was sitting at the door in the hallway. Patient 2 defended himself, stood up, and pushed Patient 1, who then fell backwards. The CNO confirmed that the fall was unwitnessed (as per nursing notes documentation), and that Rapid Response Team (RRT, a team of healthcare professionals, often including a critical care nurse and a respiratory therapist, who are quickly dispatched to provide immediate care to a patient who shows signs of acute deterioration within a hospital) was called at 2:20 p.m. on 6/5/2025 after Patient 1 was assessed to have weakness in the lower extremities (both legs), drooping (excessive sagging) on the left side of face, and left arm weakness. During a review of Patient 1’s “Nursing Progress Notes,” dated 6/5/2025 at 2:20 p.m., the note indicated the following: on 6/5/2025, Patient 1 was actually witnessed by an EVS (Environmental Services- trained cleaning support staff) worker who witnessed Patient 1 walking in the hallway, attempting to strike another patient (Patient 2). In response, Patient 2 pushed Patient 1, causing Patient 1 to fall backwards and sit down on the floor. A Rapid Response Team (RRT) was called, and Patient 1 was assessed to have bilateral (both) lower extremity weakness and was noted to be losing balance while standing. The note also stated that Patient 1 was transferred to a medical-surgical floor (a general hospital unit for adult patients who need care for a variety of illnesses and surgical recovery, but do not require intensive or highly specialized care) for further evaluation). During a review of Patient 1’s nursing note, dated 6/5/2025 at 2:20 p.m., the note indicated that Patient 1 sustained an unwitnessed fall (meaning the patient had experienced a fall that was not observed by staff or others, and the exact circumstances were unknown). During further review of Patient 1’s nursing notes documentation, dated 6/5/2025 at 2:35 p.m. (late entry), the note indicated that Patient 1 was status post (after) unwitnessed fall, and that Patient 1 began showing signs of facial drooping (sagging) on the left side, along with bilateral (both sides) leg tremors (involuntary, rhythmic shaking or trembling movements in the legs). During a review of Patient 1’s “Nursing Progress Note,” dated 6/5/2025 at 4:30 p.m., the note indicated that on 6/5/2025 at 4:00 p.m., Patient 1 was observed with increasing shaking of the left leg and bilateral lower extremities. The note also indicated that during the physician’s bedside assessment, Patient 1 was noted to have a bump on the right side of the head, with no bleeding. The note also indicated the following at 4;30 p.m. on 6/5/2025: the family was informed that, due to the fall, Patient 1 had possible fracture of the right hip ... and the physician recommended transferring Patient 1 to a higher level of care, as the patient continued to experience shaking and had a head injury with a possible subdural hematoma (a type of brain bleed that occurs when blood collects in the brain, often caused by head trauma and potentially life-threatening if not treated promptly). During an interview on 10/1/2025 at 1:31 p.m. with the House Supervisor (HS 1), HS 1 stated that typically the facility conducted daily audit for the completeness of Q 15-Minute rounding sheets (a clinical documentation tool used by healthcare staff to record patient observations at regular intervals [every 15 minutes], designed to monitor patient location, behavior, and safety status, and to ensure staff accountability and timely intervention when needed) to verify staff compliance with patient rounding. However, the HS 1 also said that the paper documentation for patient rounding was not reviewed concurrently with video footage to determine whether the documented patient rounding matched what was observed through the facility’s video surveillance cameras. During a concurrent interview and record review on 10/1/2025 at 2:06 p.m. with the Chief Nursing Officer (CNO), Patient 1’s “Patient Rounding Sheet, dated 6/5/2025 (covering the time from 7:00 a.m. to 4:30 p.m.), was reviewed. The rounding sheet indicated that Patient 1 was not agitated during this time frame (7 a.m. to 4;30 p.m.) and was consistently documented as either lying or sitting in their (Patient 1) bedroom. Specifically: -At 1:00 p.m., Patient 1 was documented as either lying or sitting -At 2:15 p.m., Patient 1 was again documented as either lying or sitting -This same documentation pattern continued through 2:45 p.m. -The Chief Nursing Officer (CNO) verified that this documentation was possibly inaccurate, noting that the Rapid Response Team was called at 2:20 p.m., and Patient 1 was found in the hallway by Patient 2’s room, yet no deviation or incident was reflected in the rounding sheet during that time. During further interview on 10/1/2025 at 3:37 p.m. with the Hospital Administrator (ADM), the ADM stated that the administration was no longer certain whether the entire incident (between Patient 1 and Patient 2) had been witnessed by the Environmental Service (EVS) worker. The ADM confirmed that nursing staff and mental health workers did not witness the altercation between the two patients (Patient 1 and Patient 2). The ADM also stated that he (ADM) could not verify whether staff were conducting Q15-minute patient rounding on that day (6/5/2025). The ADM said, “They (referring to the facility staff) should have done it (referring to the Q 15-minute rounding)- this is the expectation,” and noted that staff verbally confirmed they were conducting their rounds. However, the ADM also confirmed that the video footage, on 6/5/2025, was never reviewed to verify whether staff actions aligned with what was documented and reported on the day of the incident between Patient 1 and Patient 2. During a concurrent observation, interview and video footage review on 10/1/2025 at 11:00 a.m. with Nurse Manager (NM 1) of BHU and Medical-Surgical (Med/Surg), the video footage dated 9/19/2025, from 1:00 a.m. to 2:30 a.m., was reviewed. The following events were observed at the indicated timestamp in the video: 9/19/2025 at 1:00 a.m. -No staff seen conducting patient rounding in any of the video angles. 9/19/2025 at 1:15 a.m. -No staff seen conducting patient rounding, in any video of the angles. 9/19/2025 at 1:30 a.m. -No staff seen conducting patient rounding in any of the video angles 9/19/2025 at 1:45 a.m. -no staff seen doing rounding, one patient seen in wheelchair going down hallway with no staff present (camera angle 6) 9/19/2025 at 2:00 a.m. -two staff members seen rounding patient rooms 1, 2, 3 and 4 (camera angle 4) but not seen checking other rooms. Confirmed with NM1 that one was licensed staff (RN) and the other individual was the resource nurse. 9/19/2025 at 2:15 a.m. -two staff members sitting in chairs in BHU hallway on Camera angles 6 and 7. Not getting up to conduct rounding on patients. NM 1 was unable to identify the two staff members. 9/19/2025 at 2:30 a.m. -Same two staff members sitting in chairs in BHU hallway, not getting up to conduct rounding as seen in camera angles 6 and 7. NM 1 was unable to identify the two staff members During an interview on 10/1/2025 at 11:47 a.m. with NM 1, NM 1 stated the expectation was for staff to do Q 15-minute rounding to check on the patients, ensure safety and known location. Purpose of rounding was to know the location of the patients and make sure the patient was safe. “It allows us to notice any changes in behaviors, so that staff can address them accordingly.” NM 1 verified that rounding was only completed once for 4 rooms (rooms 1,2, 3, and 4) but not the whole unit within the 1.5 hour of video reviewed for Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 41, Patient 42, Patient 43, Patient 44. During a concurrent interview and record review on 10/1/2025 at 2:02 p.m. with NM 1, Patient 20’s “Patient Rounds Sheet” dated 9/18/2025, was reviewed. NM 1 stated that the rounding sheet began on 9/18/2025 at 7:00 a.m. and ended on 9/19/2025 at 6:45 a.m. NM 1 stated that all patient rounding sheets being reviewed started around the same time (7 a.m. to 6:45 a.m.), which captures the entire 24 hours. During an interview on 10/3/2025 at 3:44 p.m. with NM 1, NM 1 stated that, after reviewing the video footage and discussing the matter with the Chief Nursing Officer (CNO), it appeared that staff were documenting Q15-minute checks as completed, despite not actually performing them. NM 1 emphasized the importance of holding staff accountable and acknowledged that this practice falls under the category of falsification of records. During an interview on 9/30/2025 at 11:35 a.m. with the Charge Nurse (CN) 4, CN 4 stated that licensed nurses were required to conduct patient rounds every hour and document on the patient’s rounding sheet. CN 4 stated that licensed nurses could also help the MHW (Mental health Worker) with conducting Q15-minute rounding. During an interview on 10/1/2025 at 2:12 p.m. with the Chief Nursing Officer (CNO), the CNO confirmed that Q15 (every 15 minutes) patient safety checks should be conducted to: -Ensure patient safety, -Confirm responsiveness, -Assess patient behavior, -Document patient activity. During an interview on 10/1/2025 at 3:17 p.m. with the Chief Nursing Officer (CNO) and the Hospital Administrator (ADM), the CNO stated that the incident (involving Patients and 2) was investigated internally and that all key team members were interviewed, including the Environmental Services (EVS) worker who witnessed the altercation between Patient 1 and Patient 2 in the hallway. The ADM confirmed that, because of the EVS worker’s statement regarding the witnessed fall and the altercation between the two patients (Patient 1 and Patient 2), the facility had no reason to review the video footage to verify what happened during the incident. During an interview on 10/3/2025 at 3:34 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following regarding Q-15 Minutes rounding: “Q15-minute safety checks are conducted to monitor each patient’s condition and behavior at regular 15-minute intervals. The purpose is to identify any signs of agitation, frustration, or behaviors that may indicate a risk to the patient or others. These checks are preventive in nature and allow staff to intervene early and provide therapeutic support as needed. We use this time to assess whether patients are escalating and to respond in a way that promotes safety and de-escalation. While staff are expected to document these checks accurately, it’s also important to verify that the documentation aligns with actual observations, such as through video review when available.” During a review of Patient 20’s Psychiatric Evaluation (a comprehensive mental health assessment, conducted by a psychologist or psychiatrist, that uses interviews, tests, and observations to understand a person’s emotional, behavioral, and cognitive state), dated 9/11/2025 and timed 17:56 (5:56 p.m.), the record indicated Patient 20 was admitted to the facility on a 5150 (72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) hold for grave disability (GD-unable to take care of oneself). During a review of Patient 20’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 20 was sleeping, and respirations were present. During a review of Patient 21’s Psychiatric Evaluation, dated 9/12/2025 and timed 1801 (6:01 p.m.), the record indicated Patient 21 was admitted to the facility on a 5150 hold for GD due to increasing paranoid delusions (false beliefs that persist despite evidence to the contrary and are characterized by suspicion, mistrust, and persecution), yelling and screaming. During a review of Patient 21’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 22 was sleeping and respirations were present. During a review of Patient 22’s Psychiatric Evaluation, dated 9/14/2025 at 1710 (5:10 p.m.), the record indicated Patient 22 was admitted to the facility on a 5150 hold for danger to self (DTS). During a review of Patient 22’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 22 was sleeping, and respirations were present. During a review of Patient 23’s Psychiatric Evaluation, dated 9/18/2025, the record indicated that Patient 23 was admitted to the facility and was placed on a 5150 hold for Danger to others (DTO). During a review of Patient 23’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 23 was sleeping, and respirations were present. During a review of Patient 24’s Psychiatric Evaluation, dated 9/18/20225, the record indicated that Patient 24 was admitted to the facility on 9/18/2025 and was placed on a 5150 hold for GD. During a review of Patient 24’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 24 was sleeping, and respirations were present. During a review of Patient 25’s Psychiatric Evaluation, dated 9/16/2025, the record indicated Patient 25 was admitted to the facility on 9/16/2025 and was placed on a 5150 hold for DTO. During a review of Patient 25’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 25 was sleeping, and respirations were present. During a review of Patient 26’s Psychiatric Evaluation, dated 9/13/2025, the record indicated that Patient 26 was admitted to the facility on 9/13/2025 and was placed on a 5150 hold for DTO. During a review of Patient 26’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 26 was sleeping, and respirations were present. During a review of Patient 27’s Psychiatric Evaluation, dated 9/12/2025, the record indicated that Patient 27 was admitted to the facility on 9/12/2025 and was placed on a 5150 hold due to DTO. During a review of Patient 27’s “Patient Rounds Sheet,” dated 9/18/2025,the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 27 was sleeping, and respirations were present. During a review of Patient 28’s Psychiatric Evaluation, dated 9/17/2025, the record indicated that Patient 28 was admitted to facility on a 5150 involuntary hold for DTS and GD. During a review of Patient 28’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 28 was sleeping, and respirations were present. During a review of Patient 29’s psychiatric Evaluation, dated 9/18/2025, the record indicated that Patient 29 was admitted to the facility on 9/18/2025 and placed on 5150 for DTO. During a review of Patient 29’s “Patient Rounds Sheet,” dated 9/18/2025,the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 29 was sleeping, and respirations were present. During a review of Patient 30’s Psychiatric Evaluation, dated 9/19/2025, the record indicated that Patient 30 was admitted to the facility on 9/18/2025 on a 5150 hold for DTO. During a review of Patient 30’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 30 was sleeping at 0100 (1:00 a.m.), and lying or sitting from 0130 (1:30 a.m.) to 0200 (2:00 a.m.) and respirations were present. During a review of Patient 31’s Psychiatric Evaluation, dated 9/15/2025 and timed at 2017 (8:17 p.m.), the record indicated that Patient 31 was admitted to the facility on a 5150 hold due to DTO and GD. During a review of Patient 31’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 31 was sleeping at 0115 (1:15 a.m.) to 0230 (2:30 a.m.), lying or sitting at 0100 (1:00 a.m.) and was walking or pacing at 0015 (1:15 a.m.) and respirations were present. During a review of Patient 32’s Psychiatric Evaluation, dated 9/14/2025 and timed at 2016 (8:16 p.m.), the record indicated Patient 32 was admitted to the facility on a 5150 due to DTO. During a review of Patient 32’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 32 was sleeping, and respirations were present. During a review of Patient 33’s Psychiatric Evaluation, dated 9/16/2025 and timed at 0626 (6:26 a.m.), the record indicated Patient 33 was admitted to the facility on a 5150 hold due to DTO and GD. During a review of Patient 33’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 33 was lying or sitting at 0100 (1:00 a.m.) and sleeping at 0115 (1:15 a.m.) to 0230 (2:30 a.m.) with respirations present. During a review of Patient 34’s Psychiatric Evaluation, dated 9/13/2025 and timed at 1806 (6:06 p.m.), the record indicated Patient 34 was admitted to the facility on 9/13/2025 and was placed on a 5150 due to DTS and DTO. During a review of Patient 34’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 34 was sleeping, and respirations were present. During a review of Patient 35’s Psychiatric Evaluation, dated 9/16/2025, the record indicated that Patient 35 was admitted to the facility on 9/13/2025 and placed on a 5150 due to DTS and GD. During a review of Patient 35’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 35 was sleeping, and respirations were present. During a review of Patient 36’s Psychiatric Evaluation, dated 9/18/2025 and timed at 1055 (10:55 a.m.), the record indicated that Patient 36 was admitted to the facility on 9/18/2025 on a 5150 hold due to GD. During a review of Patient 36’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 36 was lying or sitting at 0115 (1:15 a.m.) and sleeping at 0100 (1:00 a.m.), 0130 (1:30 a.m.), 0145 (1:45 a.m.), 0200 (2:00 a.m.), 0215 (2:15 a.m.), and 0230 (2:30 a.m.) and respirations were present. During a review of Patient 37’s Psychiatric Evaluation, dated 9/12/2025 and timed at 1935 (7:35 p.m.), the record indicated that Patient 37 was admitted to the facility on 9/12/2025 on a 5150 hold for DTO. During a review of Patient 37’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 37 was sleeping, and respirations were present. During a review of Patient 38’s Psychiatric Evaluation, dated 9/19/2025 and timed at 1331 (1:31 p.m.), the record indicated that Patient 38 was admitted to the facility on 9/19/2025 on a 5150 hold for DTO. During a review of Patient 38’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 38 was lying or sitting and respirations were present. During a review of Patient 39’s Psychiatric Evaluation, dated 9/18/2025 and timed at 1340 (1:40 p.m.), the record indicated that Patient 39 was admitted to the facility on 9/18/2025 and placed on a 5150 hold due to GD. During a review of Patient 39’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 39 was found sleeping, and respirations were present. During a review of Patient 40’s Psychiatric Evaluation, dated 9/16/2025 and timed at 0933 (9:33 a.m.), the record indicated that Patient 40 was admitted to the facility on 9/16/2025 on a 5150 involuntary hold for DTO and GD. During a review of Patient 40’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 40 was sleeping, and respirations were present. During a review of Patient 42’s Psychiatric Evaluation, dated 9/14/2025, the record indicated Patient 42 was admitted to the facility on 9/14/2025 on a 5150 hold due to DTO. During a review of Patient 42’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 42 was sleeping, and respirations were present. During a review of Patient 43’s Psychiatric Evaluation, dated 9/19/2025 and timed at 1423 (2:43 p.m.), the record indicated that Patient 43 was admitted to the facility on 9/19/2025 on 5150 hold due to GD. During a review of Patient 43’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 43 was sleeping, and respirations were present. During a review of Patient 44’s Psychiatric Evaluation, dated 9/18/2025 and timed at 1544 (3:44 p.m.), the record indicated that Patient 44 was admitted to the facility on 9/18/2025 on 5150 hold due to DTO. During a review of Patient 44’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 44 was sleeping, and respirations were present. During a review of the facility’s policy and procedure (P&P) titled, “Every 15 Min (minute) Rounds, Patient,” last revised 3/2025, the P&P indicated the following: “It is the policy of [the facility] Behavioral Health Services to monitor the safety/locations of all patients on a continuing basis. Such rounds will be conducted at 15-minute intervals. Patients requiring additional observation will be evaluated individually, and physician orders will be generated to address the safety/needs of the patient ...Floor staff will conduct patient rounds at 15-minute intervals, including the location of the patient and his/her condition, and will verify completion of such rounds by their initial and signature. In order to accurately monitor safety and condition of patients at night and/or during non-wakeful times, staff will visually observe chest movement of the patient to ascertain respiratory effort.” During a review of the facility’s policy and procedure (P&P) titled, “Observation Levels System,” dated 3/2025, the P&P indicated, “It is the policy of [the facility] to initiate and provide the appropriate observation level of patient’s behaviors exhibited and also the information provided at the time of admission, and throughout hospitalization. All patients will be routinely observed in compliance with physician/psychologist orders and prescribed protocols. Purpose: to provide the most appropriate patient observation level is maintained throughout hospitalization. To provide patient safety at all times ... Types of Observation Level A. Level I: every 15-minute checks, routine observation. Minimal level of observation for all patients. Staff will observe patient and document on the Patient’s Observation Rounds Sheet Q15 minutes. Assigned staff will make direct contact with patients and confirm they are in no danger or distress .... Observation may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping. It is expected that the staff conducting the 15 minutes observation will enter the room, approach the patient and check their identify, respirations, and to ensure that they are not in any distress.” B. Level II: every 15 minutes checks, routine observations with precautions and taking note of precautions ordered as well ...staff will observe patient and document on the Patient’s Observation Rounds sheet every 15 minutes ...” 1.b. During a concurrent observation, interview and record review on 10/1/2025 at 12:40 p.m. with the Nurse Manager (NM) 2 of Behavioral Health Unit (BHU) and the Security Supervisor (SS)1, the facility’s security footage of Campus 2 BHU unit (Unit C), on 9/13/2025 from time period 1:20 a.m. to 4:58 a.m., was reviewed, the following events were observed: -At 1:20 a.m., a Mental Health Worker (MHW) 8 was seen sitting outside unit seclusion room (a secure, private room used to involuntarily confine an individual alone to de-escalate a situation or modify behavior). The video displayed two (2) patient rooms (Room A and Room B) and a seclusion room. -At 1:30 a.m., No staff seen rounding on patients -At 1:45 a.m., No staff seen rounding -At 2:00 a.m., No staff seen rounding -At 2:15 a.m., No staff seen rounding -At 2:23 a.m., a MHW went to the second room, left the room holding a blue blanket -At 2:30 a.m., No staff seen rounding -At 2:45 a.m., No staff seen rounding -At 3:00 a.m., No staff seen rounding -At 3:15 a.m., No staff seen rounding -At 3:30 a.m., No staff seen rounding. -At 3:45 a.m., MHW 8 got up and went to bathroom. No staff was seen to relieve MHW 8 while MHW 8 was away. -At 4:15 a.m., a male patient in green gown was seen pacing in the dayroom and no staff was seen monitoring the area. -At 4:58 a.m., a MHW went into a patient room (Room A) and performed rounding. The MHW did not enter any other rooms. During the same interview on 10/1/2025 at 12:40 p.m. with NM 2, NM 2 stated the following: there was no staff performing the Q 15-minute rounding on all BHU patients (Patients 14, 15, 16, 45, 46, 47, 48 and 49) in Unit C for about 3.5 hours (from 1:20 a.m. to 4:58 a.m.). The Q 15-minute patient rounding was important for patient safety to ensure patients were safe and with no change of condition. NM 2 stated a lot could happen when patients were not checked as patients could try to do something to self or to someone else and could harm self or others. During a concurrent observation, interview, and record review on 10/1/2025 at 1:10 p.m. with the Nurse Manager (NM) 2 of Behavioral Health Unit (BHU) and the Security Supervisor (SS)1, the facility’s security footage of Campus 2 BHU unit (Unit S) on 9/19/2025, from time period of 1:00 a.m. to 2:15 a.m., was reviewed, the following events were observed: -At 1:30 a.m., a MHW was seen walking past the unit hallway at 1:30 a.m. but did not enter any patient rooms to check on patients. -At 2:00 a.m., three clinical staff was seen in the unit hallway but did not enter any patients rooms. -At 2:10 a.m., a clinical staff was seen walking past the unit hallway (not all the way) and did not enter any patient rooms. -At 2:15 a.m. No staff seen rounding During the same interview on 10/1/2025 at 1:10 p.m. with NM 2, NM 2 stated there was no Q 15-minute rounding performed on all patients (Patients 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, and 76) in Unit S, on 9/19/2025 from 1:00 a.m. to 2:15 a.m. (1 hour). The staff should be checking patients by going inside the patient rooms to ensure patient safety. During a concurrent interview and record review on 10/2/2025 at 9:06 a.m. with NM 2, the “Patient Rounds Sheet,” for Patient 14, Patient 16 and Patient 49, dated 9/12/2025, was reviewed. The “Patient Rounds Sheet,” indicated Q 15-min rounding were completed at 1:00 a.m. 1:15 a.m., 1:30 a.m., 1:45 a.m., 2:00 a.m., 2:15 a.m., 2:30 a.m., 2:45 a.m., 3:00 a.m., 3:15 a.m., 3:30 a.m., 3:45 a.m., 4:00 a.m., 4:15 a.m., 4:30 a.m., 4:45 a.m., with documentation of patients’ activity, respiration and location. NM 2 stated the documentation was inaccurate based on the security video footage observed (the video footage indicated staff were not entering each of the patient rooms to check on the patients). NM 2 stated it was a falsification of documentation and the nurses’ documentation was inaccurate. NM 2 stated the expectations for staff were to write and document what the staff did. NM 2 stated the facility relied on the integrity of the staff to ensure that all documentation was truthful and accurately reflected the care provided. During a concurrent interview and record review on 10/2/2025 at 9:15 am with NM 2, the “Patient Rounds Sheet,” for Patients 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67,68, 69, 70, 71, 72, 73, 74, 75, and 76, dated 9/18/2025, was reviewed. The “Patient round sheet,” indicated Q 15-minute rounding was completed at 1:00 a.m., 1:15 a.m., 1:30 a.m., 1:45 a.m., 2:00 a.m. and 2: 15 a.m. with documentation of patients’ activity, respiration and location. NM 2 stated the patient rounding documentation was completed and indicated the patient’s behavior, status, location and with initials by staff attesting to completing the rounding for all patients, however, the documentation did not align with what was seen in the security video footage reviewed on 10/1/2025. During a concurrent interview and record review on 10/2/2025 at 10:06 a.m. with NM 2, the “Patient Rounds Sheet,” for Patients 15, 45, 46, 47 and 48, dated 9/12/2025, was reviewed. The “Patient round sheet” indicated Q 15-min rounding was completed at 1:00 a.m., 1:15 a.m., 1:30 a.m., 1:45 a.m., 2:00 a.m., 2:15 a.m., 2:30 a.m., 2:45 a.m., 3:00 a.m., 3:15 a.m., 3:30 a.m., 3:45 a.m., 4:00 a.m., 4:15 a.m., 4:30 a.m., 4:45 a.m. with documentation of patient’s activity, respiration and location. NM 2 stated the patient round sheet indicated documentation was completed, but the documentation did not align with what was observed in the security footage video. During the same interview and record review on 10/2/2025 at 10:06 a.m. with NM 2, NM 2 stated that after reviewing patient rounding sheet, NM 2 had concerns regarding the accuracy and credibility of the staff’s documentation. NM 2 stated the nursing team performed chart audits to verify compliance with patient rounding but did not conduct video footage reviews to verify whether the observed events correspond with the information documented by the staff. During the same interview and record review on 10/2/2025 at 10:06 a.m. with NM 2, NM 2 stated it was the responsibility of non-licensed staff such as the Certified Nursing Assistant (CNA) and the Mental Health Worker (MHW) to ensure patient round was completed and documented in the patient round sheet. NM 2 stated licensed nurses such as Registered Nurse (RN) and License Vocational Nurse (LVN) responsibilities included overseeing the patient rounding and to ensure the patient round sheet was accurately completed. NM 2 stated all MHWs could perform the Q 15-minute rounding. During an interview on 10/3/2025 at 9:22 a.m. with NM 2, NM 2 said it was expected for the staff to follow the facility policy and conduct Q 15-minute patient rounding for patient safety. During the same interview on 10/3/2025 at 9:22 a.m. with NM 2, NM 2 stated it was unacceptable to falsify documentation by indicating that patient rounds were completed when, in fact, the staff did not enter the patient’s room. During an interview on 10/3/2025 at 9:37 a.m. with NM 2, NM 2 stated during patient rounding conducted every 15 minutes, staff were expected to assess the patient’s behavior, observe the environment of the patient’s room, and verify the patient’s respiration if the patient was in bed. For bedbound (being unable to leave a bed due to illness, injury, or physical limitations) patients, staff must determine whether repositioning was needed. For ambulatory (walking) patients, staff should confirm whether the patient was in bed, breathing comfortably, calm, pacing in the room, or exhibiting signs of agitation. NM2 said it was an expectation that staff enter the patient’s room during rounding to directly visualize and assess the patient. During a review of Patient 14’s “Psychiatric Initial Evaluation ( psych eval, comprehensive assessment mental health assessment, conducted by a psychologist or psychiatrist, that uses interviews, tests, and observation to understand a person’s emotional, behavioral, and cognitive state), dated 9/6/2025, the psych eval indicated, Patient 14 was admitted to the facility’s BHU on 9/5/2025 on a 5150-hold (72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) for suicidal (thoughts of taking one’s own life) and homicidal (thoughts of killing others) ideation with increased aggression (any intentional behavior aimed at causing harm or injury to another person) behavior with diagnosis including but not limited to schizoaffective (a mental health condition characterized by symptoms of schizophrenia[a disorder that affects a person’s ability to think, feel and behave clearly] such as hallucinations [seeing, hearing, smelling, tasting, or feeling something that is not real] or delusions [a fixed, false belief held despite clear evidence to the contrary]), bipolar (a mental health condition where you have extreme mood changes). During a review of Patient 15’s, “Psychiatric Evaluation,” dated 9/4/2025, the psych eval indicated, Patient 15 was admitted to the facility’s BHU on 9/4/2025 on a 5150-hold for danger to others (DTO, a person who poses a substantial likelihood of inflicting serious bodily harm on another person) for reported increased hallucinations and aggression behavior at home and with diagnosis of paranoid schizophrenia (a subtype of schizophrenia characterized by persistent [false beliefs] and hallucinations). During a review of Patient 16’s, “Psychiatric Evaluation,” dated 9/9/2025, the psych eval indicated, Patient 16 was admitted to the facility’s BHU on 9/8/2025 on 5150-hold for danger to self (DTS, behavior from mental disorder that poses risk of serious harm to oneself), responding to internal stimuli (changes or events that occur within an individual’s body or mind that trigger a response) and complaint of hearing voices with diagnosis of schizoaffective disorder and bipolar type. During a review of Patient 45’s,”Psychaitric Evaluation,” dated 9/5/2025, the psych eval indicated, Patient 45 was admitted to the facility’s BHU on 9/5/2025 for chief complaint of auditory hallucinations and on 5150 hold for DTS/DTO “hearing voices telling him (Patient 45) to cut himself with a knife and to hurt black people.” During a review of Patient 46’s, “Psychiatric Evaluation,” dated 8/22/2025, the psych eval indicated, Patient 46 was admitted to the facility’s BHU on 8/21/2025 on 5150 for danger to self,”endorsed suicidal thoughts for the 3 days with diagnosis including but not limited to major depressive disorder (MDD, a clinical depression causes a persistently low or depressed mood and a loss of interest in activities).” During a review of Patient 47’s, “Psychiatric Evaluation,” dated 9/9/2025, the psych eval indicated, Patient 47 was admitted to the facility’s BHU on 9/9/2025 on 5150 for danger to self, stopped taking medication, endorsing suicidal ideation with diagnosis including but not limited to bipolar disorder. During a review of Patient 48’s, “Psychiatric Evaluation,” dated 9/5/2025, the psych eval indicated, Patient 48 was admitted to the facility’s BHU on 9/4/2025 on 5150 due to being a danger to others, talking about killing religious leaders and with diagnosis including but not limited to bipolar disorder. During a review of Patient 49’s “Psychiatric Evaluation,” dated 9/8/2025, the psych eval indicated, Patient 49 was admitted to the facility’s BHU on 9/8/2025 on a 5150 for danger to others, “called 911 multiple times, stated would kill everyone at [Police] headquarters and blame black lives matter and with diagnosis paranoid schizophrenia.” During a review of Patient 50’s “Psychiatric Evaluation,” dated 9/16/2025, the psych eval indicated, Patient 50 was admitted to the facility’s BHU on 9/16/2025 on a 5150 for being gravely disabled (GD, unable to take care of themselves), experienced mania (a state of abnormally elevated mood, energy, and activity that lasts for an extended period), had not slept for four (4) days, “crying and laughing.” In addition, Patient 50’s, “face sheet, (front page of the chart that contains a summary of basic information about the patient),” the face sheet, indicated Patient 50’s admitting diagnosis was “bipolar.” During a review of Patient 51’s “Psychiatric Evaluation,” dated 9/082025, the psych eval indicated, Patient 51 was admitted to the facility’s BHU on 9/08/2025 on 5150 hold for DTS, for suicidal actions running into traffic and with diagnosis of schizoaffective and bipolar disorder. During a review of Patient 52’s “Psychiatric Evaluation,” dated 9/17/2025, the psych eval indicated, Patient 52 was admitted to the facility’s BHU on 9/16/2025 and placed on 5150 hold for being a danger to others and gravely disabled with diagnosis of schizoaffective bipolar disorder. During a review of Patient 54’s “Psychiatric Evaluation,” dated 9/13/2025, the psych eval indicated, Patient 50 was admitted to the facility’s BHU on 9/12/2025 on 5150 hold for DTS, with thoughts of people coming to kill her (Patient 54), paranoia (person believes that others are trying to harm or deceive them), and delusions with diagnosis of paranoid schizophrenia. During a review of Patient 55’s “Psychiatric Evaluation,” dated 9/5/2025, the psych eval indicated, Patient 55 was admitted to the facility’s BHU on 9/4/2025 on 5150 hold for DTS/DTO/GD, was observed by homeless healthcare staff choking another client and with diagnosis of schizophrenia. During a review of Patient 56’s “Psychiatric Evaluation,” dated 9/11/2025, the psych eval indicated, Patient 56 was admitted to the facility’s BHU on 9/11/2025 on 5150 hold for DTS, Patient 56 admitted taking 4 pills mixed with copious amount of alcohol, with diagnosis including but not limited to major depression. During a review of Patient 57’s “Psychiatric Evaluation,” dated 9/18/2025, the psych eval indicated, Patient 57 was admitted to the facility’s BHU on 9/17/2025 on 5150 hold for DTS, suicidal plans to overdose on pills and with diagnosis of schizoaffective, bipolar disorder. During a review of Patient 58’s “Psychiatric Evaluation,” dated 9/16/2025, the psych eval indicated, Patient 58 was admitted to the facility’s BHU on 9/15/2025 on 5150 hold for being gravely disabled, not sleeping, manic behavior (period of abnormally elevated mood and high energy) and with diagnosis of bipolar disorder manic (extremely elevated mood). During a review of Patient 59’s “Psychiatric Evaluation,” dated 9/11/2025, the psych eval indicated, Patient 59 was admitted to the facility’s BHU on 9/11/2025 on 5150 hold for danger to others and gravely disabled, Patient 59 believed mother (Patient 59’s mother) was abusing her (Patient 59) and with diagnosis including but not limited to bipolar disorder, depressive type. During a review of Patient 60’s “Psychiatric Evaluation,” dated 9/12/2025, the psych eval indicated, Patient 60 was admitted to the facility’s BHU on 9/11/2025 on 5150 hold for being gravely disabled, had paranoid behavior, delusional, making nonsensical statements, irritable, and uncooperative with diagnosis of paranoid schizophrenia with acute exacerbation (intensification of existing mental health issues). During a review of Patient 61’s “Psychiatric Evaluation,” dated 9/9/2025, the psych eval indicated, Patient 61 was admitted to the facility’s BHU on 9/9/2025 on 5150 hold for danger to others, had been experiencing severe anxiety (Feeling overwhelmed, tense, or on edge), hyperverbal (a term used to describe someone who speaks at a very fast pace and uses many words in a short amount of time, often interrupting others), loud, angry outburst, high risk for aggression with diagnosis of schizoaffective disorder, bipolar type. During a review of Patient 62’s “Psychiatric Evaluation,” dated 9/9/2025, the psych eval indicated, Patient 62 was admitted to the facility’s BHU on 9/8/2025 on 5150 hold for DTS/DTO/GD for homicidal threats to bomb Patient 62’s family’s home and self. Patient 62’s psych eval also indicated a diagnosis of schizoaffective and bipolar disorder. During a review of Patient 63’s “Psychiatric Evaluation,” dated 9/16/2025, the psych eval indicated, Patient 63 was admitted to the facility’s BHU on 9/16/2025 on 5150 hold for danger to others, was threatening to cut off a [department store] employee, threw a glass bottle at manager and threatening to kill staff. During a review of Patient 64’s “Psychiatric Evaluation,” dated 9/13/2025, the psych eval indicated, Patient 64 was admitted to the facility’s BHU on 9/12/2025 on 5150 hold for danger to self and with diagnosis of depression (a persistent feeling of sadness, hopelessness, and loss of interest in activities that were once enjoyable). During a review of Patient 65’s “Psychiatric Evaluation,” dated 9/13/2025, the psych eval indicated, Patient 65 was admitted to the facility’s BHU on 9/13/2025 on 5150 for danger to self. Patient 65 took seven (7) Xanax tablets (medication to treat anxiety disorders and panic disorder) in an attempt to commit suicide and with diagnosis including but not limited to major depressive disorder, suicidal ideation. During a review of Patient 66’s “Psychiatric Evaluation,” dated 9/17/2025, the psych eval indicated, Patient 66 was admitted to the facility’s BHU on 9/16/2025 on 5150 for DTS. Patient 66 had a chief complaint of being suicidal and with diagnosis of schizoaffective disorder, depressive type. During a review of Patient 67’s “Psychiatric Evaluation,” dated 9/18/2025, the psych eval indicated, Patient 67 was admitted to the facility’s BHU on 9/17/2025 on 5150 for danger to self and being gravely disabled, having worsening symptoms of paranoia causing a lot of stress for the past month and with diagnosis including but not limited to schizophrenia. During a review of Patient 68’s “Psychiatric Evaluation,” dated 9/16/2025, the psych eval indicated, Patient 68 was admitted to the facility’s BHU on 9/15/2025 on 5150 for DTS and suicide attempt and with diagnosis of bipolar type 1 (a mental health condition characterized by extreme shifts in mood, energy, and behavior between manic and depressive episodes) with acute mania. During a review of Patient 72’s “Psychiatric Evaluation,” dated 9/14/2025, the psych eval indicated Patient 66 was admitted to the facility’s BHU on 9/14/2025 on 5150 for danger to self, admitted for suicidal ideation with plans to cut wrist with piece of glass and wanted to harm neighbor and with diagnosis of depression and schizophrenia. During a review of Patient 73’s “Psychiatric Evaluation,” dated 9/14/2025, the psych eval indicated, Patient 73 was admitted to the facility’s BHU on 9/14/2025 on 5150 for danger to others, making threats to harm others and with diagnosis of unspecified psychosis, rule out paranoid schizophrenia. During a review of Patient 74’s “Psychiatric Evaluation,” dated 9/15/2025, the psych eval indicated, Patient 74 was admitted to the facility’s BHU on 9/15/2025 on 5150 for DTO, increased aggression, homicidal ideations, and harmful threats towards staff at the facility and with diagnosis of schizoaffective, bipolar. During a review of Patient 75’s “Psychiatric Evaluation,” dated 9/11/2025, the psych eval indicated, Patient 75 was admitted to the facility’s BHU on 9/10/2025 on 5150 hold for danger to others, exhibited unprovoked episodes of agitation (a feeling of uneasiness and severe restlesness) and aggression toward staff, destroying facility property and with diagnosis of schizophrenia. During a review of Patient 76’s “Psychiatric Evaluation,” dated 9/10/2025, the psych eval indicated, Patient 76 was admitted to the facility’s BHU on 9/9/2025 on 5150 for DTO/GD for increased aggression risk to become assaultive towards others with diagnosis of schizoaffective, bipolar disorder. During a review of the facility’s policy and procedure (P&P) titled, “Every 15 Min (minute) Rounds, Patient,” last revised 3/2025, the P&P indicated the following: “It is the policy of [the facility] Behavioral Health Services to monitor the safety/locations of all patients on a continuing basis. Such rounds will be conducted at 15-minute intervals. Patients requiring additional observation will be evaluated individually, and physician orders will be generated to address the safety/needs of the patient ...Floor staff will conduct patient rounds at 15-minute intervals, including the location of the patient and his/her condition, and will verify completion of such rounds by their initial and signature. In order to accurately monitor safety and condition of patients at night and/or during non-wakeful times, staff will visually observe chest movement of the patient to ascertain respiratory effort.” During a review of the facility’s policy and procedure (P&P) titled, “Observation Levels System,” dated 3/2025, the P&P indicated, “It is the policy of [the facility] to initiate and provide the appropriate observation level of patient’s behaviors exhibited and also the information provided at the time of admission, and throughout hospitalization. All patients will be routinely observed in compliance with physician/psychologist orders and prescribed protocols. Purpose: to provide the most appropriate patient observation level is maintained throughout hospitalization. To provide patient safety at all times ... Types of Observation Level A. Level I: every 15-minute checks, routine observation. Minimal level of observation for all patients. Staff will observe patient and document on the Patient’s Observation Rounds Sheet Q15 minutes. Assigned staff will make direct contact with patients and confirm they are in no danger or distress .... Observation may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping. It is expected that the staff conducting the 15 minutes observation will enter the room, approach the patient and check their identify, respirations, and to ensure that they are not in any distress.” B. Level II: every 15 minutes checks, routine observations with precautions and taking note of precautions ordered as well ...staff will observe patient and document on the Patient’s Observation Rounds sheet every 15 minutes ...””

“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: 45743 Based on interview and record review, the facility failed to: 1. Protect one of 76 sampled patients (Patient 19) from alleged abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), failed to investigate the abuse allegations, and to identify or remove the alleged perpetrator (a staff member) from the environment, in accordance with the facility’s policy regarding abuse reporting, when Patient 19 reported to the Registered Nurse (RN) 1 that the night shift staff choked and placed Patient 19 in 4-point (both wrists and ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) on 4/23/2025. This deficient practice resulted in the facility not conducting an investigation and removing the alleged staff members from working duties and potentially placing Patient 19 and other patients at risk for further abuse. 2. Investigate thoroughly and report to the appropriate regulatory agencies an incident of alleged physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by the facility’s security guard (SG 1) which occurred on 10/13/2024, for one of 76 sampled patients (Patient 7), in accordance with the facility’s policy regarding abuse investigation and reporting. This deficient practice resulted in a delay in involving regulatory agencies in investigating the abuse allegation and could potentially put other patients in an unsafe environment and be at risk of being abused. 3. Report to appropriate regulatory agencies an allegation of sexual abuse (sexual conduct or a sexual act forced upon a woman, man or child without their consent), in accordance with the facility’s policy regarding abuse reporting, for one of 76 sampled patients (Patient 8), after Patient 8 reported an alleged sexual abuse on 8/29/2024. This deficient practice resulted in a delay in involving regulatory agencies in investigating the abuse allegation and could potentially put other patients in an unsafe environment and be at risk of being abused. On 10/3/2025 at 12:10 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Nursing Officer (CNO), Manager of Medical-Surgical and Behavioral Health Unit (NM 1), Hospital Administrator (ADM), Manager of Behavioral Health Unit (NM 2, from Campus 2), Director of Behavioral Health Unit (DIR 1, from Campus 2), and the Manager of Behavioral Health Unit (NM 3, from Campus 2). The facility failed to protect Patient 19 from alleged abuse, failed to investigate the abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) allegations, and to identify and remove the alleged perpetrator (a staff member) from the environment, in accordance with the facility’s policy and procedure titled, “Abuse/Mandated Reporting,” when Patient 19 reported of an alleged physical abuse by staff members to Registered Nurse 1. This deficient practice resulted in the facility not conducting an investigation and removing the alleged staff members from working duties and potentially placing other patients at risk for further abuse. During a review of Patient 19’s History & Physical (H&P), dated 4/21/2025, the H&P indicated that Patient 19 was admitted to the facility’s Behavioral Health Unit (BHU) on a 5150 (72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) hold due to increased aggression and at risk for assaultive behavior (actions likely to cause physical harm or danger to another person). During a review of Patient 19’s “Nursing Progress Notes,” dated 4/23/2025 and timed at 14:58 (2:58 p.m.), the notes indicated that according to the patient (Patient 19), he (Patient 19) was awakened around the morning of (4/23/2025) at 0100 (1:00 a.m.) by noises from his (Patient 19) roommate. When he (Patent 19) got up to check on the situation, he (Patient 19) was instructed by the night shift staff to return to his (Patient 19) bed immediately. The patient (Patient 19) stated while he (Patient 19) was preparing his bed, staff members approached him (Patient 19), choked him (Patient 19), and escorted him to the seclusion room (a secure, private room used to involuntarily confine an individual alone to de-escalate a situation or modify behavior). He (Patient 19) further reported he (Patient 19) was choked again and placed in a 4-point (both wrists and ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) for approximately 4 to 5 hours around 0100 (1:00 a.m.) on 4/23/2025. He (Patient 19) was reported released from the restraints around 0600 (6:00 a.m.) that morning (4/23/2025). The notes also indicated that the house supervisor (HS 4) and nursing manager (NM 3) were both informed of the incident. During a review of Patient 19’s “Nursing Progress Notes,” dated 5/11/2025 , the notes indicated Patient 19 was discharged to an Independent Living facility (a community designed for active adults and seniors who can live independently but want to be part of a community with amenities like housekeeping, transportation, and social activities, while also having security and maintenance-free living). During a concurrent interview and record review on 10/2/2025 at 10:47 a.m. with Registered Nurse (RN) 1, Patient 19’s “Nursing Progress Notes,” dated 4/23/2025 and timed at 14:58 (2:58 p.m.), was reviewed. RN 1 confirmed she (RN 1) wrote the progress note and notified the house supervisor (HS 4) and nurse manager (NM 3) regarding the incident involving Patient 19. RN 1 stated that everyone was a mandated reporter, and an alleged abuse must be escalated appropriately. During an interview on 10/2/2025 at 1:59 p.m. with the Nurse Manager (NM) 3 of BHU and the Director (DIR 1) of BHU, NM 3 stated this was the first time the facility administrative team heard of Patient 19’s alleged abuse. NM 3 stated that RN 1 “never reported this to me (NM 3) and if it was, I (NM 3) would have started an investigation.” DIR 1 stated when an alleged abuse incident occurred and involved staff, “we put the alleged staff member on suspension while an investigation is being conducted.” DIR 1 stated since “we (the facility) did not know about the incident regarding patient (Patient 19), there was no investigation conducted and was never reported to the proper authorities.” DIR 1 stated since the allegation was not reported, “we (facility) were unable to identify the perpetrator.” During an interview on 10/3/2025 at 10:19 a.m. with House Supervisor 4 (HS 4), stated that she (HS 4) was unaware of the alleged abuse. HS 4 stated when RN 1 became aware of the alleged abuse, RN 1 should have notified “myself (HS 4) and I (HS 4) should file an incident report. The incident report then will go to the nurse manager and performance improvement team for them to investigate.” Patient 19 was discharged from the facility on 5/1/2025 and the abuse allegation was still not investigated as of 10/2/2025. During a review of the facility’s policy and procedure (P&P) titled, “Abuse/Mandated Reporting,” revised date 3/2025, the P&P indicated all suspected cases must be investigated immediately. Any individual (employee, volunteer, or associate) who reasonably believes or has knowledge that a patient’s health or welfare has been, is, or will be adversely affected by abuse or neglect must report it within 24 hours to Administration. During a review of the facility’s policy and procedure (P&P) titled, “Incident/Occurrence Reporting,” revised 5/3/2025, indicated employees who witness or are aware of an unusual occurrence are responsible for completing an Incident Report at the time they become aware of the occurrence. On 10/6/2025 at 2:52 p.m., the IJ was removed in the presence of the Chief Executive Officer (CEO), ADM, CNO, NM 1, NM 3 and DIR 1, after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews and record reviews. The acceptable IJ Removal Plan included the following: On 10/3/2025 an immediate investigation of the alleged abuse allegations was conducted by the facility. On 10/3/2025 a re-education began for all staff members including leadership regarding the facility’s policy on abuse, with emphasis on the following key points: 1. Staff has to report to his/her immediate floor supervisor, staff summons extra help to the incident site to triage (conduct a preliminary assessment to determine the urgency of treatment needed) the situation and ensure patient safety. Onsite MD must be notified. 2. Immediate supervisor reports the incident to the resource nurse/charge nurse and converse with the house supervisor. 3. House supervisor ensures the data collection immediately and requests an immediate meeting with CNO, Administrator, CEO, and etc. 4. House Supervisor will notify the treating physicians. 5. Administrator/Designee reports serious injury within 24 hours to the appropriate regulatory agencies if it is an urgent or emergency threat to the health and safety of the patient. 6. Reports of elder abuse must be made by the Administrator/designee by telephone and followed up with a written report within 2 working days using form SOC-341 (official form used to report suspected abuse to appropriate authorities). On 10/3/2025, the facility implemented the use of an inter-shift hand off tool (Patients who express a significant change in status during shift must have physician notified in a timely manner. House supervisor/designee will ensure complaint presented is acted upon promptly) to ensure patients’ complaints are attended to timely and acted upon appropriately. Unit manager/designee will audit the inter-shift hand off tool daily to ensure compliance. Findings: 1. During a review of Patient 19’s History & Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/21/2025, the H&P indicated that Patient 19 was admitted to the facility’s Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) on a 5150 (72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) hold due to increased aggression and at risk for assaultive behavior (actions likely to cause physical harm or danger to another person). During a review of Patient 19’s “Nursing Progress Notes,” dated 4/23/2025 and timed at 14:58 (2:58 p.m.), the Nursing Progress Notes indicated that according to the patient (Patient 19), he (Patient 19) was awakened around the morning of (4/23/2025) 0100 (1:00 a.m.) by noises from his (Patient 19) roommate. When he (Patent 19) got up to check on the situation, he (Patient 19) was instructed by the night shift staff to return to his bed immediately. The patient (Patient 19) stated while he (Patient 19) was preparing his bed, staff members approached him (Patient 19), choked him (Patient 19), and escorted him to the seclusion room (a secure, private room used to involuntarily confine an individual alone to de-escalate a situation or modify behavior). He (Patient 19) further reported he (Patient 19) was choked again and placed in 4-point (both wrists and ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) for approximately four (4) to five (5) hours around 0100 (1:00 a.m.). He (Patient 19) was reported released from the restraints around 0600 (6:00 a.m.) that morning (4/23/2025). The Nursing Progress notes also indicated that the house supervisor and nursing manager were both informed of the incident. During a review of Patient 19’s “Nursing Progress Notes” dated 5/11/2025, the notes indicated Patient 19 was discharged to an Independent Living facility (a community designed for active adults and seniors who can live independently but want to be part of a community with amenities like housekeeping, transportation, and social activities, while also having security and maintenance-free living). During concurrent interview and record review on 10/2/2025 at 10:47 a.m. with Registered Nurse (RN) 1, Patient 19’s “Nursing Progress Notes,” dated 4/23/2025 and timed at 14:58 (2:58 p.m.), was reviewed. RN 1 confirmed she (RN 1) wrote the progress note and notified the house supervisor and nurse manager (NM 3) regarding the incident involving Patient 19. RN 1 stated that everyone was a mandated reporter, and an alleged abuse must be escalated appropriately. During an interview on 10/2/2025 at 1:59 p.m. with the Nurse Manager (NM) 3 of BHU and the Director (DIR 1) of BHU, NM 3 stated this was the first time of the administrative team hearing of Patient 19’s alleged abuse. NM 3 stated that RN 1 “never reported this to me (NM 3) and if it was, I (NM 3) would have started an investigation.” DIR 1 stated when an alleged abuse incident occurred and involved staff, “we put the alleged staff member on suspension while an investigation is being conducted.” DIR 1 stated since “we (the facility) did not know about the incident regarding the patient (Patient 19), there was no investigation conducted and was never reported to the proper authorities.” DIR 1 stated since the allegation was not reported to the facility administrative team, “we (facility) were unable to identify the perpetrator.” During an interview on 10/3/2025 at 10:19 a.m. with House Supervisor 4 (HS 4), HS 4 stated that she (HS 4) was unaware of the alleged abuse incident. HS 4 stated when RN 1 became aware of the alleged abuse, RN 1 “should have notified myself (HS 4) and I (HS 4) should file an incident report. The incident report then will go to the nurse manager and performance improvement team for them to investigate.” During a review of the facility’s policy and procedure (P&P) titled, “Abuse/Mandated Reporting,” dated 03/2025, the P&P indicated that: “Under applicable laws, the facility requires any person with reasonable cause to suspect abuse, neglect, or exploitation to report it to the appropriate regulatory agency. Key Procedures: Prioritize cases of suspected sexual assault, physical abuse, or neglect. Immediate investigation is required for all suspected cases. Reports must be made within 24 hours to Administration. Law enforcement must be notified when applicable. Who Must Report: All healthcare practitioners and facility employees are mandated reporters. Staff must notify their immediate supervisor and department manager, who will coordinate with the CNO or Administrator (Abuse Coordinator). Reporting Process: Document the incident in the patient’s progress notes (include date, time, source, and quotes). Generate an incident report. Notify supervisor and Quality & Risk Department. Report to authorities via phone and written report within required timeframes. Administrative Responsibilities: Leadership (CEO, CNO, Administrator, etc.) will review and determine reportability. Investigation results must be reported to management and regulatory agencies within 5 working days. During a review of the facility’s policy and procedure (P&P) titled, “Incident/Occurrence Reporting,” revised 5/3/2025, the P&P indicated employees who witness or are aware of an unusual occurrence are responsible for completing an Incident Report at the time they become aware of the occurrence. 2. During a review of Patient 7’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 10/12/2024, the Psych Eval indicated Patient 7 was admitted to the facility on 10/11/2024 due to increased agitation (feeling of irritability or severe restlessness) with diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), paranoid type (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During a review of Patient 7’s “Interdisciplinary Team Progress Notes Nursing (nursing notes),” dated 10/13/2024, the notes indicated, on 10/13/2024 at 10:40 p.m., “patient (Patient 7) had increased aggressive (behavior that is forceful, assertive, and potentially hostile or threatening) behavior verbally and physically towards staff ... called other staff member to help intervene with patient (Patient 7) behavior ... Patient (Patient 7) stayed in bed still irritable and continue to be aggressive towards staff. Patient (Patient 7) attempted to swing at staff ...” During an interview on 10/3/2025 at 11:09 a.m. with the House Supervisor (HS 5), HS 5 stated the following: on 10/13/2024 at night, she (HS 5) received a report involving Patient 7 being physically abused (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by a security guard (SG 1). HS 5 spoke with SG 1. SG 1 tried to intervene as Patient 7 was being aggressive. SG 1 admitted to HS 5 that he (SG 1) hit Patient 7 because he (SG 1) got mad (at Patient 7) and thus retaliated. HS 5 assessed Patient 7 and noted Patient 7 had bruises on his (Patient 7’s) cheek. The incident was also witnessed by other staff (Patient 7’s primary nurse and two other Mental Health Workers). SG 1 was sent home immediately. The incident was reported to department nurse manager (NM 1) and the Chief Nursing Officer (CNO) for investigation and report. HS 5 also stated she (HS 5) did not see SG 1 working anymore since then. During an interview on 10/3/2025 at 11:29 a.m. with NM 1, NM 1 stated the following: she (NM 1) recalled the incident (involving Patient 7). There was a meeting about the incident, but she (NM 1) was not involved in the investigation. The management team conducted the investigation. The investigation was handled by the previous Quality Director. NM 1 stated the incident was a physical assault resulting in injury (of Patient 7) and should have been reported to the State health department and adult protective services (a government-run social services program that investigates and responds to reports of abuse, neglect, self-neglect, and financial exploitation of vulnerable adults, including older adults and adults with disabilities) within 24 hours. During an interview on 10/3/2025 at 1:30 p.m. with NM 1, NM 1 stated there was an in-service provided to staff about abuse training after the incident (on 10/13/2024). NM 1 stated she (NM 1) could not provide any evidence if an investigation was conducted. NM 1 also stated she (NM 1) was unable to provide any evidence that this abuse incident was reported to any regulatory agencies including the state health department and adult protective services. During an interview on 10/3/2025 at 1:43 p.m. with Chief Nursing Officer (CNO), CNO stated she (CNO) was unable to determine if the abuse incident was reported to the state health department and adult protective services. CNO further stated the facility must report to the regulatory agencies so that the agencies could investigate further. CNO stated, “we need to make sure we protect the patients. It is required to report any alleged abuse in order to protect the elderly and mentally ill patients. We have people (regulatory agencies) to monitor and ensure the laws are followed.” During a review of SG 1’s termination letter issued by facility’s security guard contracted services (CS 3), dated 10/17/2024, the termination letter indicated SG 1 was terminated on 10/17/2024 due to a serious incident that occurred involving a patient (Patient 7) on 10/13/2024. The termination letter also indicated, “this type of conduct is unacceptable and goes against the values and policies of [the organization] ... it has been determined that immediate termination is the appropriate course of action.” During an interview on 10/3/2025 at 2:07 p.m. with the Chief Executive Officer (CEO 2) for the facility’s security guard contracted services (CS 3), CEO 2 stated SG 1 was terminated after the incident of physical abuse with Patient 7 was confirmed through the facility’s internal investigation. During a review of the facility’s policy and procedure (P&P) titled, “Abuse-Management of Suspected Child, Adult, Disabled Person or Elderly Abuse, Neglect,” dated 3/2022, the P&P indicated, “This policy and procedure assure mechanism for identifying, investigating, and mandatory reporting of any mistreatment, abuse, neglect, involuntary seclusion, or misappropriation of property of [the facility] patients ... A. Reportable concerns and procedural steps of suspected abuse/neglect ... 3. All cases of suspected abuse/neglect must be reported to authorities. A person, including an employee, volunteer, or other person associated with the department, who reasonably cause a person to believe that the physical or mental health or welfare of a patient of the department who is receiving medical services has been, is or will be adversely affected by abuse or neglect by any person shall, provide a mandatory report of information supporting the belief to the department of health, or the appropriate health care regulatory agency, by telephone, in writing, or by personal visit within 24-26 hours of alleged event ... 5. All reports received by any local or state law enforcement agency shall be referred to the appropriate department providing protective regulatory services ... If the perpetrator(s) of the alleged abuse, neglect, mistreatment, or misappropriation of property have been identified as a healthcare worker then he/she should be immediately removed from the patient(s) care until an investigation is completed. The allegation of abuse is to be reported to [state health department] within 36 hours of the alleged event.” During a review of the facility’s policy and procedure (P&P) titled, “Patient’s Rights,” dated 5/2025, the P&P indicated, “This policy applies to all employees, medical staff, volunteers, contractors and students providing care or services within [the facility] ... Patient Rights ... All patients receiving care at [the facility] have the rights to ... 6. Safety ... Receive care in a safe environment, free from all forms of abuse, harassment, or restraints that are not medically necessary.” 3. During a review of Patient 8’s “Psychiatric Evaluation (Psych Eval),” dated 8/29/2024, the Psych Eval indicated, Patient 8 was admitted to the facility on 8/28/2024 with agitated (feeling of irritability or severe restlessness) behavior and diagnosis of schizoaffective disorder (a mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]). The Psych Eval also indicated Patient 8 came from a nursing care facility (a nursing facility with the staff and equipment to give skilled nursing care and skilled rehabilitative services and other related health services). During a concurrent interview and record review on 10/2/2025 at 12:58 p.m. with the Nurse Manager (NM 1) of Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) and Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery), Patient 8’s “Interdisciplinary Progress Note Nursing (nursing notes),” dated 8/29/2024, was reviewed. The nursing notes indicated, on 8/29/2024 at 4:09 p.m., Patient 8 reported to Registered Nurse (RN) 6 that Patient 8 did not want to go back to the nursing care facility because “she (Patient 8) had a man come into her (Patient 8) room at 2 a.m. (unknown date) and she was striking at him because she (Patient 8) was defending herself due to her feeling that she was going to be harassed (experiencing persistent and unwanted behavior that troubles, annoys, or creates an intimidating, hostile, or degrading environment.” The nursing notes also indicated RN 6 notified social worker, and NM 1. NM 1 stated she (NM 1) spoke with Patient 8, gathered information after RN 6 reported the incident and determined it was an alleged sexual abuse (sexual conduct or a sexual act forced upon a woman, man or child without their consent) involving the nursing care facility where Patient 8 came from. NM 1 stated this incident was reportable to the state health department and adult protective services. During an interview on 10/3/2025 at 1:43 p.m. with Chief Nursing Officer (CNO), CNO stated she (CNO) was unable to determine if the abuse incident was reported to state health department and adult protective services. CNO further stated the facility must report to the regulatory agencies so that the agencies could investigate further. CNO stated, “we need to make sure we protect the patients. It is required to report any alleged abuse in order to protect the elderly and mentally ill patients. We have people (regulatory agencies) to monitor and ensure the laws are followed.” During a review of the facility’s policy and procedure (P&P) titled, “Abuse-Management of Suspected Child, Adult, Disabled Person or Elderly Abuse, Neglect,” dated 3/2022, the P&P indicated, “This policy and procedure assure mechanism for identifying, investigating, and mandatory reporting of any mistreatment, abuse, neglect, involuntary seclusion, or misappropriation of property of [the facility] patients ... A. Reportable concerns and procedural steps of suspected abuse/neglect ... 3. All cases of suspected abuse/neglect must be reported to authorities. A person, including an employee, volunteer, or other person associated with the department, who reasonably cause a person to believe that the physical or mental health or welfare of a patient of the department who is receiving medical services has been, is or will be adversely affected by abuse or neglect by any person shall, provide a mandatory report of information supporting the belief to the department of health, or the appropriate health care regulatory agency, by telephone, in writing, or by personal visit within 24-26 hours of alleged event ... 5. All reports received by any local or state law enforcement agency shall be referred to the appropriate department providing protective regulatory services ... If the perpetrator(s) of the alleged abuse, neglect, mistreatment, or misappropriation of property have been identified as a healthcare worker then he/she should be immediately removed from the patient(s) care until an investigation is completed. The allegation of abuse is to be reported to [state health department] within 36 hours of the alleged event.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(14) If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. This Standard is not met as evidenced by: 50594 Based on interview and record review, the facility failed to ensure nursing staff consulted the physician after a face to face assessment (an in person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) was performed by Registered Nurses (RNs) for two of 76 sample patients (Patient 7 and 12), in accordance with the federal regulation regarding physician notification after the completion of the face-to-face assessment. This deficient practice had the potential to result in Patient 7 and Patient 12 not receiving evaluation from physicians to determine appropriate treatment, care and intervention. Findings: 1. During a review of Patient 7’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 10/12/2024, the Psych Eval indicated Patient 7 was admitted to the facility on 10/11/2024 due to increased agitation (feeling of irritability or severe restlessness) with diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), paranoid type (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During a review of Patient 7’s “Emergency Medication Intervention (EMI) Assessment and Re-assessment (EMI form),” dated 10/11/2024, the EMI form indicated Patient 7 received Haldol (medication to treat schizophrenia [a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions] and acute [new onset] agitation [feeling of irritability or severe restlessness]) 5 milligrams (mg, unit of measure), Ativan (medication used to anxiety and produce drowsiness and has sedation [a state of calmness or drowsiness induced by drugs] effect) 1 mg, and Benadryl (medication usually used for allergic reaction, can cause drowsiness) 50 mg intramuscular (IM, delivering medication directly into the muscle tissue) injections on 10/11/2024 at 2:15 p.m. due to being combative and agitated toward staff by throwing punches on the floor. During a concurrent interview and record review 10/2/2025 at 1:40 p.m. with the Nurse Manager (NM) 1 of Behavioral Health Unit (BHU, (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) and Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery), Patient 7’s EMI form, dated 10/11/2024, was reviewed. The EMI form indicated a face-to-face assessment was completed on 10/11/2024 at 3:15 p.m. and there was no notification made to physician after face-to-face assessment was completed. NM 1 stated the Registered Nurses (RN) did not call Patient 7’s physician after the completion of the face-to-face assessment on 10/11/2024. During an interview on 10/2/2025 at 1:46 p.m. with NM 1, NM 1 stated the following: emergency medication were injections given to patients when patients’ behavior was imminent danger (a situation where a hazard exists that could reasonably be expected to cause death or serious physical harm immediately or before the danger can be eliminated) to self and/or others. The purpose of the medications was to control the patient’s behavior and maintain patient’s safety. It was a type of behavioral restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body). Trained RN must perform face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) within an hour after medication administration to evaluate the patient. Nurses would notify physicians only if there was change of condition such as the patient being not arousable or medications were ineffective. It was not the facility’s policy to notify the physician every time a face-to-face assessment was completed. During a concurrent interview and record review with NM 1 on 10/2/2025 at 1:55 p.m., the Code of Federal Regulation Title 42 (federal regulations), “Condition of Participation: Patient’s Rights,” dated 2/2020, was reviewed. The federal regulations indicated, “§482.13(e)(14) - - If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient soon as possible after the completion of the 1 hour face-to-face evaluation.” NM 1 stated she (NM 1) was not aware of this regulation. NM 1 further stated physicians should be updated on patient’s response to the emergency medication injections so the physician could determine how the medication improved the patient’s behavior and adjust the treatment plan for patients as needed. During an interview on 10/2/2025 at 8:44 a.m. with Nurse Manager (NM) 2, NM 2 stated it was not indicated in the facility’s policy to notify the physician after a face-to-face assessment was completed by a Registered Nurse (as required by the Federal regulation). During a concurrent interview and record review on 10/6/2025 at 2:53 p.m. with the Chief Nursing Officer (CNO), Hospital Administrator (ADM), and the Nurse Manager (NM) 1, the facility’s policy and procedure (P&P) pertaining to “Restraint and Seclusion Policy,” effective 3/2019, was reviewed. The CNO and NM 1 verified that the facility’s P&P did not align with the federal regulations (regarding the notification of a physician after a RN completes a face-to-face assessment). ADM stated it was the governing body’s responsibility to oversee the facility’s policy implementation and compliance of staff. During a review of the facility’s policy and procedure (P&P) titled, “Psychotropic Medications (drugs that affect the brain and central nervous system [the body’s main processing center, consisting of the brain and spinal cord] to treat mental health disorders),” dated 10/2024, the P&P indicated, “Emergency Medication Intervention (EMI) injections shall be assessed and reassessed by nursing staff in eHR (electronic health record, digital version of paper charting) including initial assessment, vital signs, conclusion assessment, and patient behavior face to face interview.” During a review of the facility’s policy and procedure (P&P) titled, “Restraint and Seclusion Policy,” dated 4/2025, the P&P indicated, “Assessment and Monitoring of Restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body)/Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) ... a. Restraint used for the management of violent behavior: One-hour face-to-face assessment: A responsible licensed independent practitioner, qualified registered nurse or physician assistant shall perform a face-to-face assessment of the patient’s physical and psychological status within 1 hour of the initiation of restraint or seclusion. Registered nurses or physician assistants who perform such assessment shall be trained and have demonstrated competence in the management of violent behavior ...” 2. During a review of Patient 12’s, “Psychiatric Initial Evaluation, dated 9/20/2025, the psychiatric eval indicated Patient 12 was admitted to the facility’s behavioral health unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) on 9/20/2025 on 5150-hold (72 hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) for danger to others (DTO, a person who poses a substantial likelihood of inflicting serious bodily harm on another person) increased aggression, threats, and instigating fight with staff. During a review of Patient 12’s “Emergency Medication and Restraint Order Sheet,” dated 9/25/2025, the emergency medication and restraint order sheet indicated Patient 12 had physician’s order for the following: -Restraint order -hard restraints (physical or mechanical devices that are rigid and difficult to remove, designed to immobilize a person’s body or limbs. They are typically made of durable materials like padded leather or heavy-duty plastic with locking mechanisms, and are used in situations where soft restraints are insufficient to prevent self-harm or escape) -not to exceed four hours, 4 point (both wrists and ankles) and seclusion - not to exceed four hours. -Medication order - Ativan 2 milligrams via IM (intramuscular, into the muscle), Haldol 10 milligrams via IM, and Benadryl 50 milligrams via IM. During a concurrent interview and record review on 10/1/2025 at 11:08 a.m. with the Medical Records Management (MRM) 1 and the Nurse Manager (NM) 2, Patient 12’s “Emergency Medication Intervention (EMI, involve the use of sedative medication [drug that slows brain activity to calm a person] to quickly calm and manage patient experiencing acute agitation) notes,” dated 9/25/2025, was reviewed. NM 2 stated Patient 12 was placed in seclusion room and placed on 4-point (both arms and legs) restraint (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) at 7:30 p.m. NM 2 also said Patient 12 and received via IM route Haldol 10 milligrams, Ativan 2 milligrams and Benadryl 50 milligrams at 7:55 p.m. on 9/25/2025. During a concurrent interview and record review on 10/2/2025 at 8:44 a.m. with Nurse Manager (NM) 2, Patient 12’s “Seclusion/Restraint face to face assessment by L.I.P/H.S. (Licensed Independent Practitioner/House Supervisor),” was reviewed. NM 2 stated face to face assessment, dated 9/25/2025, was signed by House Supervisor (HS) 6, a Registered Nurse. NM 2 verified the physician was not notified by the RN after face-to-face assessment was completed because the date and time of physician notification was left blank in the seclusion/restraint face to face assessment form. NM 2 also stated it was not indicated in the facility’s policy to notify the physician after a face-to-face assessment was completed by a Registered Nurse (as required by the Federal regulation). During the same concurrent interview and record review on 10/2/2025 at 8:44 a.m. with NM 2, the Code of Federal Regulation Title 42 (federal regulations), “Condition of Participation: Patient’s Rights,” dated 2/2020, was reviewed. The federal regulations indicated, “§482.13(e)(14) - - If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient soon as possible after the completion of the 1 hour face-to-face evaluation.” NM 2 stated the facility’s policy did not reflect the federal regulations (which required the notification of a physician after a face-to-face assessment was completed by a RN), and it was important for their (the facility’s) policy to match the regulations. NM 2 stated it was important for the nurse to inform the physician that face-to-face assessment was conducted, to report any abnormal findings, ensure patient safety, determine if restraint use was tolerated well or whether restraint should be continued. NM 2 stated there should always be a coordination among healthcare disciplines (such as between the physician and the Registered Nurse) regarding the plan of care, change in plan of care or in making adjustments in treatment plan. During a concurrent interview and record review on 10/6/2025 at 2:53 p.m. with the Chief Nursing Officer (CNO), Hospital Administrator (ADM), and the Nurse Manager (NM) 1, the facility’s policy and procedure (P&P) pertaining to “Restraint and Seclusion Policy,” effective 3/2019, was reviewed. The CNO and NM 1 verified that the facility’s P&P did not align with the federal regulations (regarding the notification of a physician after a RN completes a face-to-face assessment). ADM stated it was the governing body’s responsibility to oversee the facility’s policy implementation and compliance of staff. During a review of the facility’s policy and procedure (P&P) titled, “Psychotropic Medications (drugs that affect the brain and central nervous system [the body’s main processing center, consisting of the brain and spinal cord] to treat mental health disorders),” dated 10/2024, the P&P indicated, “Emergency Medication Intervention (EMI) injections shall be assessed and reassessed by nursing staff in eHR (electronic health record, digital version of paper charting) including initial assessment, vital signs, conclusion assessment, and patient behavior face to face interview.” During a review of the facility’s policy and procedure (P&P) titled, “Restraint and Seclusion Policy,” dated 4/2025, the P&P indicated, “Assessment and Monitoring of Restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body)/Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) ... a. Restraint used for the management of violent behavior: One-hour face-to-face assessment: A responsible licensed independent practitioner, qualified registered nurse or physician assistant shall perform a face-to-face assessment of the patient’s physical and psychological status within 1 hour of the initiation of restraint or seclusion. Registered nurses or physician assistants who perform such assessment shall be trained and have demonstrated competence in the management of violent behavior ...””

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its Quality Assessment and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) team collected, tracked and trend data on critical patient safety indicators, implement comprehensive action plan, and measure the success of actions taken and track performance to ensure improvements are sustained, when the QAPI team failed to collect data on all patient abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) incidents and report the data to the QAPI quarterly meeting, in accordance with the facility’s performance improvement plan. The facility did not retain any abuse data for 2024 including two (2) of 76 sampled patients’ (Patient 7 and Patient 8) abuse allegation incidents and did not report abuse data to QAPI committee in 2024 and 2025. The facility also failed to capture an alleged physical abuse incident for one of 76 sampled patients (Patient 19) which happened on 4/23/2025, when Patient 19 reported being choked and restrained (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) by staff. This deficient practice resulted in the facility’s QAPI team’s inability to analyze abuse data, identify and address potential problems which had the potential to affect quality of patient care and safety. This deficient practice also resulted in facility’s QAPI team’s inability to monitor state regulatory compliance with reporting patient abuse to regulatory agencies as required. Findings: During an interview on 10/2/2025 at 9:34 a.m. with the Chief Nursing Officer (CNO), the CNO stated the facility did not have any record of abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) cases reported to the state regulatory agency for 2024. During an interview on 10/3/2025 at 4:57 p.m. with the Chief Executive Officer (CEO), the CEO stated the facility lost all patient abuse related data for 2024 after the previous Director of Quality left. The CEO said the facility did not retain any patient abuse record for 2024. During a review of Patient 8’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 8/29/2024, the Psych Eval indicated, Patient 8 was admitted to the facility on 8/28/2024 with agitated (feeling of irritability or severe restlessness) behavior and diagnosis of schizoaffective disorder (a mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]). The Psych Eval also indicated Patient 8 came from a nursing care facility (a nursing facility with the staff and equipment to give skilled nursing care and skilled rehabilitative services and other related health services). During a concurrent interview and record review on 10/2/2025 at 12:58 p.m. with the Nurse Manager (NM 1) of Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) and Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery), Patient 8’s “Interdisciplinary Progress Note Nursing (nursing notes),” dated 8/29/2024, was reviewed. The nursing notes indicated, on 8/29/2024 at 4:09 p.m., Patient 8 reported to Registered Nurse (RN) 6 that Patient 8 did not want to go back to the nursing care facility because “she (Patient 8) had a man come into her (Patient 8’s) room at 2 a.m. (unknown date) and she (Patient 8) was striking at him because she (Patient 8) was defending herself (Patient 8) due to her (Patient 8’s) feeling that she (Patient 8) was going to be harassed (experiencing persistent and unwanted behavior that troubles, annoys, or creates an intimidating, hostile, or degrading environment.” The nursing notes also indicated RN 6 notified the social worker, and NM 1. NM 1 stated she (NM 1) spoke with Patient 8, gathered information after RN 6 reported the incident and determined it was an alleged sexual abuse (sexual conduct or a sexual act forced upon a woman, man or child without their consent) involving the nursing care facility where Patient 8 came from. NM 1 stated this incident was reportable to the state health department and adult protective services (a government-run social services program that investigates and responds to reports of abuse, neglect, self-neglect, and financial exploitation of vulnerable adults, including older adults and adults with disabilities). During a review of Patient 7’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 10/12/2024, the Psych Eval indicated, Patient 7 was admitted to the facility on 10/11/2024 due to increased agitation (feeling of irritability or severe restlessness) with diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), paranoid type (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During an interview on 10/3/2025 at 11:09 a.m. with the House Supervisor (HS 5), HS 5 stated the following: on 10/13/2024 at night, she (HS 5) received a report involving Patient 7 being physically abused (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by a security guard (SG 1). HS 5 spoke with SG 1. SG 1 tried to intervene as Patient 7 was being aggressive. SG 1 admitted to HS 5 that he (SG 1) hit Patient 7 because he (SG 1) got mad (at Patient 7) and retaliated. HS 5 assessed Patient 7 and noted Patient 7 had bruises on his (Patient 7’s) cheek. The incident was also witnessed by other staff (Patient 7’s primary nurse and two other Mental Health Workers). SG 1 was sent home immediately. The incident was reported to department nurse manager (NM 1) and the Chief Nursing Officer (CNO) for investigation and report. During an interview on 10/3/2025 at 1:43 p.m. with Chief Nursing Officer (CNO), CNO stated she (CNO) was unable to see if the abuse incidents (Patient 7 and 8) were reported to state health department and adult protective services. CNO further stated the facility must report to the regulatory agencies so that the agencies could investigate further. CNO stated, “we need to make sure we protect the patients. It is required to report any alleged abuse in order to protect the elderly and mentally ill patients. We have people (regulatory agencies) to monitor and ensure the laws are followed.” During a review of the facility’s QAPI (Quality Assessment and Performance Improvement, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) minutes (a formal record of the committee’s discussions, data analysis, and action plans to enhance patient care), dated 7/24/2024, 10/23/2024, 1/22/2025, 4/23/2025 and 7/23/2025, the QAPI minutes indicated there was no patient abuse data mentioned in all five (5) QAPI minutes. During an interview on 10/3/2025 at 3:03 p.m. with the Hospital Administrator (ADM), the ADM stated the following: the QAPI team consisted of all members including physicians, Chief Executive Officer (CEO), Hospital Administrator (ADM), Chief Nursing Officer (CNO), and department managers. The QAPI team would identify issues and implement them into the QAPI Program by setting benchmarks and goals. The facility had issue with keeping track of abuse data and reporting previously. Starting March 2025, each department manager was responsible for investigating any alleged abuse cases and reported to ADM. ADM stated the facility was 100% compliant with the abuse reporting policy with all the abuse cases reported in 2025. During an interview on 10/3/2025 at 3:23 p.m. with the Hospital Administrator (ADM), the ADM stated the following: the facility would report abuse data in QAPI meetings quarterly so the QAPI team could ask questions and take action as needed. The Quality Council data would then be reported to the Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issues within the hospital) and to the Governing Board meetings quarterly. ADM stated, “we want to make sure patient safety is number one priority.” During a concurrent interview and record review on 10/3/2025 at 3:30 p.m. with ADM, the facility’s QAPI meeting minutes, dated 7/23/2025, was reviewed. The QAPI meeting minutes indicated data reported for second quarter (April to June) of 2025 and did not indicate any abuse data being reported. ADM confirmed the QAPI minutes did not have any abuse data. ADM stated, “it was an oversight.” During a concurrent interview and record review on 10/3/2025 at 3:35 p.m. with the Chief Nursing Office (CNO), the facility’s “Quality Council (includes all the data collected by each department for quality improvement for second quarter [April to June] of 2025) report,” dated 7/23/2025, was reviewed. The “Quality Council” report indicated there was no abuse data mentioned for second quarter of 2025. CNO confirmed the abuse data was not included in Quality Council report. During a review of Patient 19’s History & Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/21/2025, the H&P indicated, Patient 19 was admitted to the facility’s Behavioral Health Unit (BHU) on a 5150 (72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) hold due to increased aggression and at risk for assaultive behavior (a range of actions that are intended to harm or intimate others). During a review of Patient 19’s “Nursing Progress Notes,” dated 4/23/2025, the “Nursing Progress Notes” indicated Patient 19 reported to Registered Nurse (RN) 1 that “he (Patient 19) was awakened around this morning (4/23/2025) 0100 (1:00 a.m.) by noises from his (Patient 19’s) roommate. When he (Patent 19) got up to check on the situation, he (Patient 19) was instructed by the night shift staff to return his (Patient 19’s) bed immediately. The patient (Patient 19) stated while he (Patient 19) preparing his (Patient 19’s) bed, staff members approached him (Patient 19), choked him (Patient 19), and escorted him (Patient 19) to the seclusion room (a secure, private room used to involuntarily confine an individual alone to de-escalate a situation or modify behavior). He (Patient 19) further reported he (Patient 19) was choked again and placed in 4-point (both wrists and ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) for approximately 4 to 5 hours around 0100 (1:00 a.m.). He (Patient 19) was reported released from the restraints around 0600 (6:00 a.m.) that morning. The house supervisor and nursing manager were both informed of the incident.” During an interview on 10/6/2025 at 11:20 a.m. with ADM, ADM stated he (ADM) was not aware of the alleged abuse case that happened on 4/23/2025 involving Patient 19 until 10/3/2025 (during the Federal survey). ADM stated the case was currently under investigation. ADM stated, “no, we are not 100% compliant (referring to instances of abuse investigations and referral/reporting to regulatory agencies).” The ADM stated the facility was required to investigate any alleged abuse case immediately and report the abuse to regulatory agencies. ADM further stated failure to report could cause safety issues and concern. During a review of the facility’s QAPI Plan titled, “2025 Hospital Performance Improvement Plan QAPI,” dated 1/2025, the QAPI Plan indicated, “The primary goal is to provide a comprehensive Performance Improvement Program that will coordinate and integrate ALL performance improvement activities hospital wide to assure that the highest achievable safe and quality of care is delivered to patients. Being consistent in identifying and solving problems will minimize duplication, reduce medical liability, and encourage productive interrelationships ... The Governing Board (GB, the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital’s overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) specifies the following for each department PI (Performance Improvement) plan ... 2. The Governing Board will receive no less than quarterly reports relating to Performance Improvement activities. 3. Data will be collected at least quarterly ... Quality Council is the multidisciplinary Medical Staff committee tasked with implementation of the hospital-wide PI process with direct reporting responsibility to the Governing Board ... The Quality Council/Patient Safety Committee has the responsibility to perform the following functions ... performance improvement activities will track and trend data on critical patient safety indicators including, but not limited to, [accreditation organization’s] National patient Safety Goals, medical errors and adverse events and provide feedback and education throughout the hospital. The hospital shall measure the success of actions taken and track performance to ensure improvements are sustained ... Measuring and Monitoring Performance ... the organization collects data on measures as outlined by regulatory agencies ... and as needed to evaluate the services provided by the organization and contracted services. At a minimum, the organization collects data on these measures ... local, state, and federal requirements/regulatory compliance.””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility’s Quality Assurance and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) program team failed to ensure that an ongoing program showed measurable improvements in indicators for patient safety and/or adverse events, when the facility’s QAPI team failed to thoroughly investigate, report to the regulatory agencies, measure, analyze, and track adverse patient events (any unintended or undesirable occurrence, symptom, or condition that arises during medical treatment and may result in harm) such as incidents of alleged abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), for three (3) of 76 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 19), in accordance with the facility’s performance improvement plan, when: 1. The facility failed to ensure that a thorough internal investigation was conducted following the reported patient-to-patient altercation involving Patient 1 and Patient 2 that took place on 6/5/2025. The Quality Assurance and Performance Improvement (QAPI) team did not review available video footage and was unable to provide proof demonstrating that a structured method was used to identify the underlying causes of the adverse event and to implement measures to prevent recurrence, as required by the hospital’s Performance Improvement Plan. This deficient practice had the potential to result in a missed opportunity to identify and correct systemic failures, such as staff possibly not performing Q15-minute safety checks (routine observations conducted every 15 minutes to monitor and document each patient’s condition and behavior, with the goal of identifying risks and intervening early to ensure safety) and failing to recognize and intervene to prevent Patient 1 from striking Patient 2. As a result of the altercation, Patient 1 sustained a hip fracture (break in the bone) and exhibited neurological changes, including trembling (shaking) of the arms and legs, sluggish (reduced or delayed) response of the right pupil, right upper eyelid drooping (sagging), and left-hand grip weakness. The facility’s failure to address these issues potentially created an ongoing risk for other patients in the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders). 2. The facility failed to ensure that abuse allegations (any suspected or alleged incident of physical abuse, abandonment, abduction, deprivation, financial abuse, mental suffering, neglect, exploitation, or mistreatment of an elder or dependent adult by a person responsible for their care) involving Patient 3 and nursing staff (Licensed Vocational Nurse - LVN 1) were promptly reported to the California Department of Public Health (CDPH, the department that works to protect the public’s health), within 24 hours, in accordance with the facility’s policy and procedure (P&P) regarding “Abuse Mandated Reporting,” when abuse allegations were made regarding LVN 1, who was witnessed slapping Patient 3 twice during medication pass on 1/19/2024. This deficient practice had the potential to result in continued risk of harm to Patient 3. In addition, it delayed external regulatory review and the opportunity for oversight, which may compromise patient safety when an investigation is not immediately undertaken to ensure that corrective action plans are implemented and that the facility is taking adequate steps to reduce the risk of a similar future event. 3.The facility failed to ensure that allegations of abuse (suspected or alleged incidents of physical abuse, abandonment, abduction, deprivation, financial abuse, mental suffering, neglect, exploitation, or mistreatment of an elder or dependent adult-must be reported immediately or as soon as practically possible by phone and followed by a written report (SOC 341) within 24 hours) involving Patient 19 was promptly investigated and reported to the California Department of Public Health (CDPH), in accordance with the facility’s policy and procedure titled “Abuse Mandated Reporting.” The allegation involved Patient 19 reporting to Registered Nurse (RN) 1 that night shift staff had choked and placed Patient 19 in four-point restraints (involve securing all four of a patient’s limbs-both arms and both legs-to a bed or stretcher using soft or leather straps). This deficient practice resulted in a delay in recognizing and responding to abuse allegations involving Patient 19, which compromised the patient’s safety and well-being. In addition, it reflected the facility’s failure to demonstrate an effective internal reporting system and oversight mechanisms intended to protect patients from the harm of abuse. Findings: 1. During an interview on 10/1/2025 at 3:37 p.m. with the Hospital Administrator (ADM), ADM confirmed that on 6/5/2025 at 2:20 p.m., an altercation occurred between Patient 1 and Patient 2 in the locked Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders), 5th floor (Campus 1). Patient 1 attempted to strike Patient 2, who was sitting at the door in the hallway. Patient 2 defended himself, stood up, and pushed Patient 1, who then fell backwards and later was confirmed that Patient 1 sustained a right hip fracture (a break in the upper portion of the right femur (thighbone), specifically where it connects to the hip joint on the right side of the body). Patient 1 was also later assessed to show signs and symptoms of neurological deficit (define): weakness in the lower extremities (refers to a reduction in muscle strength in the legs, which can affect a person’s ability to stand, walk, maintain balance, or perform daily activities), drooping on the left side of face (a unilateral sagging or weakness of the facial muscles, typically on one side of the face), and left arm weakness and was transferred to a higher level of care (refers to a healthcare setting that provides more advanced, specialized, or intensive medical services). There was also no video footage available for review of the incident that happened on 6/5/2025 because the facility kept the video footages for only 10 days in Campus 1. The incident was unwitnessed (as documented in the nursing progress notes) by both licensed (RN, LVN [licensed vocational nurse]) and unlicensed (MHW [mental health worker]) healthcare personnel assigned to the unit at the time. During a concurrent interview and record review on 9/30/2025 at 3:02 p.m. with the Chief Nursing Officer (CNO), Patient 1’s medical record titled, “Nursing Progress Notes,” dated 6/5/2025, was reviewed. The CNO stated that, according to the documentation, Patient 1 attempted to strike Patient 2, who was sitting at the door in the hallway. Patient 2 defended himself, stood up, and pushed Patient 1, who then fell backwards. The CNO confirmed that the fall was unwitnessed (as per nursing notes documentation), and that Rapid Response Team (RRT, a team of healthcare professionals, often including a critical care nurse and a respiratory therapist, who are quickly dispatched to provide immediate care to a patient who shows signs of acute deterioration within a hospital) was called at 2:20 p.m. after Patient 1 was assessed to have weakness in the lower extremities (both legs), drooping (excessive sagging) on the left side of face, and left arm weakness. During a concurrent interview and record review on 10/1/2025 at 2:06 p.m., with the Chief Nursing Officer (CNO), Patient 1’s “Patient Rounding (a proactive nursing practice where staff check on patients at regular intervals to anticipate and address their needs. This strategy aims to improve patient safety) Sheet, dated 6/5/2025 (covering the time from 7:00 a.m. to 4:30 p.m.), was reviewed. The documentation indicated that Patient 1 was not agitated (feeling of irritability or severe restlessness) during this time frame and was consistently documented as either lying or sitting in their (Patient 1) bedroom. Specifically: -At 1:00 p.m., Patient 1 was documented as either lying or sitting -At 2:15 p.m., Patient 1 was again documented as either lying or sitting -This same documentation pattern continued through 2:45 p.m. -The Chief Nursing Officer (CNO) verified that this documentation was possibly inaccurate, noting that the Rapid Response Team was called at 2:20 p.m. and Patient 1 was found in the hallway by Patient 2’s room, yet no deviation or incident was reflected in the rounding sheet during that time. During an interview conducted on 10/1/2025 at 2:06 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following about the incident involving Patient 1 striking Patient 2 that occurred in the hallway on 6/5/2025: The initial investigation was conducted by the House Supervisor, the resource nurse, and the primary nurse. A Root Cause Analysis (RCA, a systematic process for identifying the underlying, fundamental causes of a problem to prevent it from happening again) was later completed by the CNO, a physician (MD 2), and the Hospital Administrator (ADM). The CNO acknowledged that patient-to-patient altercations fell under the category of alleged abuse and were subject to mandated reporting requirements. When asked whether the case was investigated, the CNO confirmed that an investigation took place, during which staff were interviewed, the patient (Patient 1) was assessed, and both the family and physicians were notified. The CNO stated that it was determined the patients were fighting, based on a witness account (EVS [Environmental Service Worker] worker statement) indicating that one patient (Patient 1) attacked the other patient (Patient 2), resulting in one patient (Patient 1) falling to the floor. However, the CNO also confirmed that video footage of the incident was never reviewed. Additionally, although a mental health worker was reportedly present on the unit that day, the CNO could not recall specific details about their involvement. During an interview on 10/1/2025 at 3:17 p.m. with the Chief Nursing Officer (CNO) and the Hospital Administrator (ADM), the CNO stated that the incident was investigated internally and that all key team members were interviewed, including the Environmental Services (EVS) worker who witnessed the altercation between Patient 1 and Patient 2 in the hallway. The ADM confirmed that, because of the EVS worker’s statement regarding the witnessed fall and the altercation between the two patients (Patient 1 and Patient 2), the facility had no reason to review the video footage. During further interview on 10/1/2025 at 3:37 p.m. with the Hospital Administrator (ADM), the ADM stated that the administration was no longer certain whether the entire incident (between Patient 1 and Patient 2) had been witnessed by the Environmental Service (EVS) worker. The ADM confirmed that nursing staff and mental health workers did not witness the altercation between the two patients (Patient 1 and Patient 2). The ADM also stated that he (ADM) could not verify whether staff was conducting Q15-minute checks on that day. The ADM said, “They should have done it (referring to the Q15-minute patient rounds) - this is the expectation,” and noted that staff verbally confirmed they were conducting their rounds. However, the ADM also confirmed that the video footage was never reviewed to verify whether staff actions aligned with what was documented and reported on the day of the incident between Patient 1 and Patient 2. During a follow-up interview on 10/1/2025 at 3:37 p.m. with the Hospital Administrator (ADM), the ADM stated that following the Root Cause Analysis (RCA) of the incident involving Patient 1 and Patient 2, it was determined that Patient 1 had exhibited a sudden change in behavior. In response to the incident, the facility evaluated management practices and provided staff training on de-escalation and early recognition of behavioral changes. Although the ADM stated that all staff received in-service training, the facility was unable to provide documentation of those trainings. The RCA process document provided was dated 10/1/2025 (the incident happened on 6/5/2025), and the ADM admitted that the facility did not routinely retain RCA records and that he (ADM) had typed the document on the day it was requested. During a follow-up interview on 10/1/2025 at 3:37 p.m., with the Hospital Administrator (ADM), the ADM stated that he (the ADM) could no longer confirm whether the entire altercation between Patient 1 and Patient 2 had been witnessed by the Environmental Services (EVS) worker. This uncertainty arose due to a reviewed statement documented by the Behavioral Health Unit (BHU) Nurse Manager (NM 1) on 6/5/2025 at 4:30 p.m., which referenced a physician’s finding of a bump on the right side of Patient 1’s head. The ADM acknowledged that he had not been aware of this possible head injury sustained by Patient 1 during the fall following the altercation. The ADM further confirmed that neither nursing staff nor mental health workers had witnessed the incident. The ADM also stated that he could not verify whether Q15-minute safety checks were conducted on the day of the incident, although staff verbally reported that they had completed their rounds. However, the ADM confirmed that video footage from the unit was never reviewed to validate whether staff actions aligned with documentation and verbal reports regarding the incident involving Patient 1 and Patient 2. During an interview on 10/3/2025 at 3:34 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following regarding Q-15 Minutes rounding: “Q15-minute safety checks are conducted to monitor each patient’s condition and behavior at regular 15-minute intervals. The purpose is to identify any signs of agitation, frustration, or behaviors that may indicate a risk to the patient or others. These checks are preventive in nature and allow staff to intervene early and provide therapeutic support as needed. We use this time to assess whether patients are escalating and to respond in a way that promotes safety and de-escalation. While staff are expected to document these checks accurately, it’s also important to verify that the documentation aligns with actual observations, such as through video review when available.” During a review of the facility’s “2025 Hospital Performance Improvement Plan-QAPI,” dated 2025, the plan indicated that, “When a sentinel or significant adverse event occurs, the facility is required to immediately conduct a Root Cause Analysis (RCA) as outlined in its Sentinel Event policy. An action plan must then be developed to address the underlying system failures, and follow-up monitoring is incorporated to evaluate the effectiveness of the corrective actions. The results of the RCA are reported to the Medical Executive Committee and the Patient Safety Committee, which is a subcommittee of the Quality Council.” During a review of the facility’s “2025 Hospital Performance Improvement Plan-QAPI,” dated 2025, the plan indicated that the hospital’s 2025 Performance Improvement Plan (QAPI) outlines a comprehensive, organization-wide approach to improving patient care and safety. It emphasizes the importance of tracking and analyzing data on critical patient safety indicators to identify trends, educate staff, and implement corrective actions. The plan requires that the effectiveness of these actions be measured over time to ensure that improvements are sustained. It also highlights the need to prioritize issues that have the greatest impact on patient outcomes and satisfaction. Hospital administration is responsible for implementing the plan and ensuring that all departments actively participate in performance improvement efforts. Department leaders are accountable for monitoring quality within their areas, identifying trends, and collaborating across departments to address systemic issues. The Quality Council, a multidisciplinary committee, oversees the hospital-wide improvement process and reports directly to the Governing Board. The plan further ensures that staff, physicians, and leadership receive the necessary education and support to engage in meaningful performance improvement activities. Overall, the goal is to create a culture of continuous improvement that enhances patient safety, reduces risk, and promotes high-quality care. 2. During a concurrent interview and record review conducted on 10/3/2025 at 12:36 p.m. with House Supervisor (HS 1), Patient 3’s admissions to the facility for the year 2024 were reviewed. HS 1 stated that Patient 3 was not admitted to the facility in January 2024. During an interview on 10/3/2025 at 11:32 a.m., with the Nurse Manager (NM 1) of the Medical-Surgical and Behavioral Health Units, NM 1 confirmed that the facility had no access to 2024 data to verify whether the abuse allegations involving Patient 3 were reported to the California Department of Public Health (CDPH, department that works to protect the public’s health). NM 1 explained that the information was no longer available because the former Director of Quality had left the organization, and the facility was unsure whether the incident had ever been reported. During a follow-up interview on 10/3/2025 at 1:40 p.m. with Nurse Manager (NM 1), NM 1 said the following: “The former Director of Quality did the investigation of the alleged abuse. I am not aware if she did or did not report the abuse allegations to California Department of Public Health (CDPH, department that works to protect the public’s health). When the former Director of Quality got the call regarding the abuse, and once the investigation was done, we went to the patient, we wanted to make sure the patient was handled by a female CNA only. Another person said the nurse hit the patient. The former Quality Director did have the file for the case, and I am not aware if this was reported or not. I remember we discussed this with management. When she (former Director of Quality) resigned, she (former Director of Quality) did not perform proper endorsement of her cases.” During an interview conducted on 10/3/2025, at 1:52 p.m. with the QAPI team, which included the Hospital Administrator (ADM), Chief Nursing Officer (CNO), Nurse Manager (NM 2), Quality Coordinator (QC), and Manager of the Behavioral Health Unit (NM 2), NM 2 confirmed that Patient 3 was admitted to the facility for aggressive behavior and striking out. NM 2 said that Patient 3 was admitted to the Behavioral Health Unit on 1/19/2024 due to danger to self and placed on a 5150 hold (refers to the involuntary detention of an individual for up to 72 hours for psychiatric evaluation when they are deemed a danger to themselves, others, or are gravely disabled due to a mental health disorder). The NM 2 then said that Patient 3 was discharged on 1/25/2024. During an interview on 10/2/2025 at 3:52 p.m. with the Chief Nursing Officer (CNO), the CNO provided documentation of an investigation into alleged abuse reported to the facility on 1/22/2024 by a staff member who witnessed Licensed Vocational Nurse (LVN 2) slapping Patient 3 twice during the morning medication pass on 1/19/2024. During a review of the investigation into the alleged abuse incident, dated January 22, 2024, the facility’s records indicated the following: -“On January 22, 2025, at 10:30 a.m., the Human Resources (HR) Coordinator received an anonymous phone call reporting the following: “I want to report an anonymous incident that on Friday, January 19 [2024], in the morning, in room number [#], LVN 2 was giving medication to the patient (Patient 3), and the patient did not want to take the medication. LVN 2 slapped the patient (Patient 3) twice.” -The record also indicated that Interviews were conducted with the following individuals: LVN 2 (the alleged perpetrator) A witness who observed LVN 2 punch Patient 3 Patient 3 (the alleged victim) -The documentation also confirmed that LVN 2 was suspended on January 22, 2024, pending the outcome of the investigation. During an interview on 10/3/2025 at 3:06 p.m. with the Hospital Administrator (ADM), Chief Nursing Officer (CNO), and both Nurse Managers of the Behavioral Health Unit (NM 1 and NM 2), the ADM stated that the position of Director of Quality is neither open nor currently occupied. The ADM explained that the QAPI team comprised of departmental managers, physicians, and the Chief Executive Officer (CEO) of the hospital. The ADM stated, “If there are issues that we identify, we incorporate them into our QAPI program, and we want to achieve the benchmark,” referring to the facility’s performance goals. As an example, the ADM described the abuse reporting process, stating that each department was responsible for mandated reporting, and that the facility followed procedures to ensure compliance. The ADM added, “We are currently at 100% for abuse reporting. We had two incidents, and we are in 100% compliance for reporting ... and we follow policy.” During a follow-up interview conducted on 10/3/2025 at 4:36 p.m. with the Chief Nursing Officer (CNO), the CNO stated: “”I don’t have a tracking report (if the alleged abuse incident was reported to regulatory agencies) for this abuse case. It’s supposed to be reported within 24 hours, since it’s alleged abuse and the patient had no injury...” During a review of the facility’s Policy and Procedure (P&P) titled, “Abuse - Management of Suspected Child, Adult, Disabled Person or Elderly Abuse, Neglect,” dated March 2022, the P&P indicated the following: “-It is the policy of the facility, in accordance with applicable laws, that any person with reasonable cause to believe that an individual is experiencing abuse, exploitation, or neglect must report the information to the appropriate regulatory agency. -Cases of suspected sexual assault, physical abuse, or neglect should be given priority. -All reports received by local or state law enforcement must be referred to the appropriate protective regulatory services or county agency responsible for human rights protection. -Individuals may report alleged violations to the Department of Health or the appropriate state healthcare regulatory agency by telephone, in writing, or in person. -If the alleged perpetrator is a healthcare worker, they must be immediately removed from patient care duties until the investigation is completed. -Allegations of abuse must be reported to CDPH within 36 hours of the alleged event.” During a review of the facility’s “2025 Hospital Performance Improvement Plan-QAPI,” dated 2025, the plan indicated that, “When a sentinel or significant adverse event occurs, the facility is required to immediately conduct a Root Cause Analysis (RCA) as outlined in its Sentinel Event policy. An action plan must then be developed to address the underlying system failures, and follow-up monitoring is incorporated to evaluate the effectiveness of the corrective actions. The results of the RCA are reported to the Medical Executive Committee and the Patient Safety Committee, which is a subcommittee of the Quality Council.” During a review of the facility’s “2025 Hospital Performance Improvement Plan-QAPI,” dated 2025, the plan indicated that the hospital’s 2025 Performance Improvement Plan (QAPI) outlines a comprehensive, organization-wide approach to improving patient care and safety. It emphasizes the importance of tracking and analyzing data on critical patient safety indicators to identify trends, educate staff, and implement corrective actions. The plan requires that the effectiveness of these actions be measured over time to ensure that improvements are sustained. It also highlights the need to prioritize issues that have the greatest impact on patient outcomes and satisfaction. Hospital administration is responsible for implementing the plan and ensuring that all departments actively participate in performance improvement efforts. Department leaders are accountable for monitoring quality within their areas, identifying trends, and collaborating across departments to address systemic issues. The Quality Council, a multidisciplinary committee, oversees the hospital-wide improvement process and reports directly to the Governing Board. The plan further ensures that staff, physicians, and leadership receive the necessary education and support to engage in meaningful performance improvement activities. Overall, the goal is to create a culture of continuous improvement that enhances patient safety, reduces risk, and promotes high-quality care. 3. During a review of Patient 19’s “Nursing Progress Notes,” dated 4/23/2025 at 2:58 p.m., recorded by the registered nurse (RN 1), the note indicated that, according to Patient 19, “He (Patient 19) was awakened around 0100 (1:00 a.m.) that morning (4/23/2025) by noises from the roommate. When he (Patient 19) got up to check on the situation, he (Patient 19) was instructed by night shift staff to return to the bed immediately... Patient 19 then stated that while he (Patient 19) was preparing the bed, staff members approached him (Patient 19), choked him (Patient 19), and escorted him to the seclusion room (a secure, private room used to involuntarily confine an individual alone to de-escalate a situation or modify behavior). He further reported that he was choked again and placed in 4-point restraints (A 4-point restraint is a medical or security measure that uses restraints on all four of a person’s limbs-both wrists and both ankles-simultaneously to prevent movement. It is a restrictive intervention typically used only in emergencies when a person is an immediate danger to themselves, or others and less restrictive alternatives have failed) for approximately 4 to 5 hours starting around 0100 (1:00 a.m.). Patient 19 was reportedly released from the restraints around 0600 (6:00 a.m.) that morning (4/23/2025).” The House Supervisor (HS 4) and Nurse Manager (NM 3) were both documented as having been informed by RN 1 of the incident. During a concurrent interview and record review on 10/2/2025 at 10:47 a.m. with Registered Nurse (RN 1), Patient 19’s “Nursing Progress Notes,” dated 4/23/2025 at 14:58 (2:58 p.m.), were reviewed. RN 1 confirmed that she (RN 1) authored the progress note and stated she (RN 19) had notified both the House Supervisor (HS 4) and Nurse Manager (NM 3). RN 1 said that all staff were mandated reporters (legally obligated to report. Failure to do so can result in criminal liability, including fines and jail time, as well as civil lawsuits) and that any alleged (said, without proof) abuse must be escalated appropriately. During an interview on 10/2/2025 at 1:59 p.m. with Nurse Manager (NM 3) and the Director (DIR 1) of BHU, NM 3 stated this was the first time she had heard of Patient 19’s alleged abuse. NM 3 stated, “RN 1 never reported this to me, and if she (RN 1) had, I would have started an investigation.” DIR 1 stated that when an alleged abuse incident involving staff occurred, “we place the alleged staff member on suspension while an investigation is conducted.” DIR 1 further stated that since the facility was unaware of the incident involving Patient 19, no investigation was conducted, and the incident was never reported to the appropriate authorities. As a result, the facility was unable to identify the alleged perpetrator. During an interview on 10/3/2025 at 10:19 a.m. with House Supervisor 4 (HS 4), HS 4 stated that HS 4 was unaware of the alleged abuse claims. HS 4 said that when RN 1 became aware of the allegation (a claim made without proof), RN 1 should have notified the supervisor (HS 4) and “I (HS 4) should file an incident report. The incident report would then be forwarded to the Nurse Manager and Performance Improvement for investigation.” Patient 19 was discharged from the facility on 5/1/2025, and as of 10/2/2025, the abuse allegation had not been investigated. During an interview on 10/3/2025 at 11:32 a.m. with Nurse Manager (NM 1), NM 1 stated: “We don’t have the data from 2024 because our Director of Quality has left, and we no longer have access to that information. As a result, we implemented a new reporting process in 2025.” During an interview on 10/3/2025 at 3:06 p.m. with the Hospital Administrator (ADM), Chief Nursing Officer (CNO), and both Nurse Managers of the Behavioral Health Unit (NM 1 and NM 2), when asked about tracking abuse reporting incidents, the ADM said that the facility was tracking and maintaining records for both incident and abuse reporting (Patient 19’s abuse allegation was not in the facility’s tracking report). The ADM also said that the process followed the facility’s new policy and chain of command: if a floor nurse observed a reportable incident, they notify the direct supervisor or resource nurse, who then informs the house supervisor. The nurse was expected to document the incident in the patient’s progress notes, including direct statements from the patient. The same reporting process was followed at both campuses (Campus 1 and Campus 2) and the house supervisor should submit the incident report. The ADM verified that abuse reporting was handled separately from sentinel (a serious, unexpected occurrence in a healthcare setting that results in death, serious physical or psychological injury, or the risk thereof) or adverse event reporting. And also said that the abuse reporting policy was revised in March 2025 to make the process more concise and directive, and that the Administrator now served as the coordinator for the abuse reporting process. During an interview on 10/3/2025 at 3:36 p.m. with the Hospital Administrator (ADM), Chief Nursing Officer (CNO), and both Nurse Managers of the Behavioral Health Unit (NM 1 and NM 2), the ADM stated that the position of Director of Quality was neither open nor currently occupied. The ADM explained that the QAPI team was comprised of departmental managers, physicians, and the Chief Executive Officer (CEO) of the hospital. The ADM stated, “If there are issues that we identify, we implement them into our QAPI program, and we want to achieve the benchmark,” referring to the facility’s performance goals. As an example, the ADM described the abuse reporting process, stating that each department was responsible for mandated reporting, and that the facility followed procedures to ensure compliance. The ADM added, “We are currently at 100% for abuse reporting. We had two incidents, and we are in 100% compliance for reporting ... and we follow policy.” During the same interview on 10/3/2025 at 3:36 p.m. with the Hospital Administrator (ADM), Chief Nursing Officer (CNO), and both Nurse Managers of the Behavioral Health Unit (NM 1 and NM 2), the CNO stated that while each department was responsible for collecting their patient safety data, abuse and adverse events were not measurable data. The CNO further stated that abuse cases do not fall under the scope of nursing metrics. During a review of the facility’s policy and procedure (P&P) titled “Abuse/Mandated Reporting,” dated 3/2025, the P&P indicated, that “All suspected cases must be investigated immediately. Any individual (employee, volunteer, or associate) who reasonably believes or has knowledge that a patient’s health or welfare has been, is, or will be adversely affected by abuse or neglect must report it within 24 hours to Administration... Law enforcement agencies must refer reports to the appropriate protective services agency. o If an alleged perpetrator is a healthcare worker, they must be immediately removed from patient care pending an investigation. [The Facility] prohibits retaliation against employees or individuals who report suspected violations in good faith... All healthcare practitioners and [The Facility] employees are mandated reporters. Employees must notify their immediate supervisors, Department Manager, who will collaborate with the CNO/Hospital Administrator/Designee (the Abuse Coordinator) in the final analysis of the reportable incident. The reporting process includes documenting the incident in the patient’s progress notes with the date, time, source, and direct quotes; generating an incident report; notifying the supervisor and the Quality & Risk Department; and reporting the incident to authorities both by phone and in writing within the required timeframes. Administrative responsibilities include leadership review by the CEO, CNO, or Administrator to determine reportability, and ensuring that investigation results are reported to management and regulatory agencies within five working days.” During a review of the facility’s Bylaws (define), dated 5/2019, the Bylaws indicated the following: “The Governing Board, through the Administrator, shall provide whatever administrative assistance is reasonably necessary to support and facilitate the implementation and ongoing operations of these quality review and evaluation activities. These quality review and evaluation activities shall ensure that the same level of overall quality and appropriateness of care is provided to all patients of the Hospital. Monitoring and evaluating the quality and appropriateness of patient care through a valid and reliable quality assessment program.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50515 Based on interview and record review, the facility failed to promptly evaluate and provide immediate medical intervention and treatment, in accordance with the facility’s policy and procedure regarding plan for provision of care pertaining to safe, effective, timely care and treatment, when one of 76 sampled patient (Patient 18), a Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) patient (Patient 18), swallowed a foreign object (any item that does not belong in the body). This deficient practice resulted in Patient 18’s claim of swallowing a razor (sharp blade instrument) not validated and evaluated by nursing staff until two days later (on 9/8/2025) after Patient 18’s initial claim (9/6/2025) of having swallowed a razor, which led to Patient 18 being transferred to another facility and undergoing a procedure for removal of the foreign object. This deficient practice also had the potential of Patient 18 losing a large amount of blood and damage to his esophagus (canal that connect the throat to the stomach), which may result in further serious injury or even death. On 10/2/2025 at 2:32 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Nursing Officer (CNO), Manager of Medical Surgical and Behavioral Health Unit (NM 1), Hospital Administrator (ADM), Manager of Medical Surgical and Behavior Health Unit (NM 2), Facility Director of Behavior Health Unit (DIR 1) and Nurse Manager of Behavior Health Unit (NM 3). the facility failed to promptly evaluate and provide immediate medical intervention and treatment, in accordance with the facility’s policy and procedure regarding plan for provision of care pertaining to safe, effective, timely care and treatment, when one of 76 sampled patient (Patient 18), a Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) patient (Patient 18), swallowed a foreign object (any item that does not belong in the body). This deficient practice resulted in Patient 18’s claim of swallowing a razor (sharp blade instrument) not validated and evaluated by nursing staff until two days later (on 9/8/2025) after Patient 18’s initial claim (9/6/2025) of having swallowed a razor, which led to Patient 18 being transferred to another facility and undergoing a procedure for removal of the foreign object. This deficient practice also had the potential of Patient 18 losing a large amount of blood and damage to his esophagus (canal that connect the throat to the stomach), which may result in further serious injury or even death. During a review of Patient 18’s (a BHU patient, on involuntary hold (involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] evaluation and treatment) Nursing Progress Notes, dated 9/6/2025 at 1808 (6:08 p.m.), indicated Patient 18 reported to nurse (RN 1) he (Patient 18) swallowed a razor, Nurse Practitioner (NP 1) was notified, and order was given to monitor and send to Emergency Department (ED) if with symptoms. During a review of Patient 18’s Nursing Progress Notes, dated 9/7/2025 at 1608 (4:08 p.m.) indicated Patient 18 stated, “you never did anything about the razor I swallowed yesterday (referring to 9/6/2025).” There was no record of a nurse notifying the physician regarding Patient 18’s statement on 9/7/2025. During a review of Patient 18’s Nursing progress Notes, dated 9/8/2025 at 7:46 a.m. indicated Patient 18 stated he (Patient 18) swallowed a razor that he hid inside his (Patient 18) “butt.” During a review of Patient 18’s Nursing progress notes, dated 9/8/2025 at 1828 (6:28 p.m.) indicated Patient 18 stated he (Patient 18) was going to swallow a razor and also stated he (Patient 18) swallowed a razor “send me to ER (Emergency Room) now.” The notes also indicated Patient 18 was observed spitting out small amount of serosanguinous (pink or light red color) drainage from his mouth. During a review of Patient 18’s “Operative Report,” dated 9/9/2025, the record indicated, Patient 18 underwent Esophagogastroduodenoscopy (EGD, medical procedure that allows the doctor to examine the inside of throat, stomach and small intestine) on 9/9/2025 with “a huge metallic foreign body ... very thick metal ... measured about 6 centimeter (cm, unit of measurement) in length, 2 cm in width” removed from the esophagus. During a review of Patient 18’s Discharge Summary (a comprehensive medical document created when a patient leaves a hospital or other care setting, detailing the reason for admission, the care received, key findings, and post [after]-discharge instructions), dated 9/9/2025, the discharge summary indicated Patient 18 was transferred to another facility (on 9/8/2025) for swallowing a foreign object and was later admitted at the receiving facility. During an interview on 10/1/2025 at 1:33 p.m. with BHU manager (NM 3), NM 3 stated charge nurse or primary nurse should assess patient, call doctor, and send patient to ED for evaluation to verify patient did not swallow anything. “We (staff) cannot ignore what patients say, in this case patient (Patient 18) should have been sent to higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]) to verify what he was saying.” During an interview on 10/1/2025 at 3:56 p.m. with the Chief Nursing Officer (CNO), CNO stated when a patient reported to a nurse that he or she had swallowed a foreign object, the nurse should assess and notify the physician right away. Depending on the symptoms, the nurse may call 911 for emergency (patient’s bleeding or unstable vital signs) or send the patient to emergency department for higher level of care. The CNO stated, “Nurse should take the report seriously and not to make any assumption.” On 10/6/2025 at 2:51 p.m. the IJ was removed in the presence of the CNO, NM 1, ADM, Chief Executive Officer (CEO), DIR 1 and NM 3, after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that immediate action taken by the facility were the following: starting 10/2/2025, Immediate Response -Nursing staff shall acknowledge and validate patient complaints, obtain vital signs (includes body temperature, heart rate, respiratory rate, blood pressure) and perform a focused assessment related to complaint. Document the patient’s exact words and findings. Call the onsite physician, house supervisor and clinical Manager to reassess the patient situation/condition and contact treating physician. Additionally, the nurse must also call one of the facility’s Governing Board physician members to make final determination whether patient will be transferred or not. Re-education of all Licensed staff on the topic of Patient Rights Facility policy, Contraband (any item that is prohibited because it poses a risk to the safety and security of patients, staff, or visitors. This includes a wide range of items that could be used for harm, escape, or intimidation, such as weapons, illegal drugs, lighters, and alcohol) Handling policy, Behavior Health Unit Criteria and SBAR (a communication tool used in nursing to update team about patient, it stands for Situation, Background, Assessment and recommendations)/Significant change. Transfer protocol/guidelines Policy established and inter shift hand off (the transfer of information, responsibility, and authority from one person or team to another as a shift ends and a new one begins) process for patients who present/express a significant change during shift the house supervisor will ensure complaint presented is acted upon timely and physician notified. Findings: During a review of Patient 18’s Behavioral Health History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 9/6/2025 at 1445 (2:45 p.m.), the H&P indicated, Patient 18 was admitted to the facility’s Behavioral Health Unit (BHU- inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders)) on 5150 (involuntary hold/involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) hold for danger to self (DTS) stating he (Patient 18) wanted to run into traffic and a danger to others (DTO) for wanting to hurt people in Mexico. During a review of Patient 18’s “Nursing Progress Notes,” dated 9/6/2025 at 1808 (6:08 p.m.), the Nursing Progress Notes indicated Patient 18 reported to nurse (RN 1) he (Patient 18) swallowed a razor, Nurse Practitioner (NP 1) was notified, and an order was given by the NP 1 to monitor Patient 18 and send to emergency department if with symptoms. During a review of Patient 18’s “Nursing Progress Notes,” dated 9/7/2025 at 1608 (4:08 p.m.), The Nursing Progress Notes indicated that Patient 18 stated, “you never did anything about the razor I swallowed yesterday (referring to 9/6/2025).” There was no record of a nurse notifying the physician regarding Patient 18’s statement on 9/7/2025 (this was verified by Nurse Manager (NM) 3 during an interview on 10/2/2025 at 10:44 a.m.). During a review of Patient 18’s “Nursing Progress Notes,” dated 9/8/2025 at 7:46 a.m., the Nursing progress Notes indicated Patient 18 stated he swallowed a razor that he hid inside his (Patient 18) “butt.” During a review of Patient 18’s “Nursing Progress Notes,” dated 9/8/2025 at 1828 (6:28 p.m.), the Nursing Progress Notes indicated Patient 18 stated he (Patient 18) was going to swallow a razor and also stated he swallowed razor “send me to ER (emergency room) now.” The notes also indicated Patient 18 was observed spitting out small amount of serosanguinous (pink or light red color) drainage from his (Patient 18) mouth. During a review of Patient 18’s” Discharge Summary (a comprehensive medical document created when a patient leaves a hospital or other care setting, detailing the reason for admission, the care received, key findings, and post [after]-discharge instructions),” dated 9/9/2025, the discharge summary indicated Patient 18 was transferred to another facility (on 9/8/2025) for swallowing a foreign object and was later admitted at the receiving facility. During an interview on 10/2/2025 at 11:00 a.m. with Registered Nurse (RN) 1, RN 1 stated Patient 18 reported swallowing a razor on 9/6/2025. RN 1 stated she (RN 1) reported it to NP 1 on the floor and was told to monitor Patient 18 and send Patient 18 to ER if something was abnormal. RN 1 further stated there was no order for x-ray (a diagnostic imaging procedure that uses a small dose of high-energy radiation to create pictures of the inside of the body) given on 9/6/2025. During an interview on 10/1/2025 at 10:48 a.m. with Registered Nurse 3 (RN 3), RN 3 stated that on 9/8/2025, Patient 18 went to the nursing station and reported he (Patient 18) swallowed something, “we (staff) were not sure if he (Patient 18) did, later he (Patient 18) started spitting out blood and we (staff) called the Nurse Practitioner (NP 2) and patient (Patient 18) was sent to Emergency Department via facility van.” During an interview on 10/1/2025 at 12:24 p.m. with the Behavioral Health Unit Manager (NM 3), NM 3 stated that for a patient who reported they swallowed a razor, staff should have called 911 because “we (staff) do not know what is going on with patient internally.” During an interview on 10/1/2025 at 1:33 p.m. with BHU manager (NM 3), NM 3 stated Charge Nurse or primary nurse should have assessed the patient, called the doctor and sent patient to ER for evaluation to verify patient did not swallow anything. “We (staff) cannot ignore what patients say, in this case patient (Patient 18) should have been sent to higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]) to verify what he was saying.” During an interview on 10/1/2025 at 3:13 p.m. with house supervisor (HS 3), HS 3 stated she (HS 3) was doing rounds (patient rounds, a proactive nursing practice where staff check on patients at regular intervals to anticipate and address their needs. This strategy aims to improve patient safety) on 9/8/2025 and overheard Patient 18 report to Charge Nurse (CN) 6 that he (Patient 18) swallowed a razor. During an interview on 10/1/2025 at 3:56 p.m. with the Chief Nursing Officer (CNO), CNO stated when a patient reported to a nurse that he or she had swallowed a foreign object, the nurse should assess and notify the physician right away. Depending on the symptoms, the nurse may call 911 for emergency (patient’s bleeding or unstable vital signs) or send the patient to emergency department for higher level of care. CNO stated, “Nurse should take the report seriously and not to make any assumption.” During an interview on 10/1/2025 at 4:27 p.m. with the Chief of Staff (COS), COS stated the following: when a patient reported he or she swallowed a foreign object, we need to believe the patient even though they have poor insight and judgement. When a patient reported he or she swallowed a foreign object, the provider needed to be notified, and examination performed on the patient. There should be a STAT (immediately) chest X ray and abdomen X ray to rule out the foreign object and to determine the next step for treatment. Once the foreign object was confirmed, the patient should be sent out to emergency department (ED) for medical intervention. During an interview on 10/1/2025 at 4:45 p.m. with the Chief of Staff (COS), COS stated the following: for Patient 18’s incident, Patient 18 was seen by a provider (NP 2) and sent out to an emergency department for EGD 48 hours later on 9/8/2025 (from the first time [9/6/2025] of Patient 18 reporting swallowing a foreign object). There would be an extensive discussion of this incident in the next MEC (Medical Executive Committee, acts as a representative of the medical staff. The committee proposes change and enacts policies, procedures, and other items in an effort to improve patient care and medical staff structure) meeting this month on the 22nd (10/22/2025). COS also stated, “We are trying to recognize this better so we can put a stop to this (referring to the delayed treatment for Patient 18).” During an interview on 10/2/2025 at 10:44 a.m. with NM 3, NM 3 stated, there were no physician progress notes documented from 9/6/2025 to 9/8/2025 regarding Patient 18 having swallowed a foreign object. During a review of Patient 18’s “Operative Report” dated 9/9/2025, the Operative Report indicated, Patient 18 underwent Esophagogastroduodenoscopy (EGD-medical procedure that allows doctors to examine throat, stomach and small intestine) on 9/9/2025 with “a huge metallic foreign body ... very thick metal ... measured about 6 cm in length, 2 cm in width” removed from the esophagus (canal connecting the throat to the stomach). During a review of the facility’s policy and procedure (P&P) titled, “Patient’s Rights,” dated 3/2025, the P&P indicated, “Basic Rights. 1. The patient has a basic right to treatment. Provision of treatment is the physician’s and hospital’s fundamental responsibility to the patient ... B. Rights which May not Be Limited. 3. To humane care and treatment.” During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for Provision of Care,” dated 2022, the P&P indicated, “[the facility] is committed to assuring a single standard of culturally competent care to patients. Patient Services at [the facility] are delivered through organized and systemic process designed to ensure the delivery of safe, effective, timely care and treatment. Patients have access to the appropriate level of care based on their individual condition and needs.” During a review of the facility’s “Medical Staff Bylaws”, dated 10/2024, the Bylaws indicated “Basic Responsibilities of Medical Staff Membership ... (a) providing patients with quality of care meeting the professional standards of the medical staff of this hospital.” During a review of the facility’s policy and procedure (P&P) titled, “Higher level of care transfer of patient to another facility,” revised 3/2023, the P&P indicated, “If a patient has an emergency medical condition, (facility name) will provide the necessary stabilizing examination and treatment with its capabilities, if and when the hospital does not have the necessary capability to treat the patient, the hospital will make all required arrangement for transfer, including but not limited to: stabilizing, treating and monitoring the patient condition, performing any and all life saving measures that may be needed and are within our capabilities ...Clinical Situations based on. 3. Or any other clinical diagnosis requiring specialty services not offered at [the facility] will be stabilized and transferred expeditiously to high level of care receiving facility based on Emergency Medical Services. During a review of the facility’s policy and procedure (P&P) titled, “SBAR/Significant Change of Condition,” dated 5/2025, the P&P indicated, “The facility must inform the patient, consult with the patient’s physician and/or notify the patient’s family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include ... 1. Accidents ... b. potential to require physician intervention ... 2. Significant change in the patient’s physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include ... a. life-threatening conditions, or b. clinical complications.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50594 Based on observation, interview, and record review, the facility failed to: 1. Ensure nursing staff adhered to the facility’s policy and procedure regarding “ Every 15 Min (minute) Rounds, Patient,” and the facility’s charting/documentation policy, when staff did not consistently perform and accurately document the Q (every) 15?minute rounding (observing patient location and behavior), for 62 of 76 sampled patients (Patient 1, Patient 2, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 41, Patient 42, Patient 43, Patient 44, Patient 14, Patient 15, Patient 16, Patient 45, Patient 46, Patient 47, Patient 48, Patient 49, Patient 50, Patient 51, Patient 52, Patient 53, Patient 54, Patient 55, Patient 56, Patient 57, Patient 58, Patient 59, Patient 60, Patient 61, Patient 62, Patient 63, Patient 64, Patient 65, Patient 66, Patient 67, Patient 68, Patient 69, Patient 70, Patient 71, Patient 72, Patient 73, Patient 74, Patient 75 and Patient 76), on 9/19/2025 from 1:00 a.m. to 2:30 a.m. in Campus 1, on 9/13/2025 from time period 1:20 a.m. to 4:58 a.m. in Campus 2, and on 9/19/2025 from time period of 1:00 a.m. to 2:15 a.m. in Campus 2. This deficient practice had potentially placed the patients in an unsafe environment, at risk of self?harm, or harm to others, psychological trauma and/or death. 2. Ensure implementation of a safe transfer to a higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]), in accordance with the facility’s policy regarding Higher level of care transfer of patients to another facility, when one of 76 sampled patients (Patient 18), was transferred to another hospital for evaluation and treatment, in a hospital van which was not equipped with lifesaving equipment or a licensed staff capable of providing emergency service, after Patient 18 swallowed a foreign object (any item that does not belong in the body). This deficient practice had the potential for inadequate medical support and compromised monitoring of Patient 18 who was at risk of losing a large amount of blood and damage to his esophagus (canal that connect throat to stomach), which had the potential to result in harm, serious injury or even death. Findings: 1.a. During a review of Patient 1’s History and Physical (H&P, a comprehensive clinical document that includes a patient’s medical history and findings from a physical examination), dated 6/4/2025, the H&P indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) due to being “agitated (feeling of uneasiness and severe restlessness) and aggressive.” The H&P also indicated that Patient 1 was placed on assaultive (safety measures implemented for patients who exhibit or are at risk of exhibiting violent or aggressive behavior) and homicidal precautions (safety interventions used when a patient expresses or demonstrates thoughts, intentions, or behaviors indicating a risk of harming others). During a review of Patient 1’s “Behavioral Admission Assessment,” dated 6/4/2025, the record indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU) at 2:45 p.m. on a 5150 Hold (involuntary hold/involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to others and being gravely disabled (GD, a condition in which a person, due to a mental health disorder, is unable to provide for their basic personal needs such as food, clothing, or shelter).” The record also stated that Patient 1 required “line of sight observation,” meaning continuous visual monitoring by staff to ensure immediate intervention if needed, and was placed on 15-minute Close Observation Level II, which involved staff checking on the patient every 15 minutes due to a history of threatening and/or assaultive behavior within the past 30 days. During a review of Patient 1’s “Behavioral Health Daily Nursing Assessment,” dated 6/5/2025, the record indicated that on 6/5/2025 Patient 1 continued to remain on 15-minute Close Observation Level II (patient was monitored every 15 minutes due to concerns about potential harm to self or others) and also had assault/aggression precautions in place (implemented due to the patient exhibiting, or being at risk of exhibiting, aggressive or violent behavior; includes increased supervision, environmental safety measures, and use of de-escalation techniques [methods used to reduce the intensity of a conflict or agitation in a person through calm, verbal, and non-verbal communication]). During a review of Patient 2’s History and Physical (H&P), dated 6/3/2025, The H&P indicated that Patient 2 was admitted to the Behavioral Health Unit (BHU) on 6/3/2025 for agitation and aggressive behavior. During a review of Patient 2’s Psychiatric Evaluation, dated 6/3/2025, the record indicated that Patient 2 was admitted on a 5150 Involuntary Hold. The record also indicated that the Hold was initiated due to danger to others after Patient 2 became “increasingly aggressive at the nursing home (a residential facility that provides 24-hour medical and personal care for individuals, who are unable to live independently due to illness, disability, or cognitive decline).” During a review of Patient 2’s “Nursing Progress Note,” dated 6/5/2025 at 3:43 p.m., the note indicated that Patient 2 was involved in an altercation with another patient (Patient 1) and stated that he (Patient 2) was defending himself after Patient 1 struck him in the face, specifically on the left cheek and/or jaw. During a review of Patient 2’s “Rounds Sheet, dated 6/5/2025, the sheet indicated that Patient 2 was documented as either lying or sitting in his “BR” (bedroom) for the entire time from 7:00 a.m. to 7:00 p.m. During a concurrent interview and record review on 9/30/2025 at 3:02 p.m. with the Chief Nursing Officer (CNO), Patient 1’s medical record titled, “Nursing Progress Notes,” dated 6/5/2025, was reviewed. The CNO stated that, according to the documentation, Patient 1 attempted to strike Patient 2, who was sitting at the door in the hallway. Patient 2 defended himself, stood up, and pushed Patient 1, who then fell backwards. The CNO confirmed that the fall was unwitnessed (as per nursing notes documentation), and that Rapid Response Team (RRT, a team of healthcare professionals, often including a critical care nurse and a respiratory therapist, who are quickly dispatched to provide immediate care to a patient who shows signs of acute deterioration within a hospital) was called at 2:20 p.m. on 6/5/2025 after Patient 1 was assessed to have weakness in the lower extremities (both legs), drooping (excessive sagging) on the left side of face, and left arm weakness. During a review of Patient 1’s “Nursing Progress Notes,” dated 6/5/2025 at 2:20 p.m., the note indicated the following: on 6/5/2025, Patient 1 was actually witnessed by an EVS (Environmental Services- trained cleaning support staff) worker who witnessed Patient 1 walking in the hallway, attempting to strike another patient (Patient 2). In response, Patient 2 pushed Patient 1, causing Patient 1 to fall backwards and sit down on the floor. A Rapid Response Team (RRT) was called, and Patient 1 was assessed to have bilateral (both) lower extremity weakness and was noted to be losing balance while standing. The note also stated that Patient 1 was transferred to a medical-surgical floor (a general hospital unit for adult patients who need care for a variety of illnesses and surgical recovery, but do not require intensive or highly specialized care) for further evaluation). During a review of Patient 1’s nursing note, dated 6/5/2025 at 2:20 p.m., the note indicated that Patient 1 sustained an unwitnessed fall (meaning the patient had experienced a fall that was not observed by staff or others, and the exact circumstances were unknown). During further review of Patient 1’s nursing notes documentation, dated 6/5/2025 at 2:35 p.m. (late entry), the note indicated that Patient 1 was status post (after) unwitnessed fall, and that Patient 1 began showing signs of facial drooping (sagging) on the left side, along with bilateral (both sides) leg tremors (involuntary, rhythmic shaking or trembling movements in the legs). During a review of Patient 1’s “Nursing Progress Note,” dated 6/5/2025 at 4:30 p.m., the note indicated that on 6/5/2025 at 4:00 p.m., Patient 1 was observed with increasing shaking of the left leg and bilateral lower extremities. The note also indicated that during the physician’s bedside assessment, Patient 1 was noted to have a bump on the right side of the head, with no bleeding. The note also indicated the following at 4;30 p.m. on 6/5/2025: the family was informed that, due to the fall, Patient 1 had possible fracture of the right hip ... and the physician recommended transferring Patient 1 to a higher level of care, as the patient continued to experience shaking and had a head injury with a possible subdural hematoma (a type of brain bleed that occurs when blood collects in the brain, often caused by head trauma and potentially life-threatening if not treated promptly). During an interview on 10/1/2025 at 1:31 p.m. with the House Supervisor (HS 1), HS 1 stated that typically the facility conducted daily audit for the completeness of Q 15-Minute rounding sheets (a clinical documentation tool used by healthcare staff to record patient observations at regular intervals [every 15 minutes], designed to monitor patient location, behavior, and safety status, and to ensure staff accountability and timely intervention when needed) to verify staff compliance with patient rounding. However, the HS 1 also said that the paper documentation for patient rounding was not reviewed concurrently with video footage to determine whether the documented patient rounding matched what was observed through the facility’s video surveillance cameras. During a concurrent interview and record review on 10/1/2025 at 2:06 p.m. with the Chief Nursing Officer (CNO), Patient 1’s “Patient Rounding Sheet, dated 6/5/2025 (covering the time from 7:00 a.m. to 4:30 p.m.), was reviewed. The rounding sheet indicated that Patient 1 was not agitated during this time frame (7 a.m. to 4;30 p.m.) and was consistently documented as either lying or sitting in their (Patient 1) bedroom. Specifically: -At 1:00 p.m., Patient 1 was documented as either lying or sitting -At 2:15 p.m., Patient 1 was again documented as either lying or sitting -This same documentation pattern continued through 2:45 p.m. -The Chief Nursing Officer (CNO) verified that this documentation was possibly inaccurate, noting that the Rapid Response Team was called at 2:20 p.m., and Patient 1 was found in the hallway by Patient 2’s room, yet no deviation or incident was reflected in the rounding sheet during that time. During further interview on 10/1/2025 at 3:37 p.m. with the Hospital Administrator (ADM), the ADM stated that the administration was no longer certain whether the entire incident (between Patient 1 and Patient 2) had been witnessed by the Environmental Service (EVS) worker. The ADM confirmed that nursing staff and mental health workers did not witness the altercation between the two patients (Patient 1 and Patient 2). The ADM also stated that he (ADM) could not verify whether staff were conducting Q15-minute patient rounding on that day (6/5/2025). The ADM said, “They (referring to the facility staff) should have done it (referring to the Q 15-minute rounding)- this is the expectation,” and noted that staff verbally confirmed they were conducting their rounds. However, the ADM also confirmed that the video footage, on 6/5/2025, was never reviewed to verify whether staff actions aligned with what was documented and reported on the day of the incident between Patient 1 and Patient 2. During a concurrent observation, interview and video footage review on 10/1/2025 at 11:00 a.m. with Nurse Manager (NM 1) of BHU and Medical-Surgical (Med/Surg), the video footage dated 9/19/2025, from 1:00 a.m. to 2:30 a.m., was reviewed. The following events were observed at the indicated timestamp in the video: 9/19/2025 at 1:00 a.m. -No staff seen conducting patient rounding in any of the video angles. 9/19/2025 at 1:15 a.m. -No staff seen conducting patient rounding, in any video of the angles. 9/19/2025 at 1:30 a.m. -No staff seen conducting patient rounding in any of the video angles 9/19/2025 at 1:45 a.m. -no staff seen doing rounding, one patient seen in wheelchair going down hallway with no staff present (camera angle 6) 9/19/2025 at 2:00 a.m. -two staff members seen rounding patient rooms 1, 2, 3 and 4 (camera angle 4) but not seen checking other rooms. Confirmed with NM1 that one was licensed staff (RN) and the other individual was the resource nurse. 9/19/2025 at 2:15 a.m. -two staff members sitting in chairs in BHU hallway on Camera angles 6 and 7. Not getting up to conduct rounding on patients. NM 1 was unable to identify the two staff members. 9/19/2025 at 2:30 a.m. -Same two staff members sitting in chairs in BHU hallway, not getting up to conduct rounding as seen in camera angles 6 and 7. NM 1 was unable to identify the two staff members During an interview on 10/1/2025 at 11:47 a.m. with NM 1, NM 1 stated the expectation was for staff to do Q 15-minute rounding to check on the patients, ensure safety and known location. Purpose of rounding was to know the location of the patients and make sure the patient was safe. “It allows us to notice any changes in behaviors, so that staff can address them accordingly.” NM 1 verified that rounding was only completed once for 4 rooms (rooms 1,2, 3, and 4) but not the whole unit within the 1.5 hour of video reviewed for Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 41, Patient 42, Patient 43, Patient 44. During a concurrent interview and record review on 10/1/2025 at 2:02 p.m. with NM 1, Patient 20’s “Patient Rounds Sheet” dated 9/18/2025, was reviewed. NM 1 stated that the rounding sheet began on 9/18/2025 at 7:00 a.m. and ended on 9/19/2025 at 6:45 a.m. NM 1 stated that all patient rounding sheets being reviewed started around the same time (7 a.m. to 6:45 a.m.), which captures the entire 24 hours. During an interview on 10/3/2025 at 3:44 p.m. with NM 1, NM 1 stated that, after reviewing the video footage and discussing the matter with the Chief Nursing Officer (CNO), it appeared that staff were documenting Q15-minute checks as completed, despite not actually performing them. NM 1 emphasized the importance of holding staff accountable and acknowledged that this practice falls under the category of falsification of records. During an interview on 9/30/2025 at 11:35 a.m. with the Charge Nurse (CN) 4, CN 4 stated that licensed nurses were required to conduct patient rounds every hour and document on the patient’s rounding sheet. CN 4 stated that licensed nurses could also help the MHW (Mental health Worker) with conducting Q15-minute rounding. During an interview on 10/1/2025 at 2:12 p.m. with the Chief Nursing Officer (CNO), the CNO confirmed that Q15 (every 15 minutes) patient safety checks should be conducted to: -Ensure patient safety, -Confirm responsiveness, -Assess patient behavior, -Document patient activity. During an interview on 10/1/2025 at 3:17 p.m. with the Chief Nursing Officer (CNO) and the Hospital Administrator (ADM), the CNO stated that the incident (involving Patients and 2) was investigated internally and that all key team members were interviewed, including the Environmental Services (EVS) worker who witnessed the altercation between Patient 1 and Patient 2 in the hallway. The ADM confirmed that, because of the EVS worker’s statement regarding the witnessed fall and the altercation between the two patients (Patient 1 and Patient 2), the facility had no reason to review the video footage to verify what happened during the incident. During an interview on 10/3/2025 at 3:34 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following regarding Q-15 Minutes rounding: “Q15-minute safety checks are conducted to monitor each patient’s condition and behavior at regular 15-minute intervals. The purpose is to identify any signs of agitation, frustration, or behaviors that may indicate a risk to the patient or others. These checks are preventive in nature and allow staff to intervene early and provide therapeutic support as needed. We use this time to assess whether patients are escalating and to respond in a way that promotes safety and de-escalation. While staff are expected to document these checks accurately, it’s also important to verify that the documentation aligns with actual observations, such as through video review when available.” During a review of Patient 20’s Psychiatric Evaluation (psych eval, a comprehensive mental health assessment, conducted by a psychologist or psychiatrist, that uses interviews, tests, and observations to understand a person’s emotional, behavioral, and cognitive state), dated 9/11/2025 and timed 17:56 (5:56 p.m.), the record indicated Patient 20 was admitted to the facility on a 5150 (72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) hold for grave disability (GD-unable to take care of oneself). During a review of Patient 20’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 20 was sleeping, and respirations were present. During a review of Patient 21’s Psychiatric Evaluation, dated 9/12/2025 and timed 1801 (6:01 p.m.), the record indicated Patient 21 was admitted to the facility on a 5150 hold for GD due to increasing paranoid delusions (false beliefs that persist despite evidence to the contrary and are characterized by suspicion, mistrust, and persecution), yelling and screaming. During a review of Patient 21’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 22 was sleeping and respirations were present. During a review of Patient 22’s Psychiatric Evaluation, dated 9/14/2025 at 1710 (5:10 p.m.), the record indicated Patient 22 was admitted to the facility on a 5150 hold for danger to self (DTS). During a review of Patient 22’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 22 was sleeping, and respirations were present. During a review of Patient 23’s Psychiatric Evaluation, dated 9/18/2025, the record indicated that Patient 23 was admitted to the facility and was placed on a 5150 hold for Danger to others (DTO). During a review of Patient 23’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 23 was sleeping, and respirations were present. During a review of Patient 24’s Psychiatric Evaluation, dated 9/18/20225, the record indicated that Patient 24 was admitted to the facility on 9/18/2025 and was placed on a 5150 hold for GD. During a review of Patient 24’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 24 was sleeping, and respirations were present. During a review of Patient 25’s Psychiatric Evaluation, dated 9/16/2025, the record indicated Patient 25 was admitted to the facility on 9/16/2025 and was placed on a 5150 hold for DTO. During a review of Patient 25’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 25 was sleeping, and respirations were present. During a review of Patient 26’s Psychiatric Evaluation, dated 9/13/2025, the record indicated that Patient 26 was admitted to the facility on 9/13/2025 and was placed on a 5150 hold for DTO. During a review of Patient 26’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 26 was sleeping, and respirations were present. During a review of Patient 27’s Psychiatric Evaluation, dated 9/12/2025, the record indicated that Patient 27 was admitted to the facility on 9/12/2025 and was placed on a 5150 hold due to DTO. During a review of Patient 27’s “Patient Rounds Sheet,” dated 9/18/2025,the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 27 was sleeping, and respirations were present. During a review of Patient 28’s Psychiatric Evaluation, dated 9/17/2025, the record indicated that Patient 28 was admitted to facility on a 5150 involuntary hold for DTS and GD. During a review of Patient 28’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 28 was sleeping, and respirations were present. During a review of Patient 29’s psychiatric Evaluation, dated 9/18/2025, the record indicated that Patient 29 was admitted to the facility on 9/18/2025 and placed on 5150 for DTO. During a review of Patient 29’s “Patient Rounds Sheet,” dated 9/18/2025,the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 29 was sleeping, and respirations were present. During a review of Patient 30’s Psychiatric Evaluation, dated 9/19/2025, the record indicated that Patient 30 was admitted to the facility on 9/18/2025 on a 5150 hold for DTO. During a review of Patient 30’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 30 was sleeping at 0100 (1:00 a.m.), and lying or sitting from 0130 (1:30 a.m.) to 0200 (2:00 a.m.) and respirations were present. During a review of Patient 31’s Psychiatric Evaluation, dated 9/15/2025 and timed at 2017 (8:17 p.m.), the record indicated that Patient 31 was admitted to the facility on a 5150 hold due to DTO and GD. During a review of Patient 31’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 31 was sleeping at 0115 (1:15 a.m.) to 0230 (2:30 a.m.), lying or sitting at 0100 (1:00 a.m.) and was walking or pacing at 0015 (1:15 a.m.) and respirations were present. During a review of Patient 32’s Psychiatric Evaluation, dated 9/14/2025 and timed at 2016 (8:16 p.m.), the record indicated Patient 32 was admitted to the facility on a 5150 due to DTO. During a review of Patient 32’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 32 was sleeping, and respirations were present. During a review of Patient 33’s Psychiatric Evaluation, dated 9/16/2025 and timed at 0626 (6:26 a.m.), the record indicated Patient 33 was admitted to the facility on a 5150 hold due to DTO and GD. During a review of Patient 33’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 33 was lying or sitting at 0100 (1:00 a.m.) and sleeping at 0115 (1:15 a.m.) to 0230 (2:30 a.m.) with respirations present. During a review of Patient 34’s Psychiatric Evaluation, dated 9/13/2025 and timed at 1806 (6:06 p.m.), the record indicated Patient 34 was admitted to the facility on 9/13/2025 and was placed on a 5150 due to DTS and DTO. During a review of Patient 34’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 34 was sleeping, and respirations were present. During a review of Patient 35’s Psychiatric Evaluation, dated 9/16/2025, the record indicated that Patient 35 was admitted to the facility on 9/13/2025 and placed on a 5150 due to DTS and GD. During a review of Patient 35’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 35 was sleeping, and respirations were present. During a review of Patient 36’s Psychiatric Evaluation, dated 9/18/2025 and timed at 1055 (10:55 a.m.), the record indicated that Patient 36 was admitted to the facility on 9/18/2025 on a 5150 hold due to GD. During a review of Patient 36’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 36 was lying or sitting at 0115 (1:15 a.m.) and sleeping at 0100 (1:00 a.m.), 0130 (1:30 a.m.), 0145 (1:45 a.m.), 0200 (2:00 a.m.), 0215 (2:15 a.m.), and 0230 (2:30 a.m.) and respirations were present. During a review of Patient 37’s Psychiatric Evaluation, dated 9/12/2025 and timed at 1935 (7:35 p.m.), the record indicated that Patient 37 was admitted to the facility on 9/12/2025 on a 5150 hold for DTO. During a review of Patient 37’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 37 was sleeping, and respirations were present. During a review of Patient 38’s Psychiatric Evaluation, dated 9/19/2025 and timed at 1331 (1:31 p.m.), the record indicated that Patient 38 was admitted to the facility on 9/19/2025 on a 5150 hold for DTO. During a review of Patient 38’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 38 was lying or sitting and respirations were present. During a review of Patient 39’s Psychiatric Evaluation, dated 9/18/2025 and timed at 1340 (1:40 p.m.), the record indicated that Patient 39 was admitted to the facility on 9/18/2025 and placed on a 5150 hold due to GD. During a review of Patient 39’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 39 was found sleeping, and respirations were present. During a review of Patient 40’s Psychiatric Evaluation, dated 9/16/2025 and timed at 0933 (9:33 a.m.), the record indicated that Patient 40 was admitted to the facility on 9/16/2025 on a 5150 involuntary hold for DTO and GD. During a review of Patient 40’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 40 was sleeping, and respirations were present. During a review of Patient 41’s Psychiatric Evaluation dated 9/12/2025, the psych eval indicated Patient 41 was admitted to the facility on 9/12/2025 with agitation (a state of restless excitement and emotional upset, characterized by a feeling of being “stirred up,” tense, confused, or irritable, often accompanied by physical actions like pacing or gesturing), mood lability (having rapid, intense, and unpredictable shifts in your emotions) and irritability (a feeling of being easily annoyed, frustrated, or angered, often by small or insignificant things. During a review of Patient 41’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 41 was sleeping, and respirations were present. During a review of Patient 42’s Psychiatric Evaluation, dated 9/14/2025, the record indicated Patient 42 was admitted to the facility on 9/14/2025 on a 5150 hold due to DTO. During a review of Patient 42’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 42 was sleeping, and respirations were present. During a review of Patient 43’s Psychiatric Evaluation, dated 9/19/2025 and timed at 1423 (2:43 p.m.), the record indicated that Patient 43 was admitted to the facility on 9/19/2025 on 5150 hold due to GD. During a review of Patient 43’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 43 was sleeping, and respirations were present. During a review of Patient 44’s Psychiatric Evaluation, dated 9/18/2025 and timed at 1544 (3:44 p.m.), the record indicated that Patient 44 was admitted to the facility on 9/18/2025 on 5150 hold due to DTO. During a review of Patient 44’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 44 was sleeping, and respirations were present. During a review of the facility’s policy and procedure (P&P) titled, “Every 15 Min (minute) Rounds, Patient,” last revised 3/2025, the P&P indicated the following: “It is the policy of [the facility] Behavioral Health Services to monitor the safety/locations of all patients on a continuing basis. Such rounds will be conducted at 15-minute intervals. Patients requiring additional observation will be evaluated individually, and physician orders will be generated to address the safety/needs of the patient ...Floor staff will conduct patient rounds at 15-minute intervals, including the location of the patient and his/her condition, and will verify completion of such rounds by their initial and signature. In order to accurately monitor safety and condition of patients at night and/or during non-wakeful times, staff will visually observe chest movement of the patient to ascertain respiratory effort.” During a review of the facility’s policy and procedure (P&P) titled, “Observation Levels System,” dated 3/2025, the P&P indicated, “It is the policy of [the facility] to initiate and provide the appropriate observation level of patient’s behaviors exhibited and also the information provided at the time of admission, and throughout hospitalization. All patients will be routinely observed in compliance with physician/psychologist orders and prescribed protocols. Purpose: to provide the most appropriate patient observation level is maintained throughout hospitalization. To provide patient safety at all times ... Types of Observation Level A. Level I: every 15-minute checks, routine observation. Minimal level of observation for all patients. Staff will observe patient and document on the Patient’s Observation Rounds Sheet Q15 minutes. Assigned staff will make direct contact with patients and confirm they are in no danger or distress .... Observation may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping. It is expected that the staff conducting the 15 minutes observation will enter the room, approach the patient and check their identify, respirations, and to ensure that they are not in any distress.” B. Level II: every 15 minutes checks, routine observations with precautions and taking note of precautions ordered as well ...staff will observe patient and document on the Patient’s Observation Rounds sheet every 15 minutes ...” 1.b. During a concurrent observation, interview and record review on 10/1/2025 at 12:40 p.m. with the Nurse Manager (NM) 2 of Behavioral Health Unit (BHU) and the Security Supervisor (SS)1, the facility’s security footage of Campus 2 BHU unit (Unit C), on 9/13/2025 from time period 1:20 a.m. to 4:58 a.m., was reviewed, the following events were observed: -At 1:20 a.m., a Mental Health Worker (MHW) 8 was seen sitting outside unit seclusion room (a secure, private room used to involuntarily confine an individual alone to de-escalate a situation or modify behavior). The video displayed two (2) patient rooms (Room A and Room B) and a seclusion room. -At 1:30 a.m., No staff seen rounding on patients -At 1:45 a.m., No staff seen rounding -At 2:00 a.m., No staff seen rounding -At 2:15 a.m., No staff seen rounding -At 2:23 a.m., a MHW went to the second room, left the room holding a blue blanket -At 2:30 a.m., No staff seen rounding -At 2:45 a.m., No staff seen rounding -At 3:00 a.m., No staff seen rounding -At 3:15 a.m., No staff seen rounding -At 3:30 a.m., No staff seen rounding. -At 3:45 a.m., MHW 8 got up and went to bathroom. No staff was seen to relieve MHW 8 while MHW 8 was away. -At 4:15 a.m., a male patient in green gown was seen pacing in the dayroom and no staff was seen monitoring the area. -At 4:58 a.m., a MHW went into a patient room (room A) and performed rounding. The MHW did not enter any other rooms. During the same interview on 10/1/2025 at 12:40 p.m. with NM 2, NM 2 stated the following: there was no staff performing the Q 15-minute rounding on all BHU patients (Patients 14, 15, 16, 45, 46, 47, 48 and 49) in Unit C for about 3.5 hours (from 1:20 a.m. to 4:58 a.m.). The Q 15-minute patient rounding was important for patient safety to ensure patients were safe and with no change of condition. NM 2 stated a lot could happen when patients were not checked as patients could try to do something to self or to someone else and could harm self or others. During a concurrent observation, interview, and record review on 10/1/2025 at 1:10 p.m. with the Nurse Manager (NM) 2 of Behavioral Health Unit (BHU) and the Security Supervisor (SS)1, the facility’s security footage of Campus 2 BHU unit (Unit S) on 9/19/2025, from time period of 1:00 a.m. to 2:15 a.m., was reviewed, the following events were observed: -At 1:30 a.m., a MHW was seen walking past the unit hallway at 1:30 a.m. but did not enter any patient rooms to check on patients. -At 2:00 a.m., three clinical staff was seen in the unit hallway but did not enter any patients’ rooms. -At 2:10 a.m., a clinical staff was seen walking past the unit hallway (not all the way) and did not enter any patient rooms. -At 2:15 a.m. No staff seen rounding During the same interview on 10/1/2025 at 1:10 p.m. with NM 2, NM 2 stated there was no Q 15-minute rounding performed on all patients (Patients 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, and 76) in Unit S, on 9/19/2025 from 1:00 a.m. to 2:15 a.m. (1 hour). The staff should be checking patients by going inside the patient rooms to ensure patient safety. During a concurrent interview and record review on 10/2/2025 at 9:06 a.m. with NM 2, the “Patient Rounds Sheet,” for Patient 14, Patient 16 and Patient 49, dated 9/12/2025, was reviewed. The “Patient Rounds Sheet,” indicated Q 15-min rounding were completed at 1:00 a.m. 1:15 a.m., 1:30 a.m., 1:45 a.m., 2:00 a.m., 2:15 a.m., 2:30 a.m., 2:45 a.m., 3:00 a.m., 3:15 a.m., 3:30 a.m., 3:45 a.m., 4:00 a.m., 4:15 a.m., 4:30 a.m., 4:45 a.m., with documentation of patients’ activity, respiration and location. NM 2 stated the documentation was inaccurate based on the security video footage observed (the video footage indicated staff were not entering each of the patient rooms to check on the patients). NM 2 stated it was a falsification of documentation and the nurses’ documentation was inaccurate. NM 2 stated the expectations for staff were to write and document what the staff did. NM 2 stated the facility relied on the integrity of the staff to ensure that all documentation was truthful and accurately reflected the care provided. During a concurrent interview and record review on 10/2/2025 at 9:15 am with NM 2, the “Patient Rounds Sheet,” for Patients 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67,68, 69, 70, 71, 72, 73, 74, 75, and 76, dated 9/18/2025, was reviewed. The “Patient round sheet,” indicated Q 15-minute rounding was completed at 1:00 a.m., 1:15 a.m., 1:30 a.m., 1:45 a.m., 2:00 a.m. and 2: 15 a.m. with documentation of patients’ activity, respiration and location. NM 2 stated the patient rounding documentation was completed and indicated the patient’s behavior, status, location and with initials by staff attesting to completing the rounding for all patients, however, the documentation did not align with what was seen in the security video footage reviewed on 10/1/2025. During a concurrent interview and record review on 10/2/2025 at 10:06 a.m. with NM 2, the “Patient Rounds Sheet,” for Patients 15, 45, 46, 47 and 48, dated 9/12/2025, was reviewed. The “Patient round sheet” indicated Q 15-min rounding was completed at 1:00 a.m., 1:15 a.m., 1:30 a.m., 1:45 a.m., 2:00 a.m., 2:15 a.m., 2:30 a.m., 2:45 a.m., 3:00 a.m., 3:15 a.m., 3:30 a.m., 3:45 a.m., 4:00 a.m., 4:15 a.m., 4:30 a.m., 4:45 a.m. with documentation of patient’s activity, respiration and location. NM 2 stated the patient round sheet indicated documentation was completed, but the documentation did not align with what was observed in the security footage video. During the same interview and record review on 10/2/2025 at 10:06 a.m. with NM 2, NM 2 stated that after reviewing patient rounding sheet, NM 2 had concerns regarding the accuracy and credibility of the staff’s documentation. NM 2 stated the nursing team performed chart audits to verify compliance with patient rounding but did not conduct video footage reviews to verify whether the observed events correspond with the information documented by the staff. During the same interview and record review on 10/2/2025 at 10:06 a.m. with NM 2, NM 2 stated it was the responsibility of non-licensed staff such as the Certified Nursing Assistant (CNA) and the Mental Health Worker (MHW) to ensure patient round was completed and documented in the patient round sheet. NM 2 stated licensed nurses such as Registered Nurse (RN) and License Vocational Nurse (LVN) responsibilities included overseeing the patient rounding and to ensure the patient round sheet was accurately completed. NM 2 stated all MHWs could perform the Q 15-minute rounding. During an interview on 10/3/2025 at 9:22 a.m. with NM 2, NM 2 said it was expected for the staff to follow the facility policy and conduct Q 15-minute patient rounding for patient safety. During the same interview on 10/3/2025 at 9:22 a.m. with NM 2, NM 2 stated it was unacceptable to falsify documentation by indicating that patient rounds were completed when, in fact, the staff did not enter the patient’s room. During an interview on 10/3/2025 at 9:37 a.m. with NM 2, NM 2 stated during patient rounding conducted every 15 minutes, staff were expected to assess the patient’s behavior, observe the environment of the patient’s room, and verify the patient’s respiration if the patient was in bed. For bedbound (being unable to leave a bed due to illness, injury, or physical limitations) patients, staff must determine whether repositioning was needed. For ambulatory (walking) patients, staff should confirm whether the patient was in bed, breathing comfortably, calm, pacing in the room, or exhibiting signs of agitation. NM2 said it was an expectation that staff enter the patient’s room during rounding to directly visualize and assess the patient. During a concurrent observation, interview and record review on 10/1/2025 at 12:40 p.m. with the Nurse Manager (NM) 2 of Behavioral Health Unit (BHU) and the Security Supervisor (SS)1, the facility’s security footage of Campus 2 BHU unit (Unit C), on 9/13/2025 from time period 1:20 a.m. to 4:58 a.m., was reviewed, the following events were observed: During a review of Patient 14’s “Psychiatric Initial Evaluation ( psych eval, comprehensive assessment mental health assessment, conducted by a psychologist or psychiatrist, that uses interviews, tests, and observation to understand a person’s emotional, behavioral, and cognitive state), dated 9/6/2025, the psych eval indicated, Patient 14 was admitted to the facility’s BHU on 9/5/2025 on a 5150-hold (72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) for suicidal (thoughts of taking one’s own life) and homicidal (thoughts of killing others) ideation with increased aggression (any intentional behavior aimed at causing harm or injury to another person) behavior with diagnosis including but not limited to schizoaffective (a mental health condition characterized by symptoms of schizophrenia[a disorder that affects a person’s ability to think, feel and behave clearly] such as hallucinations [seeing, hearing, smelling, tasting, or feeling something that is not real] or delusions [a fixed, false belief held despite clear evidence to the contrary]), bipolar (a mental health condition where you have extreme mood changes). During a review of Patient 15’s, “Psychiatric Evaluation,” dated 9/4/2025, the psych eval indicated, Patient 15 was admitted to the facility’s BHU on 9/4/2025 on a 5150-hold for danger to others (DTO, a person who poses a substantial likelihood of inflicting serious bodily harm on another person) for reported increased hallucinations and aggression behavior at home and with diagnosis of paranoid schizophrenia (a subtype of schizophrenia characterized by persistent [false beliefs] and hallucinations). During a review of Patient 16’s, “Psychiatric Evaluation,” dated 9/9/2025, the psych eval indicated, Patient 16 was admitted to the facility’s BHU on 9/8/2025 on 5150-hold for danger to self (DTS, behavior from mental disorder that poses risk of serious harm to oneself), responding to internal stimuli (changes or events that occur within an individual’s body or mind that trigger a response) and complaint of hearing voices with diagnosis of schizoaffective disorder and bipolar type. During a review of Patient 45’s,”Psychaitric Evaluation,” dated 9/5/2025, the psych eval indicated, Patient 45 was admitted to the facility’s BHU on 9/5/2025 for chief complaint of auditory hallucinations and on 5150 hold for DTS/DTO “hearing voices telling him (Patient 45) to cut himself with a knife and to hurt black people.” During a review of Patient 46’s, “Psychiatric Evaluation,” dated 8/22/2025, the psych eval indicated, Patient 46 was admitted to the facility’s BHU on 8/21/2025 on 5150 for danger to self, “endorsed suicidal thoughts for the 3 days with diagnosis including but not limited to major depressive disorder (MDD, a clinical depression causes a persistently low or depressed mood and a loss of interest in activities).” During a review of Patient 47’s, “Psychiatric Evaluation,” dated 9/9/2025, the psych eval indicated, Patient 47 was admitted to the facility’s BHU on 9/9/2025 on 5150 for danger to self, stopped taking medication, endorsing suicidal ideation with diagnosis including but not limited to bipolar disorder. During a review of Patient 48’s, “Psychiatric Evaluation,” dated 9/5/2025, the psych eval indicated, Patient 48 was admitted to the facility’s BHU on 9/4/2025 on 5150 due to being a danger to others, talking about killing religious leaders and with diagnosis including but not limited to bipolar disorder. During a review of Patient 49’s “Psychiatric Evaluation,” dated 9/8/2025, the psych eval indicated, Patient 49 was admitted to the facility’s BHU on 9/8/2025 on a 5150 for danger to others, “called 911 multiple times, stated would kill everyone at [Police] headquarters and blame black lives matter and with diagnosis paranoid schizophrenia.” During a review of Patient 50’s “Psychiatric Evaluation,” dated 9/16/2025, the psych eval indicated, Patient 50 was admitted to the facility’s BHU on 9/16/2025 on a 5150 for being gravely disabled (GD, unable to take care of themselves), experienced mania (a state of abnormally elevated mood, energy, and activity that lasts for an extended period), had not slept for four (4) days, “crying and laughing.” In addition, Patient 50’s, “face sheet, (front page of the chart that contains a summary of basic information about the patient),” the face sheet, indicated Patient 50’s admitting diagnosis was “bipolar.” During a review of Patient 51’s “Psychiatric Evaluation,” dated 9/082025, the psych eval indicated, Patient 51 was admitted to the facility’s BHU on 9/08/2025 on 5150 hold for DTS, for suicidal actions running into traffic and with diagnosis of schizoaffective and bipolar disorder. During a review of Patient 52’s “Psychiatric Evaluation,” dated 9/17/2025, the psych eval indicated, Patient 52 was admitted to the facility’s BHU on 9/16/2025 and placed on 5150 hold for being a danger to others and gravely disabled with diagnosis of schizoaffective bipolar disorder. During a review of Patient 54’s “Psychiatric Evaluation,” dated 9/13/2025, the psych eval indicated, Patient 50 was admitted to the facility’s BHU on 9/12/2025 on 5150 hold for DTS, with thoughts of people coming to kill her (Patient 54), paranoia (person believes that others are trying to harm or deceive them), and delusions with diagnosis of paranoid schizophrenia. During a review of Patient 55’s “Psychiatric Evaluation,” dated 9/5/2025, the psych eval indicated, Patient 55 was admitted to the facility’s BHU on 9/4/2025 on 5150 hold for DTS/DTO/GD, was observed by homeless healthcare staff choking another client and with diagnosis of schizophrenia. During a review of Patient 56’s “Psychiatric Evaluation,” dated 9/11/2025, the psych eval indicated, Patient 56 was admitted to the facility’s BHU on 9/11/2025 on 5150 hold for DTS, Patient 56 admitted taking 4 pills mixed with copious amount of alcohol, with diagnosis including but not limited to major depression. During a review of Patient 57’s “Psychiatric Evaluation,” dated 9/18/2025, the psych eval indicated, Patient 57 was admitted to the facility’s BHU on 9/17/2025 on 5150 hold for DTS, suicidal plans to overdose on pills and with diagnosis of schizoaffective, bipolar disorder. During a review of Patient 58’s “Psychiatric Evaluation,” dated 9/16/2025, the psych eval indicated, Patient 58 was admitted to the facility’s BHU on 9/15/2025 on 5150 hold for being gravely disabled, not sleeping, manic behavior (period of abnormally elevated mood and high energy) and with diagnosis of bipolar disorder manic (extremely elevated mood). During a review of Patient 59’s “Psychiatric Evaluation,” dated 9/11/2025, the psych eval indicated, Patient 59 was admitted to the facility’s BHU on 9/11/2025 on 5150 hold for danger to others and gravely disabled, Patient 59 believed mother (Patient 59’s mother) was abusing her (Patient 59) and with diagnosis including but not limited to bipolar disorder, depressive type. During a review of Patient 60’s “Psychiatric Evaluation,” dated 9/12/2025, the psych eval indicated, Patient 60 was admitted to the facility’s BHU on 9/11/2025 on 5150 hold for being gravely disabled, had paranoid behavior, delusional, making nonsensical statements, irritable, and uncooperative with diagnosis of paranoid schizophrenia with acute exacerbation (intensification of existing mental health issues). During a review of Patient 61’s “Psychiatric Evaluation,” dated 9/9/2025, the psych eval indicated, Patient 61 was admitted to the facility’s BHU on 9/9/2025 on 5150 hold for danger to others, had been experiencing severe anxiety (Feeling overwhelmed, tense, or on edge), hyperverbal (a term used to describe someone who speaks at a very fast pace and uses many words in a short amount of time, often interrupting others), loud, angry outburst, high risk for aggression with diagnosis of schizoaffective disorder, bipolar type. During a review of Patient 62’s “Psychiatric Evaluation,” dated 9/9/2025, the psych eval indicated, Patient 62 was admitted to the facility’s BHU on 9/8/2025 on 5150 hold for DTS/DTO/GD for homicidal threats to bomb Patient 62’s family’s home and self. Patient 62’s psych eval also indicated a diagnosis of schizoaffective and bipolar disorder. During a review of Patient 63’s “Psychiatric Evaluation,” dated 9/16/2025, the psych eval indicated, Patient 63 was admitted to the facility’s BHU on 9/16/2025 on 5150 hold for danger to others, was threatening to cut off a [department store] employee, threw a glass bottle at manager and threatening to kill staff. During a review of Patient 64’s “Psychiatric Evaluation,” dated 9/13/2025, the psych eval indicated, Patient 64 was admitted to the facility’s BHU on 9/12/2025 on 5150 hold for danger to self and with diagnosis of depression (a persistent feeling of sadness, hopelessness, and loss of interest in activities that were once enjoyable). During a review of Patient 65’s “Psychiatric Evaluation,” dated 9/13/2025, the psych eval indicated, Patient 65 was admitted to the facility’s BHU on 9/13/2025 on 5150 for danger to self. Patient 65 took seven (7) Xanax tablets (medication to treat anxiety disorders and panic disorder) in an attempt to commit suicide and with diagnosis including but not limited to major depressive disorder, suicidal ideation. During a review of Patient 66’s “Psychiatric Evaluation,” dated 9/17/2025, the psych eval indicated, Patient 66 was admitted to the facility’s BHU on 9/16/2025 on 5150 for DTS. Patient 66 had a chief complaint of being suicidal and with diagnosis of schizoaffective disorder, depressive type. During a review of Patient 67’s “Psychiatric Evaluation,” dated 9/18/2025, the psych eval indicated, Patient 67 was admitted to the facility’s BHU on 9/17/2025 on 5150 for danger to self and being gravely disabled, having worsening symptoms of paranoia causing a lot of stress for the past month and with diagnosis including but not limited to schizophrenia. During a review of Patient 68’s “Psychiatric Evaluation,” dated 9/16/2025, the psych eval indicated, Patient 68 was admitted to the facility’s BHU on 9/15/2025 on 5150 for DTS and suicide attempt and with diagnosis of bipolar type 1 (a mental health condition characterized by extreme shifts in mood, energy, and behavior between manic and depressive episodes) with acute mania. During a review of Patient 69’s “Psychiatric Evaluation,” dated 9/14/2025, the psych eval indicated, Patient 69 was admitted to the facility’s BHU on 9/13/2025 for chief complaint of psychosis and with diagnosis of bipolar disorder, schizophrenia. During a review of Patient 70’s “Face Sheet,” the face sheet indicated Patient 70 was admitted to the facility’s BHU on 9/17/2025 for chief complaint of psychosis with diagnosis of paranoid schizophrenia. During a review of Patient 70’s “Multidisciplinary master treatment plan,” dated 9/17/2025, the treatment plan indicated Patient 70’s legal status on admission was voluntary hold (when a person admits themselves to a psychiatric facility for treatment, meaning they are not being held against their will). During a review of Patient 72’s “Psychiatric Evaluation,” dated 9/14/2025, the psych eval indicated Patient 66 was admitted to the facility’s BHU on 9/14/2025 on 5150 for danger to self, admitted for suicidal ideation with plans to cut wrist with piece of glass and wanted to harm neighbor and with diagnosis of depression and schizophrenia. During a review of Patient 73’s “Psychiatric Evaluation,” dated 9/14/2025, the psych eval indicated, Patient 73 was admitted to the facility’s BHU on 9/14/2025 on 5150 for danger to others, making threats to harm others and with diagnosis of unspecified psychosis, rule out paranoid schizophrenia. During a review of Patient 74’s “Psychiatric Evaluation,” dated 9/15/2025, the psych eval indicated, Patient 74 was admitted to the facility’s BHU on 9/15/2025 on 5150 for DTO, increased aggression, homicidal ideations, and harmful threats towards staff at the facility and with diagnosis of schizoaffective, bipolar. During a review of Patient 75’s “Psychiatric Evaluation,” dated 9/11/2025, the psych eval indicated, Patient 75 was admitted to the facility’s BHU on 9/10/2025 on 5150 hold for danger to others, exhibited unprovoked episodes of agitation (a feeling of uneasiness and severe restlesness) and aggression toward staff, destroying facility property and with diagnosis of schizophrenia. During a review of Patient 76’s “Psychiatric Evaluation,” dated 9/10/2025, the psych eval indicated, Patient 76 was admitted to the facility’s BHU on 9/9/2025 on 5150 for DTO/GD for increased aggression risk to become assaultive towards others with diagnosis of schizoaffective, bipolar disorder. During a review of the facility’s policy and procedure (P&P) titled, “Every 15 Min (minute) Rounds, Patient,” last revised 3/2025, the P&P indicated the following: “It is the policy of [the facility] Behavioral Health Services to monitor the safety/locations of all patients on a continuing basis. Such rounds will be conducted at 15-minute intervals. Patients requiring additional observation will be evaluated individually, and physician orders will be generated to address the safety/needs of the patient ...Floor staff will conduct patient rounds at 15-minute intervals, including the location of the patient and his/her condition, and will verify completion of such rounds by their initial and signature. In order to accurately monitor safety and condition of patients at night and/or during non-wakeful times, staff will visually observe chest movement of the patient to ascertain respiratory effort.” During a review of the facility’s policy and procedure (P&P) titled, “Observation Levels System,” dated 3/2025, the P&P indicated, “It is the policy of [the facility] to initiate and provide the appropriate observation level of patient’s behaviors exhibited and also the information provided at the time of admission, and throughout hospitalization. All patients will be routinely observed in compliance with physician/psychologist orders and prescribed protocols. Purpose: to provide the most appropriate patient observation level is maintained throughout hospitalization. To provide patient safety at all times ... Types of Observation Level A. Level I: every 15-minute checks, routine observation. Minimal level of observation for all patients. Staff will observe patient and document on the Patient’s Observation Rounds Sheet Q15 minutes. Assigned staff will make direct contact with patients and confirm they are in no danger or distress .... Observation may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping. It is expected that the staff conducting the 15 minutes observation will enter the room, approach the patient and check their identify, respirations, and to ensure that they are not in any distress.” B. Level II: every 15 minutes checks, routine observations with precautions and taking note of precautions ordered as well ...staff will observe patient and document on the Patient’s Observation Rounds sheet every 15 minutes ...” 2. During a review of Patient 18’s Behavioral Health History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 9/6/2025 at 1445 (2:45 p.m.), the H&P indicated, Patient 18 was admitted to the facility’s Behavioral Health Unit (BHU- inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) on 5150 (involuntary hold/involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) hold for danger to self (DTS) stating he (Patient 18) wanted to run into traffic and a danger to others (DTO) for wanting to hurt people in Mexico. During a review of Patient 18’s “Nursing Progress Notes,” dated 9/6/2025 at 1808 (6:08 p.m.), the Nursing Progress Notes indicated Patient 18 reported to nurse (RN 1) he (Patient 18) swallowed a razor, Nurse Practitioner (NP 1) was notified, and order was given to monitor and send Patient 18 to the emergency department if with symptoms. During a review of Patient 18’s “Nursing Progress Notes,” dated 9/7/2025 at 1608 (4:08 p.m.), the Nursing Progress Notes indicated that Patient 18 stated, “you never did anything about the razor I swallowed yesterday (9/6/2025).” There was no record of a nurse notifying the physician regarding Patient 18’s statement made on 9/7/2025. During a review of Patient 18’s “Nursing Progress Notes,” dated 9/8/2025 at 7:46 a.m., the Nursing Progress Notes indicated Patient 18 stated he (Patient 18) swallowed a razor that he hid inside his “butt.” During a review of Patient 18’s “Nursing Progress Notes,” dated 9/8/2025 at 1828 (6:28 p.m.), the Nursing Progress Notes indicated Patient 18 stated he (Patient 18) was going to swallow a razor and also stated he swallowed a razor “send me to ER (emergency room/emergency department) now.” The Nursing Progress Notes also indicated Patient 18 was observed spitting out small amount of serosanguinous (pink or light red color) drainage from mouth. During an interview on 10/1/2025 at 10:48 a.m. with Registered Nurse 3 (RN 3), RN 3 stated that on 9/8/2025, Patient 18 went to the nursing station and reported he (Patient 18) swallowed something, “we (staff) were not sure if he (Patient 18) did, later he (Patient 18) started spitting out blood and we (staff) called the Nurse Practitioner (NP 2) and patient (Patient 18) was sent to the Emergency Department (ED) via facility van with a Mental Health Worker (MHW 6).” During an interview on 10/1/2025 at 10 :59 a.m. with Charge Nurse (CN 7), CN 7 stated “when there is a change in patient condition, we (licensed staff) assess the patient, call the doctor and the patient is either transferred via ambulance we (facility) contracts with or we (nurses) call 911.” The CN 7 further stated she (CN 7) would not use a facility van but would use an ambulance to transfer a patient to higher level of care. During an interview on 10/1/2025 at 11:10 a.m. with Mental Health Worker (MHW 6), MHW 6 stated he (MHW 6) was asked by Charge Nurse (CN 6) to accompany Patient 18 to another facility’s Emergency Department in the Facility’s hospital van. During an interview on 10/1/2025 at 11:42 a.m. with the House Supervisor (HS 4), HS 4 stated “when a patient needs a higher level of care then we call the doctor, then either call 911 or ambulance.” During an interview on 10/1/2025 at 12:24 p.m. with the Behavioral Health Unit Manager (NM 3), NM 3 stated that for a patient who reported they swallowed a razor, staff should have called 911 because “we (staff) do not know what is going on with patient internally.” The NM 3 further stated, the facility’s van does not have lifesaving equipment such as a crash cart (mobile cart with quick access to essential equipment, supplies for emergencies to sustain life, which can be utilized in case of an emergency while the patient is enroute to another facility). During an interview on 10/1/2025 at 3:13 p.m. with the House Supervisor (HS 3), HS 3 stated that she (HS 3) was not informed about Patient 18 spitting blood. If she (HS 3) had been informed, her decision to send Patient 18 via the facility’s van would have changed, and she would have called 911 or an ambulance instead. HS 3 also mentioned that she was unaware of the qualifications or requirements for the MHW to assist in emergency situations. During a review of Patient 18’s “Operative Report,” dated 9/9/2025, the Operative report indicated Patient 18 underwent Esophagogastroduodenoscopy (EGD-medical procedure that allows doctors to examine throat, stomach and small intestine) on 9/9/2025 with “a huge metallic foreign body ... very thick metal ... measured about 6 cm (centimeters, a unit of measurement) in length, 2 cm in width,” removed from the esophagus (canal that connect throat to stomach). During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for Provision of Care,” dated 2022, the P&P indicated, “[the facility] is committed to assuring a single standard of culturally competent care to patients. Patient Services at [the facility] are delivered through organized and systemic process designed to ensure the delivery of safe, effective, timely care and treatment. Patients have access to the appropriate level of care based on their individual condition and needs.” During a review of the facility’s policy and procedure (P&P) titled, “Higher level of care transfer of patient to another facility,” revised 3/2023, the P&P indicated, “If a patient has an emergency medical condition, (facility name) will provide the necessary stabilizing examination and treatment with its capabilities, if and when the hospital does not have the necessary capability to treat the patient, the hospital will make all required arrangement for transfer, including but not limited to: stabilizing, treating and monitoring the patient condition, performing any and all life saving measures that may be needed and are within our capabilities ...Clinical Situations based on. 3. Or any other clinical diagnosis requiring specialty services not offered at [the facility] will be stabilized and transferred expeditiously to high level of care receiving facility based on Emergency Medical Services.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 46238 Based on observation, interview and record review, the facility failed to ensure that 62 of 76 sampled patients’ (Patients 1, 2, 14, 15, 16, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75 and 76) Q15-minute safety checks/rounding (routine observations conducted every 15 minutes to monitor and document each patient’s condition and behavior, with the goal of identifying risks and intervening early to ensure patient safety), were accurately documented, in accordance with the facility’s policy on patient rounds and accurate chart completion when: 1. The documented completion of rounds by staff for Patients 1 and 2, did not accurately reflect the actual rounding activities conducted, in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) in Campus 1. This deficient practice had the potential to compromise the safety of Patient 1 and Patient 2 and may have contributed to harm sustained by Patient 1, who, during an attempt to strike Patient 2, fell backward, resulting in a hip fracture (break in the bone) and neurological deficit (an abnormality or impairment in the function of the nervous system when there is damage or disruption to the brain, spinal cord, nerves, or other components of the nervous system). Patient 1 was subsequently transferred to a higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]). 2.a. There was no proper documentation of the Q15-minute rounds conducted for 25 patients (Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 41, Patient 42, Patient 43, Patient 44) in the Behavioral Health Unit in Campus 1. The documentation did not match what was observed on video surveillance footage on 9/19/2025 from 1:00 a.m. to 2:30 a.m. This deficient practice had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, psychological trauma and/or death. 2.b. There was no proper documentation of the Q15-minute rounds conducted for 35 patients (Patients 14, 15, 16, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75 and 76) in the BHU in Campus 2. The documentation did not match what was observed on video surveillance footage on 9/13/2025 from time period 1:20 a.m. to 4:58 a.m., and on 9/19/2025 from time period of 1:00 a.m. to 2:15 a.m. This deficient practice had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, psychological trauma and/or death. Findings: 1. During a review of Patient 1’s History and Physical (H&P, a comprehensive clinical document that includes a patient’s medical history and findings from a physical examination), dated 6/4/2025, the H&P indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU) due to being “agitated (feeling of uneasiness and severe restlessness) and aggressive.” The H&P also indicated that Patient 1 was placed on assaultive (safety measures implemented for patients who exhibit or are at risk of exhibiting violent or aggressive behavior) and homicidal precautions (safety interventions used when a patient expresses or demonstrates thoughts, intentions, or behaviors indicating a risk of harming others). During a review of Patient 1’s “Behavioral Admission Assessment,” dated 6/4/2025, the record indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU) on a 5150 Hold (a legal provision under the State law, that allows for the involuntary detention of an individual for up to 72 hours when they are deemed a danger to themselves, others, or are gravely disabled due to a mental health disorder) for danger to others and being gravely disabled (GD, a condition in which a person, due to a mental health disorder, is unable to provide for their basic personal needs such as food, clothing, or shelter).” The record also indicated that Patient 1 required “line of sight observation,” meaning continuous visual monitoring by staff to ensure immediate intervention if needed, and Patient 1 was also placed on 15-minute Close Observation Level II, which involved staff checking on the patient every 15 minutes due to a history of threatening and/or assaultive behavior within the past 30 days. During a review of Patient 1’s “Behavioral Health Daily Nursing Assessment,” dated 6/5/2025, the record indicated that on 6/5/2025, Patient 1 continued to remain on 15-minute Close Observation Level II (patient was monitored every 15 minutes due to concerns about potential harm to self or others) and also had assault/aggression precautions in place (implemented due to the patient exhibiting, or being at risk of exhibiting, aggressive or violent behavior; includes increased supervision, environmental safety measures, and use of de-escalation techniques [methods used to reduce the intensity of a conflict or agitation in a person through calm, verbal, and non-verbal communication]). During a review of Patient 1’s “Nursing Progress Notes,” dated 6/5/2025 at 2:20 p.m., the note indicated the following: On 6/5/2025, Patient 2 pushed Patient 1, causing Patient 1 to fall backwards and sit down on the floor. A Rapid Response Team (RRT, a team of healthcare professionals, often including a critical care nurse and a respiratory therapist, who are quickly dispatched to provide immediate care to a patient who shows signs of acute deterioration within a hospital) was called, and Patient 1 was assessed to have bilateral (both) lower extremity weakness and was noted to be losing balance while standing. The note also stated that Patient 1 was transferred to a medical-surgical floor (a general hospital unit for adult patients who need care for a variety of illnesses and surgical recovery, but do not require intensive or highly specialized care) for further evaluation. During an interview on 10/1/2025 at 1:31 p.m. with the House Supervisor (HS 1), HS 1 stated that typically the facility conducted daily audit for the completeness of the Q15-minute rounding sheets (a clinical documentation tool used by healthcare staff to record patient observations at regular intervals [every 15 minutes], designed to monitor patient location, behavior, and safety status, and to ensure staff accountability and timely intervention when needed) to verify staff compliance with rounding. However, the HS 1 also said that the paper documentation for rounding was not reviewed concurrently with video footage to determine whether the documented rounding matched what was observed through the facility’s video surveillance cameras. During a concurrent interview and record review on 10/1/2025 at 2:06 p.m. with the Chief Nursing Officer (CNO), Patient 1’s “Patient Rounding Sheet, dated 6/5/2025 (covering the time from 7:00 a.m. to 4:30 p.m.), was reviewed. The documentation indicated that Patient 1 was not recorded to be agitated during this time frame (dated 6/5/2025, covering the time from 7:00 a.m. to 4:30 p.m.) and was consistently documented as either lying or sitting in their (Patient 1) bedroom. Specifically: -At 1:00 p.m., Patient 1 was documented as either lying or sitting -At 2:15 p.m., Patient 1 was again documented as either lying or sitting -This same documentation pattern continued through 2:45 p.m. -The Chief Nursing Officer (CNO) verified that this documentation was possibly inaccurate, noting that the Rapid Response Team was called at 2:20 p.m. and Patient 1 was documented to be obtaining computed tomography (CT) scan (a medical imaging procedure that uses X-rays to create detailed cross-sectional images of the body) at 1:00 p.m. (while also documented to be in the room sitting or lying])and Patient 1 was also found in the hallway by Patient 2’s room (between 2:00 to 2:20 p.m.), yet no deviation or incident was reflected in the rounding sheet dated 6/5/2025 during that time. During an interview on 10/1/2025 at 2:12 p.m. with the Chief Nursing Officer (CNO), the CNO also confirmed that Q15 (every 15 minutes) patient safety checks should be conducted to: -Ensure patient safety, -Confirm responsiveness, -Assess patient behavior, -Document patient activity. During further interview on 10/1/2025 at 3:37 p.m. with the Hospital Administrator (ADM), the ADM confirmed that nursing staff and mental health workers did not witness the altercation between the two patients (Patient 1 and Patient 2). The ADM also stated that he (ADM) could not verify whether staff were conducting Q15-minute checks on that day (6/5/2025). The ADM said, “They should have done it (referring to accurate patient rounding every 15 minutes) - this is the expectation,” and noted that staff verbally confirmed they were conducting their rounds. However, the ADM also confirmed that the video footage pertaining to patient rounding on 6/5/2025, was never reviewed to verify whether staff actions aligned with what was documented and reported on the day of the incident between Patient 1 and Patient 2. During an interview on 10/3/2025, at 3:34 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following regarding Q-15 Minutes rounding: “Q15-minute safety checks are conducted to monitor each patient’s condition and behavior at regular 15-minute intervals. The purpose is to identify any signs of agitation, frustration, or behaviors that may indicate a risk to the patient or others. These checks are preventive in nature and allow staff to intervene early and provide therapeutic support as needed. We use this time to assess whether patients are escalating and to respond in a way that promotes safety and de-escalation. While staff are expected to document these checks accurately, it’s also important to verify that the documentation aligns with actual observations, such as through video review when available.” During a review of Patient 2’s Psychiatric Evaluation, dated 6/3/2025, the record indicated that Patient 2 was admitted on a 5150 Involuntary Hold. The record also indicated that the Hold was initiated due to danger to others after Patient 2 became “increasingly aggressive at the nursing home (a residential facility that provides 24-hour medical and personal care for individuals, who are unable to live independently due to illness, disability, or cognitive decline). During a review of Patient 2’s “Nursing Progress Note,” dated 6/5/2025 at 3:43 p.m., the note indicated that Patient 2 was involved in an altercation with another patient (Patient 1) and stated that he (Patient 2) was defending himself after Patient 1 struck him in the face, specifically on the left cheek and/or jaw. During a review of Patient 2’s “Rounds Sheet, dated 6/5/2025, the sheet indicated that Patient 2 was documented as either lying or sitting in his “BR” (bedroom) for the entire time from 7:00 a.m. to 7:00 p.m. During an interview on 10/3/2025 at 3:44 p.m. with the Manager of the Medical-Surgical and Behavioral Units (NM 1), NM 1 stated that, after reviewing the video footage on other dates of patient rounding and discussing the matter with the Chief Nursing Officer (CNO), it appeared that staff were documenting Q15-minute checks as completed, despite not actually performing them. NM 1 emphasized the importance of holding staff accountable and acknowledged that this practice falls under the category of falsification of records. During a review of the facility’s policy and procedure (P&P) titled, Chart Completion,” last revised 9/2025, the P&P indicated the following: “To ensure that the medical records at (Facility) fully and accurately reflect a patient’s care and are completed in accordance with federal and state law, the facility requires that types of treatment records shall be included in the medical record and are to be counted for the reporting purposes of the applicable accrediting agency...” During a review of the facility’s policy and procedure (P&P) titled, “Every 15 Min Rounds, Patient,” last revised 3/2025, the P&P indicated the following: “It is the policy of [the facility] Behavioral Health Services to monitor the safety/locations of all patients on a continuing basis. Such rounds will be conducted at 15-minute intervals. Patients requiring additional observation will be evaluated individually, and physician orders will be generated to address the safety/needs of the patient ...Floor staff will conduct patient rounds at 15-minute intervals, including the location of the patient and his/her condition, and will verify completion of such rounds by their initial and signature. In order to accurately monitor safety and condition of patients at night and/or during non-wakeful times, staff will visually observe chest movement of the patient to ascertain respiratory effort.” During a review of the facility’s policy and procedure (P&P) titled, “Observation Levels System,” dated 3/2025, the P&P indicated, “It is the policy of [the facility] to initiate and provide the appropriate observation level of patient’s behaviors exhibited and also the information provided at the time of admission, and throughout hospitalization. All patients will be routinely observed in compliance with physician/psychologist orders and prescribed protocols. Purpose: to provide the most appropriate patient observation level is maintained throughout hospitalization. To provide patient safety at all times ... Types of Observation Level A. Level I: every 15-minute checks, routine observation. Minimal level of observation for all patients. Staff will observe patient and document on the Patient’s Observation Rounds Sheet Q15 minutes. Assigned staff will make direct contact with patients and confirm they are in no danger or distress .... Observation may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping. It is expected that the staff conducting the 15 minutes observation will enter the room, approach the patient and check their identify, respirations, and to ensure that they are not in any distress.” B. Level II: every 15 minutes checks, routine observations with precautions and taking note of precautions ordered as well ...staff will observe patient and document on the Patient’s Observation Rounds sheet every 15 minutes ...” 2.a. During a review of Patient 20’s Psychiatric Evaluation (psych eval, a comprehensive mental health assessment, conducted by a psychologist or psychiatrist, that uses interviews, tests, and observations to understand a person’s emotional, behavioral, and cognitive state), dated 9/11/2025 and timed 17:56 (5:56 p.m.), the record indicated Patient 20 was admitted to the facility on a 5150 (72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) hold for grave disability (GD-unable to take care of oneself). During a review of Patient 20’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 20 was sleeping, and respirations were present. During a review of Patient 21’s Psychiatric Evaluation, dated 9/12/2025 and timed 1801 (6:01 p.m.), the record indicated Patient 21 was admitted to the facility on a 5150 hold for GD due to increasing paranoid delusions (false beliefs that persist despite evidence to the contrary and are characterized by suspicion, mistrust, and persecution), yelling and screaming. During a review of Patient 21’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 22 was sleeping and respirations were present. During a review of Patient 22’s Psychiatric Evaluation, dated 9/14/2025 at 1710 (5:10 p.m.), the record indicated Patient 22 was admitted to the facility on a 5150 hold for danger to self (DTS). During a review of Patient 22’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 22 was sleeping, and respirations were present. During a review of Patient 23’s Psychiatric Evaluation, dated 9/18/2025, the record indicated that Patient 23 was admitted to the facility and was placed on a 5150 hold for Danger to others (DTO). During a review of Patient 23’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 23 was sleeping, and respirations were present. During a review of Patient 24’s Psychiatric Evaluation, dated 9/18/20225, the record indicated that Patient 24 was admitted to the facility on 9/18/2025 and was placed on a 5150 hold for GD. During a review of Patient 24’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 24 was sleeping, and respirations were present. During a review of Patient 25’s Psychiatric Evaluation, dated 9/16/2025, the record indicated Patient 25 was admitted to the facility on 9/16/2025 and was placed on a 5150 hold for DTO. During a review of Patient 25’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 25 was sleeping, and respirations were present. During a review of Patient 26’s Psychiatric Evaluation, dated 9/13/2025, the record indicated that Patient 26 was admitted to the facility on 9/13/2025 and was placed on a 5150 hold for DTO. During a review of Patient 26’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 26 was sleeping, and respirations were present. During a review of Patient 27’s Psychiatric Evaluation, dated 9/12/2025, the record indicated that Patient 27 was admitted to the facility on 9/12/2025 and was placed on a 5150 hold due to DTO. During a review of Patient 27’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 27 was sleeping, and respirations were present. During a review of Patient 28’s Psychiatric Evaluation, dated 9/17/2025, the record indicated that Patient 28 was admitted to facility on a 5150 involuntary hold for DTS and GD. During a review of Patient 28’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 28 was sleeping, and respirations were present. During a review of Patient 29’s psychiatric Evaluation, dated 9/18/2025, the record indicated that Patient 29 was admitted to the facility on 9/18/2025 and placed on 5150 for DTO. During a review of Patient 29’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 29 was sleeping, and respirations were present. During a review of Patient 30’s Psychiatric Evaluation, dated 9/19/2025, the record indicated that Patient 30 was admitted to the facility on 9/18/2025 on a 5150 hold for DTO. During a review of Patient 30’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 30 was sleeping at 0100 (1:00 a.m.), and lying or sitting from 0130 (1:30 a.m.) to 0200 (2:00 a.m.) and respirations were present. During a review of Patient 31’s Psychiatric Evaluation, dated 9/15/2025 and timed at 2017 (8:17 p.m.), the record indicated that Patient 31 was admitted to the facility on a 5150 hold due to DTO and GD. During a review of Patient 31’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 31 was sleeping at 0115 (1:15 a.m.) to 0230 (2:30 a.m.), lying or sitting at 0100 (1:00 a.m.) and was walking or pacing at 0015 (1:15 a.m.) and respirations were present. During a review of Patient 32’s Psychiatric Evaluation, dated 9/14/2025 and timed at 2016 (8:16 p.m.), the record indicated Patient 32 was admitted to the facility on a 5150 due to DTO. During a review of Patient 32’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 32 was sleeping, and respirations were present. During a review of Patient 33’s Psychiatric Evaluation, dated 9/16/2025 and timed at 0626 (6:26 a.m.), the record indicated Patient 33 was admitted to the facility on a 5150 hold due to DTO and GD. During a review of Patient 33’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 33 was lying or sitting at 0100 (1:00 a.m.) and sleeping at 0115 (1:15 a.m.) to 0230 (2:30 a.m.) with respirations present. During a review of Patient 34’s Psychiatric Evaluation, dated 9/13/2025 and timed at 1806 (6:06 p.m.), the record indicated Patient 34 was admitted to the facility on 9/13/2025 and was placed on a 5150 due to DTS and DTO. During a review of Patient 34’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 34 was sleeping, and respirations were present. During a review of Patient 35’s Psychiatric Evaluation, dated 9/16/2025, the record indicated that Patient 35 was admitted to the facility on 9/13/2025 and placed on a 5150 due to DTS and GD. During a review of Patient 35’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 35 was sleeping, and respirations were present. During a review of Patient 36’s Psychiatric Evaluation, dated 9/18/2025 and timed at 1055 (10:55 a.m.), the record indicated that Patient 36 was admitted to the facility on 9/18/2025 on a 5150 hold due to GD. During a review of Patient 36’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 36 was lying or sitting at 0115 (1:15 a.m.) and sleeping at 0100 (1:00 a.m.), 0130 (1:30 a.m.), 0145 (1:45 a.m.), 0200 (2:00 a.m.), 0215 (2:15 a.m.), and 0230 (2:30 a.m.) and respirations were present. During a review of Patient 37’s Psychiatric Evaluation, dated 9/12/2025 and timed at 1935 (7:35 p.m.), the record indicated that Patient 37 was admitted to the facility on 9/12/2025 on a 5150 hold for DTO. During a review of Patient 37’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 37 was sleeping, and respirations were present. During a review of Patient 38’s Psychiatric Evaluation, dated 9/19/2025 and timed at 1331 (1:31 p.m.), the record indicated that Patient 38 was admitted to the facility on 9/19/2025 on a 5150 hold for DTO. During a review of Patient 38’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 38 was lying or sitting and respirations were present. During a review of Patient 39’s Psychiatric Evaluation, dated 9/18/2025 and timed at 1340 (1:40 p.m.), the record indicated that Patient 39 was admitted to the facility on 9/18/2025 and placed on a 5150 hold due to GD. During a review of Patient 39’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 39 was found sleeping, and respirations were present. During a review of Patient 40’s Psychiatric Evaluation, dated 9/16/2025 and timed at 0933 (9:33 a.m.), the record indicated that Patient 40 was admitted to the facility on 9/16/2025 on a 5150 involuntary hold for DTO and GD. During a review of Patient 40’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 40 was sleeping, and respirations were present. During a review of Patient 41’s Psychiatric Evaluation dated 9/12/2025, the psych eval indicated Patient 41 was admitted to the facility on 9/12/2025 with agitation (a state of restless excitement and emotional upset, characterized by a feeling of being “stirred up,” tense, confused, or irritable, often accompanied by physical actions like pacing or gesturing), mood lability (having rapid, intense, and unpredictable shifts in your emotions) and irritability (a feeling of being easily annoyed, frustrated, or angered, often by small or insignificant things. During a review of Patient 41’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 41 was sleeping, and respirations were present. During a review of Patient 42’s Psychiatric Evaluation, dated 9/14/2025, the record indicated Patient 42 was admitted to the facility on 9/14/2025 on a 5150 hold due to DTO. During a review of Patient 42’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 42 was sleeping, and respirations were present. During a review of Patient 43’s Psychiatric Evaluation, dated 9/19/2025 and timed at 1423 (2:43 p.m.), the record indicated that Patient 43 was admitted to the facility on 9/19/2025 on 5150 hold due to GD. During a review of Patient 43’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 43 was sleeping, and respirations were present. During a review of Patient 44’s Psychiatric Evaluation, dated 9/18/2025 and timed at 1544 (3:44 p.m.), the record indicated that Patient 44 was admitted to the facility on 9/18/2025 on 5150 hold due to DTO. During a review of Patient 44’s “Patient Rounds Sheet,” dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 44 was sleeping, and respirations were present. During an interview on 9/30/2025 at 11:35 a.m. with the Charge Nurse (CN) 4, CN 4 stated that licensed nurses were required to conduct patient rounds every hour and document on the patient’s rounding sheet. CN 4 stated that licensed nurses could also help the MHW (Mental health Worker) with conducting Q15-minute rounding. During a concurrent observation, interview and video footage review on 10/1/2025 at 11:00 a.m. with Nurse Manager (NM 1) of BHU and Medical-Surgical (Med/Surg), the video footage dated 9/19/2025, from 1:00 a.m. to 2:30 a.m., was reviewed. The following events were observed at the indicated timestamp in the video: 9/19/2025 at 1:00 a.m. -No staff seen conducting patient rounding in any of the video angles. 9/19/2025 at 1:15 a.m. -No staff seen conducting patient rounding, in any video of the angles. 9/19/2025 at 1:30 a.m. -No staff seen conducting patient rounding in any of the video angles 9/19/2025 at 1:45 a.m. -no staff seen doing rounding, one patient seen in wheelchair going down hallway with no staff present (camera angle 6) 9/19/2025 at 2:00 a.m. -two staff members seen rounding patient rooms 1, 2, 3 and 4 (camera angle 4) but not seen checking other rooms. Confirmed with NM1 that one was licensed staff (RN) and the other individual was the resource nurse. 9/19/2025 at 2:15 a.m. -two staff members sitting in chairs in BHU hallway on Camera angles 6 and 7. Not getting up to conduct rounding on patients. NM 1 was unable to identify the two staff members. 9/19/2025 at 2:30 a.m. -Same two staff members sitting in chairs in BHU hallway, not getting up to conduct rounding as seen in camera angles 6 and 7. NM 1 was unable to identify the two staff members During an interview on 10/1/2025 at 11:47 a.m. with NM 1, NM 1 stated the expectation was for staff to do Q 15-minute rounding to check on the patients, ensure safety and known location. Purpose of rounding was to know the location of the patients and make sure the patient was safe. “It allows us to notice any changes in behaviors, so that staff can address them accordingly.” NM 1 verified that rounding was only completed once for 4 rooms (rooms 1, 2, 3, and 4) but not the whole unit within the 1.5 hour of video reviewed for Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 41, Patient 42, Patient 43, Patient 44. During a concurrent interview and record review on 10/1/2025 at 2:02 p.m. with NM 1, Patient 20’s “Patient Rounds Sheet” dated 9/18/2025, was reviewed. NM 1 stated that the rounding sheet began on 9/18/2025 at 7:00 a.m. and ended on 9/19/2025 at 6:45 a.m. NM 1 stated that all patient rounding sheets being reviewed started around the same time (7 a.m. to 6:45 a.m.), which captures the entire 24 hours. During an interview on 10/3/2025 at 3:44 p.m. with NM 1, NM 1 stated that, after reviewing the video footage and discussing the matter with the Chief Nursing Officer (CNO), it appeared that staff were documenting Q15-minute checks as completed, despite not actually performing them. NM 1 emphasized the importance of holding staff accountable and acknowledged that this practice falls under the category of falsification of records. During a review of the facility’s policy and procedure (P&P) titled, Chart Completion,” last revised 9/2025, the P&P indicated the following: “To ensure that the medical records at [Name of Facility] fully and accurately reflect a patient’s care and are completed in accordance with federal and state law, the facility requires that types of treatment records shall be included in the medical record and are to be counted for the reporting purposes of the applicable accrediting agency...” During a review of the facility’s policy and procedure (P&P) titled, “Every 15 Min (Minute) Rounds, Patient,” last revised 3/2025, the P&P indicated the following: “It is the policy of [the facility] Behavioral Health Services to monitor the safety/locations of all patients on a continuing basis. Such rounds will be conducted at 15-minute intervals. Patients requiring additional observation will be evaluated individually, and physician orders will be generated to address the safety/needs of the patient ...Floor staff will conduct patient rounds at 15-minute intervals, including the location of the patient and his/her condition, and will verify completion of such rounds by their initial and signature. In order to accurately monitor safety and condition of patients at night and/or during non-wakeful times, staff will visually observe chest movement of the patient to ascertain respiratory effort.” During a review of the facility’s policy and procedure (P&P) titled, “Observation Levels System,” dated 3/2025, the P&P indicated, “It is the policy of [the facility] to initiate and provide the appropriate observation level of patient’s behaviors exhibited and also the information provided at the time of admission, and throughout hospitalization. All patients will be routinely observed in compliance with physician/psychologist orders and prescribed protocols. Purpose: to provide the most appropriate patient observation level is maintained throughout hospitalization. To provide patient safety at all times ... Types of Observation Level A. Level I: every 15-minute checks, routine observation. Minimal level of observation for all patients. Staff will observe patient and document on the Patient’s Observation Rounds Sheet Q15 minutes. Assigned staff will make direct contact with patients and confirm they are in no danger or distress .... Observation may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping. It is expected that the staff conducting the 15 minutes observation will enter the room, approach the patient and check their identify, respirations, and to ensure that they are not in any distress.” B. Level II: every 15 minutes checks, routine observations with precautions and taking note of precautions ordered as well ...staff will observe patient and document on the Patient’s Observation Rounds sheet every 15 minutes ...” 2.b. During a concurrent observation, interview and record review on 10/1/2025 at 12:40 p.m. with the Nurse Manager (NM) 2 of Behavioral Health Unit (BHU) and the Security Supervisor (SS)1, the facility’s security footage of Campus 2 BHU unit (Unit C), on 9/13/2025 from time period 1:20 a.m. to 4:58 a.m., was reviewed, the following events were observed: -At 1:20 a.m., a Mental Health Worker (MHW) 8 was seen sitting outside unit seclusion room (a secure, private room used to involuntarily confine an individual alone to de-escalate a situation or modify behavior). The video displayed two (2) patient rooms (Room A and Room B) and a seclusion room. -At 1:30 a.m., No staff seen rounding on patients -At 1:45 a.m., No staff seen rounding -At 2:00 a.m., No staff seen rounding -At 2:15 a.m., No staff seen rounding -At 2:23 a.m., a MHW went to the second room, left the room holding a blue blanket -At 2:30 a.m., No staff seen rounding -At 2:45 a.m., No staff seen rounding -At 3:00 a.m., No staff seen rounding -At 3:15 a.m., No staff seen rounding -At 3:30 a.m., No staff seen rounding. -At 3:45 a.m., MHW 8 got up and went to bathroom. No staff was seen to relieve MHW 8 while MHW 8 was away. -At 4:15 a.m., a male patient in green gown was seen pacing in the dayroom and no staff was seen monitoring the area. -At 4:58 a.m., a MHW went into a patient room (room A) and performed rounding. The MHW did not enter any other rooms. During the same interview on 10/1/2025 at 12:40 p.m. with NM 2, NM 2 stated the following: there was no staff performing the Q 15-minute rounding on all BHU patients (Patients 14, 15, 16, 45, 46, 47, 48 and 49) in Unit C for about 3.5 hours (from 1:20 a.m. to 4:58 a.m.). The Q 15-minute patient rounding was important for patient safety to ensure patients were safe and with no change of condition. NM 2 stated a lot could happen when patients were not checked as patients could try to do something to self or to someone else and could harm self or others. During a concurrent observation, interview, and record review on 10/1/2025 at 1:10 p.m. with the Nurse Manager (NM) 2 of Behavioral Health Unit (BHU) and the Security Supervisor (SS)1, the facility’s security footage of Campus 2 BHU unit (Unit S) on 9/19/2025, from time period of 1:00 a.m. to 2:15 a.m., was reviewed, the following events were observed: -At 1:30 a.m., a MHW was seen walking past the unit hallway at 1:30 a.m. but did not enter any patient rooms to check on patients. -At 2:00 a.m., three clinical staff were seen in the unit hallway but did not enter any patients rooms. -At 2:10 a.m., a clinical staff was seen walking past the unit hallway (not all the way) and did not enter any patient rooms. -At 2:15 a.m. No staff seen rounding During the same interview on 10/1/2025 at 1:10 p.m. with NM 2, NM 2 stated there was no Q 15-minute rounding performed on all patients (Patients 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, and 76) in Unit S, on 9/19/2025 from 1:00 a.m. to 2:15 a.m. (1 hour). The staff should be checking patients by going inside the patient rooms to ensure patient safety. During a concurrent interview and record review on 10/2/2025 at 9:06 a.m. with NM 2, the “Patient Rounds Sheet,” for Patient 14, Patient 16 and Patient 49, dated 9/12/2025, was reviewed. The “Patient Rounds Sheet,” indicated Q 15-min rounding were completed at 1:00 a.m. 1:15 a.m., 1:30 a.m., 1:45 a.m., 2:00 a.m., 2:15 a.m., 2:30 a.m., 2:45 a.m., 3:00 a.m., 3:15 a.m., 3:30 a.m., 3:45 a.m., 4:00 a.m., 4:15 a.m., 4:30 a.m., 4:45 a.m., with documentation of patients’ activity, respiration and location. NM 2 stated the documentation were inaccurate based on the security video footage observed (the video footage indicated staff were not entering each of the patient rooms to check on the patients). NM 2 stated it was a falsification of documentation and the nurses’ documentation were inaccurate. NM 2 stated the expectations for staff was to write and document what the staff did. NM 2 stated the facility relied on the integrity of the staff to ensure that all documentation was truthful and accurately reflected the care provided. During a concurrent interview and record review on 10/2/2025 at 9:15 am with NM 2, the “Patient Rounds Sheet,” for Patients 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67,68, 69, 70, 71, 72, 73, 74, 75, and 76, dated 9/18/2025, was reviewed. The “Patient round sheet,” indicated Q 15-minute rounding was completed at 1:00 a.m., 1:15 a.m., 1:30 a.m., 1:45 a.m., 2:00 a.m. and 2: 15 a.m. with documentation of patients’ activity, respiration and location. NM 2 stated the patient rounding documentation was completed and indicated the patient’s behavior, status, location and with initials by staff attesting to completing the rounding for all patients, however, the documentation did not align with what was seen in the security video footage reviewed on 10/1/2025. During a concurrent interview and record review on 10/2/2025 at 10:06 a.m. with NM 2, the “Patient Rounds Sheet,” for Patients 15, 45, 46, 47 and 48, dated 9/12/2025, was reviewed. The “Patient round sheet” indicated Q 15-min rounding was completed at 1:00 a.m., 1:15 a.m., 1:30 a.m., 1:45 a.m., 2:00 a.m., 2:15 a.m., 2:30 a.m., 2:45 a.m., 3:00 a.m., 3:15 a.m., 3:30 a.m., 3:45 a.m., 4:00 a.m., 4:15 a.m., 4:30 a.m., 4:45 a.m. with documentation of patient’s activity, respiration and location. NM 2 stated the patient round sheet indicated documentation was completed, but the documentation did not align with what was observed in the security footage video. During the same interview and record review on 10/2/2025 at 10:06 a.m. with NM 2, NM 2 stated that after reviewing the patient rounding sheet, NM 2 had concerns regarding the accuracy and credibility of the staff’s documentation. NM 2 stated the nursing team performed chart audits to verify compliance with patient rounding but did not conduct video footage reviews to verify whether the observed events correspond with the information documented by the staff. During the same interview and record review on 10/2/2025 at 10:06 a.m. with NM 2, NM 2 stated it was the responsibility of non-licensed staff such as the Certified Nursing Assistant (CNA) and the Mental Health Worker (MHW) to ensure patient round was completed and documented in the patient round sheet. NM 2 stated licensed nurses such as Registered Nurse (RN) and License Vocational Nurse (LVN) responsibilities included overseeing the patient rounding and to ensure the patient round sheet was accurately completed. NM 2 stated all MHWs could perform the Q 15-minute rounding. During an interview on 10/3/2025 at 9:22 a.m. with NM 2, NM 2 said it was expected for the staff to follow the facility policy and conduct Q 15-minute patient rounding for patient safety. During the same interview on 10/3/2025 at 9:22 a.m. with NM 2, NM 2 stated it was unacceptable to falsify documentation by indicating that patient rounds were completed when, in fact, the staff did not enter the patient’s room. During an interview on 10/3/2025 at 9:37 a.m. with NM 2, NM 2 stated during patient rounding conducted every 15 minutes, staff were expected to assess the patient’s behavior, observe the environment of the patient’s room, and verify the patient’s respiration if the patient was in bed. For bedbound (being unable to leave a bed due to illness, injury, or physical limitations) patients, staff must determine whether repositioning was needed. For ambulatory (walking) patients, staff should confirm whether the patient was in bed, breathing comfortably, calm, pacing in the room, or exhibiting signs of agitation. NM 2 said it was an expectation that staff enter the patient’s room during rounding to directly visualize and assess the patient. During a review of Patient 14’s “Psychiatric Initial Evaluation ( psych eval, comprehensive assessment mental health assessment, conducted by a psychologist or psychiatrist, that uses interviews, tests, and observation to understand a person’s emotional, behavioral, and cognitive state), dated 9/6/2025, the psych eval indicated, Patient 14 was admitted to the facility’s BHU on 9/5/2025 on a 5150-hold (72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) for suicidal (thoughts of taking one’s own life) and homicidal (thoughts of killing others) ideation with increased aggression (any intentional behavior aimed at causing harm or injury to another person) behavior with diagnosis including but not limited to schizoaffective (a mental health condition characterized by symptoms of schizophrenia[a disorder that affects a person’s ability to think, feel and behave clearly] such as hallucinations [seeing, hearing, smelling, tasting, or feeling something that is not real] or delusions [a fixed, false belief held despite clear evidence to the contrary]), bipolar (a mental health condition where you have extreme mood changes). During a review of Patient 15’s, “Psychiatric Evaluation,” dated 9/4/2025, the psych eval indicated, Patient 15 was admitted to the facility’s BHU on 9/4/2025 on a 5150-hold for danger to others (DTO, a person who poses a substantial likelihood of inflicting serious bodily harm on another person) for reported increased hallucinations and aggression behavior at home and with diagnosis of paranoid schizophrenia (a subtype of schizophrenia characterized by persistent [false beliefs] and hallucinations). During a review of Patient 16’s, “Psychiatric Evaluation,” dated 9/9/2025, the psych eval indicated, Patient 16 was admitted to the facility’s BHU on 9/8/2025 on 5150-hold for danger to self (DTS, behavior from mental disorder that poses risk of serious harm to oneself), responding to internal stimuli (changes or events that occur within an individual’s body or mind that trigger a response) and complaint of hearing voices with diagnosis of schizoaffective disorder and bipolar type. During a review of Patient 45’s,”Psychaitric Evaluation,” dated 9/5/2025, the psych eval indicated, Patient 45 was admitted to the facility’s BHU on 9/5/2025 for chief complaint of auditory hallucinations and on 5150 hold for DTS/DTO “hearing voices telling him (Patient 45) to cut himself with a knife and to hurt black people.” During a review of Patient 46’s, “Psychiatric Evaluation,” dated 8/22/2025, the psych eval indicated, Patient 46 was admitted to the facility’s BHU on 8/21/2025 on 5150 for danger to self, “endorsed suicidal thoughts for the 3 days with diagnosis including but not limited to major depressive disorder (MDD, a clinical depression causes a persistently low or depressed mood and a loss of interest in activities).” During a review of Patient 47’s, “Psychiatric Evaluation,” dated 9/9/2025, the psych eval indicated, Patient 47 was admitted to the facility’s BHU on 9/9/2025 on 5150 for danger to self, stopped taking medication, endorsing suicidal ideation with diagnosis including but not limited to bipolar disorder. During a review of Patient 48’s, “Psychiatric Evaluation,” dated 9/5/2025, the psych eval indicated, Patient 48 was admitted to the facility’s BHU on 9/4/2025 on 5150 due to being a danger to others, talking about killing religious leaders and with diagnosis including but not limited to bipolar disorder. During a review of Patient 49’s “Psychiatric Evaluation,” dated 9/8/2025, the psych eval indicated, Patient 49 was admitted to the facility’s BHU on 9/8/2025 on a 5150 for danger to others, “called 911 multiple times, stated would kill everyone at [Police] headquarters and blame black lives matter and with diagnosis paranoid schizophrenia.” During a review of Patient 50’s “Psychiatric Evaluation,” dated 9/16/2025, the psych eval indicated, Patient 50 was admitted to the facility’s BHU on 9/16/2025 on a 5150 for being gravely disabled (GD, unable to take care of themselves), experienced mania (a state of abnormally elevated mood, energy, and activity that lasts for an extended period), had not slept for four (4) days, “crying and laughing.” In addition, Patient 50’s, “face sheet, (front page of the chart that contains a summary of basic information about the patient),” the face sheet, indicated Patient 50’s admitting diagnosis was “bipolar.” During a review of Patient 51’s “Psychiatric Evaluation,” dated 9/082025, the psych eval indicated, Patient 51 was admitted to the facility’s BHU on 9/08/2025 on 5150 hold for DTS, for suicidal actions running into traffic and with diagnosis of schizoaffective and bipolar disorder. During a review of Patient 52’s “Psychiatric Evaluation,” dated 9/17/2025, the psych eval indicated, Patient 52 was admitted to the facility’s BHU on 9/16/2025 and placed on 5150 hold for being a danger to others and gravely disabled with diagnosis of schizoaffective bipolar disorder. During a review of Patient 54’s “Psychiatric Evaluation,” dated 9/13/2025, the psych eval indicated, Patient 50 was admitted to the facility’s BHU on 9/12/2025 on 5150 hold for DTS, with thoughts of people coming to kill her (Patient 54), paranoia (person believes that others are trying to harm or deceive them), and delusions with diagnosis of paranoid schizophrenia. During a review of Patient 55’s “Psychiatric Evaluation,” dated 9/5/2025, the psych eval indicated, Patient 55 was admitted to the facility’s BHU on 9/4/2025 on 5150 hold for DTS/DTO/GD, was observed by homeless healthcare staff choking another client and with diagnosis of schizophrenia. During a review of Patient 56’s “Psychiatric Evaluation,” dated 9/11/2025, the psych eval indicated, Patient 56 was admitted to the facility’s BHU on 9/11/2025 on 5150 hold for DTS, Patient 56 admitted taking 4 pills mixed with copious amount of alcohol, with diagnosis including but not limited to major depression. During a review of Patient 57’s “Psychiatric Evaluation,” dated 9/18/2025, the psych eval indicated, Patient 57 was admitted to the facility’s BHU on 9/17/2025 on 5150 hold for DTS, suicidal plans to overdose on pills and with diagnosis of schizoaffective, bipolar disorder. During a review of Patient 58’s “Psychiatric Evaluation,” dated 9/16/2025, the psych eval indicated, Patient 58 was admitted to the facility’s BHU on 9/15/2025 on 5150 hold for being gravely disabled, not sleeping, manic behavior (period of abnormally elevated mood and high energy) and with diagnosis of bipolar disorder manic (extremely elevated mood). During a review of Patient 59’s “Psychiatric Evaluation,” dated 9/11/2025, the psych eval indicated, Patient 59 was admitted to the facility’s BHU on 9/11/2025 on 5150 hold for danger to others and gravely disabled, Patient 59 believed mother (Patient 59’s mother) was abusing her (Patient 59) and with diagnosis including but not limited to bipolar disorder, depressive type. During a review of Patient 60’s “Psychiatric Evaluation,” dated 9/12/2025, the psych eval indicated, Patient 60 was admitted to the facility’s BHU on 9/11/2025 on 5150 hold for being gravely disabled, had paranoid behavior, delusional, making nonsensical statements, irritable, and uncooperative with diagnosis of paranoid schizophrenia with acute exacerbation (intensification of existing mental health issues). During a review of Patient 61’s “Psychiatric Evaluation,” dated 9/9/2025, the psych eval indicated, Patient 61 was admitted to the facility’s BHU on 9/9/2025 on 5150 hold for danger to others, had been experiencing severe anxiety (Feeling overwhelmed, tense, or on edge), hyperverbal (a term used to describe someone who speaks at a very fast pace and uses many words in a short amount of time, often interrupting others), loud, angry outburst, high risk for aggression with diagnosis of schizoaffective disorder, bipolar type. During a review of Patient 62’s “Psychiatric Evaluation,” dated 9/9/2025, the psych eval indicated, Patient 62 was admitted to the facility’s BHU on 9/8/2025 on 5150 hold for DTS/DTO/GD for homicidal threats to bomb Patient 62’s family’s home and self. Patient 62’s psych eval also indicated a diagnosis of schizoaffective and bipolar disorder. During a review of Patient 63’s “Psychiatric Evaluation,” dated 9/16/2025, the psych eval indicated, Patient 63 was admitted to the facility’s BHU on 9/16/2025 on 5150 hold for danger to others, was threatening to cut off a [department store] employee, threw a glass bottle at manager and threatening to kill staff. During a review of Patient 64’s “Psychiatric Evaluation,” dated 9/13/2025, the psych eval indicated, Patient 64 was admitted to the facility’s BHU on 9/12/2025 on 5150 hold for danger to self and with diagnosis of depression (a persistent feeling of sadness, hopelessness, and loss of interest in activities that were once enjoyable). During a review of Patient 65’s “Psychiatric Evaluation,” dated 9/13/2025, the psych eval indicated, Patient 65 was admitted to the facility’s BHU on 9/13/2025 on 5150 for danger to self. Patient 65 took seven (7) Xanax tablets (medication to treat anxiety disorders and panic disorder) in an attempt to commit suicide and with diagnosis including but not limited to major depressive disorder, suicidal ideation. During a review of Patient 66’s “Psychiatric Evaluation,” dated 9/17/2025, the psych eval indicated, Patient 66 was admitted to the facility’s BHU on 9/16/2025 on 5150 for DTS. Patient 66 had a chief complaint of being suicidal and with diagnosis of schizoaffective disorder, depressive type. During a review of Patient 67’s “Psychiatric Evaluation,” dated 9/18/2025, the psych eval indicated, Patient 67 was admitted to the facility’s BHU on 9/17/2025 on 5150 for danger to self and being gravely disabled, having worsening symptoms of paranoia causing a lot of stress for the past month and with diagnosis including but not limited to schizophrenia. During a review of Patient 68’s “Psychiatric Evaluation,” dated 9/16/2025, the psych eval indicated, Patient 68 was admitted to the facility’s BHU on 9/15/2025 on 5150 for DTS and suicide attempt and with diagnosis of bipolar type 1 (a mental health condition characterized by extreme shifts in mood, energy, and behavior between manic and depressive episodes) with acute mania. During a review of Patient 69’s “Psychiatric Evaluation,” dated 9/14/2025, the psych eval indicated, Patient 69 was admitted to the facility’s BHU on 9/13/2025 for chief complaint of psychosis and with diagnosis of bipolar disorder, schizophrenia. During a review of Patient 70’s “Face Sheet,” the face sheet indicated Patient 70 was admitted to the facility’s BHU on 9/17/2025 for chief complaint of psychosis with diagnosis of paranoid schizophrenia. During a review of Patient 70’s “Multidisciplinary master treatment plan,” dated 9/17/2025, the treatment plan indicated Patient 70’s legal status on admission was voluntary hold (when a person admits themselves to a psychiatric facility for treatment, meaning they are not being held against their will). During a review of Patient 72’s “Psychiatric Evaluation,” dated 9/14/2025, the psych eval indicated Patient 66 was admitted to the facility’s BHU on 9/14/2025 on 5150 for danger to self, admitted for suicidal ideation with plans to cut wrist with piece of glass and wanted to harm neighbor and with diagnosis of depression and schizophrenia. During a review of Patient 73’s “Psychiatric Evaluation,” dated 9/14/2025, the psych eval indicated, Patient 73 was admitted to the facility’s BHU on 9/14/2025 on 5150 for danger to others, making threats to harm others and with diagnosis of unspecified psychosis, rule out paranoid schizophrenia. During a review of Patient 74’s “Psychiatric Evaluation,” dated 9/15/2025, the psych eval indicated, Patient 74 was admitted to the facility’s BHU on 9/15/2025 on 5150 for DTO, increased aggression, homicidal ideations, and harmful threats towards staff at the facility and with diagnosis of schizoaffective, bipolar. During a review of Patient 75’s “Psychiatric Evaluation,” dated 9/11/2025, the psych eval indicated, Patient 75 was admitted to the facility’s BHU on 9/10/2025 on 5150 hold for danger to others, exhibited unprovoked episodes of agitation (a feeling of uneasiness and severe restlesness) and aggression toward staff, destroying facility property and with diagnosis of schizophrenia. During a review of Patient 76’s “Psychiatric Evaluation,” dated 9/10/2025, the psych eval indicated, Patient 76 was admitted to the facility’s BHU on 9/9/2025 on 5150 for DTO/GD for increased aggression risk to become assaultive towards others with diagnosis of schizoaffective, bipolar disorder. During a review of the facility’s policy and procedure (P&P) titled, Chart Completion,” last revised 9/2025, the P&P indicated the following: “To ensure that the medical records at [Name of Facility] fully and accurately reflect a patient’s care and are completed in accordance with federal and state law, the facility requires that types of treatment records shall be included in the medical record and are to be counted for the reporting purposes of the applicable accrediting agency...” During a review of the facility’s policy and procedure (P&P) titled, “Every 15 Min (Minute) Rounds, Patient,” last revised 3/2025, the P&P indicated the following: “It is the policy of [the facility] Behavioral Health Services to monitor the safety/locations of all patients on a continuing basis. Such rounds will be conducted at 15-minute intervals. Patients requiring additional observation will be evaluated individually, and physician orders will be generated to address the safety/needs of the patient ...Floor staff will conduct patient rounds at 15-minute intervals, including the location of the patient and his/her condition, and will verify completion of such rounds by their initial and signature. In order to accurately monitor safety and condition of patients at night and/or during non-wakeful times, staff will visually observe chest movement of the patient to ascertain respiratory effort.” During a review of the facility’s policy and procedure (P&P) titled, “Observation Levels System,” dated 3/2025, the P&P indicated, “It is the policy of [the facility] to initiate and provide the appropriate observation level of patient’s behaviors exhibited and also the information provided at the time of admission, and throughout hospitalization. All patients will be routinely observed in compliance with physician/psychologist orders and prescribed protocols. Purpose: to provide the most appropriate patient observation level is maintained throughout hospitalization. To provide patient safety at all times ... Types of Observation Level A. Level I: every 15-minute checks, routine observation. Minimal level of observation for all patients. Staff will observe patient and document on the Patient’s Observation Rounds Sheet Q15 minutes. Assigned staff will make direct contact with patients and confirm they are in no danger or distress .... Observation may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping. It is expected that the staff conducting the 15 minutes observation will enter the room, approach the patient and check their identify, respirations, and to ensure that they are not in any distress.” B. Level II: every 15 minutes checks, routine observations with precautions and taking note of precautions ordered as well ...staff will observe patient and document on the Patient’s Observation Rounds sheet every 15 minutes ...””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure the Condition of Participation for Governing Body was met as evidenced by: 1. The facility ’ s Governing Body (responsible for guiding the hospital ’ s long-term goals and policies, and assists with strategic planning and decision making) failed to ensure Medical Staff followed the facility ’ s “Medical Staff Bylaws, Rules and Regulations,” for two of 30 sampled patients (Patients 20 and 21) when Patient 20 and 21 were not seen by the physician within 24 hours of admission, per policy and procedures. This deficient practice had the potential for medical care and treatment to be delayed for Patients 20 and 21. (Refer to A – 0048) 2. The facility ’ s governing body (responsible for guiding the hospital ’ s long-term goals and policies and assists with strategic planning and decision-making) failed to assume full legal responsibility for implementing and monitoring policies governing the facility ’ s process of background check for all contracted staff members by not ensuring the contracted services perform background check on one of three sampled contracted services staff members (Mental Health Worker [MHW 1]) prior working at the facility. This deficient practice had the potential exposing patients to criminals and put patients ’ safety at risk for abuse. (Refer to A – 0084) The cumulative effects of these deficient practices resulted in the facility ’ s inability to provide quality healthcare in a safe setting.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36206 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by: 1. The facility failed to notify patient representatives, of patient-to-patient altercations (verbal or physical aggression) for two of 30 sampled patients (Patient 1 and 2), in accordance with the facility ’ s policy regarding patient-to-patient altercations. This deficient practice had the potential for patient representatives to be unaware of patient-to-patient altercations, and patient ’ s health status. (Refer to A – 0131) 2. The facility failed to provide a safe environment for two of 30 sampled patients (Patients 17 and 19), when Patients 17 and 19, both on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation) for gravely disabled (GD, a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic needs), were left unmonitored on the behavioral health unit (an area of the hospital that provides mental health care and treatment), not in accordance with facility policy. This deficient practice had the potential for the patients to cause harm to themselves or each other. (Refer to A – 0144) 3. The facility failed to report allegations of abuse to the appropriate health care regulatory agency for two sampled patients (Patient 1). This deficient practice had the potential for the incidents not to be investigated by the regulatory agency, and places other patients at risk of injury or harm. (Refer to A – 0145) 4. The facility failed to ensure a background check was performed on three of 10 sampled staff members (Mental Health Worker [MHW 1 and MHW 3] and Behavioral Health Assistant [BHA 1]) prior starting to work at the facility. This deficient practice had the potential exposing patients to criminals and put patients ’ safety at risk for abuse. (Refer to A – 0145) 5. The facility failed to ensure patient electronic health records (eHR, a digital version of a patient’s medical record) maintained secured, in one of three sampled units (Unit 3, medical surgical and behavioral health unit), when patient information on the workstation on wheels (WOW, a mobile computer) was left open and accessible for anyone to access in unit hallway. This deficient practice had the potential for unauthorized individuals to access patient ’ s protected health information. (Refer to A – 0146) The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality healthcare in a safe environment and placing patients at risk of abuse, or other patient right ’ s violations, such as right to confidentiality, right to be informed of patients ’ health status.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 36206 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to ensure one of 30 sampled patients (Patient 20) was reassessed by a Registered Nurse (RN) after Ativan (medication used to treat anxiety), Haldol (a medication used to treat mental/mood disorders) and Benadryl (a medication used to treat allergies that has sedative effects) were administered concurrently as emergency medications (immediate administration of psychotropic medications [medications used to treat mental health disorders] to a person to treat severe agitation and/or aggressive behaviors). This deficient practice had the potential for the medication to be ineffective or for medication adverse reactions not to be identified, which may cause a delay in care and interventions. (Refer to A – 0395) 2. The facility failed to ensure a care plan (a summary of a patient ’ s health conditions, specific care needs, and current treatment) was developed for two of 30 sampled patient ’ s (Patient 15 and Patient 26) medical diagnosis of epilepsy (seizures) for Patient 15, and anemia (not enough red blood cells to carry oxygen in the blood) for Patient 26. This deficient practice had the potential for Patient 15 to be at risk for injury due to lack of appropriate nursing interventions for patients with epilepsy and had the potential for Patient 26 not receiving monitoring and evaluation for anemia and blood transfusion. (Refer to A – 0396) 3. The facility failed to ensure two of 10 sampled staff members (Mental Health Worker [MHW 3] and Behavior Health Assistant [BHA 1]) had a BLS (Basic Life Support, type of care that first-responders provide to anyone who is experiencing a cardiac or respiratory arrest) card in their personnel file. This deficient practice had the potential for the staff ’ s inability to identify and respond to a medical emergency if a patient suffers from a cardiac (heart) or respiratory arrest. (Refer to A – 0397) 4. The facility failed to reassess (to reevaluate a patient ’ s health status) one of 30 sampled patients (Patient 19) after the administration of as needed medication, Ativan (a medication for anxiety), in accordance with policy and procedure. This deficient practice had the potential for the medication to be ineffective or for medication adverse reactions not to be identified, which may cause a delay in care and interventions. (Refer to A – 0398) 5. The facility failed to ensure nursing staff performed a proper risk assessment on three of 30 sampled patients (Patient 3, 29, and 30) in accordance with its policy and procedure for suicidal risk assessment. This deficient practice had the potential to result in nursing staff not recognizing patients ’ suicidal thoughts, and not providing interventions to prevent patients from harming self. (Refer to A – 0398) 6. The facility failed to ensure blood pressure medication was administered safely for one of 30 sampled patients (Patient 14) when Patient 14 was administered blood pressure medication without Patient 14 ’ s blood pressure or pulse rate being evaluated or assessed. This deficient practice had the potential for Patient 14 to experience serious side effects of low blood pressure or heart rate such as confusion, dizziness, blurry vision, weakness, or fainting. (Refer to A – 0405) 7. The facility failed to ensure antibiotics (medications used to treat infection) were given in a timely manner for two of 30 sampled patients (Patients 16 and 18) in accordance with the physician ’ s order (a doctor ’ s instructions for care and treatment) and the facility ’ s policy and procedure regarding medication administration. This deficient practice resulted in a delay in treatment and had the potential for the antibiotics to be ineffective. (Refer to A – 405) The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“MEDICAL STAFF - BYLAWS AND RULES CFR(s): 482.12(a)(4) [The governing body must] approve medical staff bylaws and other medical staff rules and regulations. This Standard is not met as evidenced by: 48186 Based on interview and record review, the facility ’ s Governing Body (responsible for guiding the hospital ’ s long-term goals and policies, and assists with strategic planning and decision making) failed to ensure Medical Staff followed the facility ’ s “Medical Staff Bylaws, Rules and Regulations,” for two of 30 sampled patients (Patients 20 and 21) when Patient 20 and 21 were not seen by the physician within 24 hours of admission, per policy and procedures. This deficient practice had the potential for medical care and treatment to be delayed for Patients 20 and 21. Findings: 1. During a concurrent interview and record review on 8/7/2024 at 2:24 p.m. with the Nurse Manager 1 (NM 1), the NM 1 stated the following: Patient 20 Face Sheet indicated Patient 20 was admitted 7/31/2024 at 12:10 p.m. Patient 20 ’ s “History and Physical” (H&P, a formal and complete assessment of the patient and the problem) was completed and dated 8/1/2024 at 3:43 p.m. Patient 20 ’ s “Initial Psychiatric Evaluation (comprehensive evaluation conducted by a qualified mental health physician)” was completed 8/1/2024 at 2:05 p.m. The NM 1 verified Patient 20 ’ s H&P and initial psychiatric evaluation was not completed within 24 hours, per policy. The NM 1 further stated the following: Patient 20 ’ s H&P and initial psychiatric evaluation should have been completed within 24 hours. Patient 20 should be seen by a Medical Doctor and Psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) within 24 hours to evaluate the patient for the need of inpatient care and start the plan of care. If patients are not seen within 24 hours, there could be a delay in care. During an interview on 8/9/2024 at 3:36 p.m. with the Chief Nursing Officer (CNO) and Chief Executive Officer (CEO), the CEO stated the following: The governing board (the highest decision-making authority within an organization) has the ultimate responsibility over the entire hospital. It is the responsibility of the governing board to ensure physicians complete the H&P and Initial Psychiatric Evaluations within 24 hours per policy. The CNO stated that physicians need to see patients within 24 hours. During a record review of Patient 20 ’ s Face Sheet, the Face Sheet indicated Patient 20 was admitted to the facility on 7/31/2024 at 12:10 p.m. During a record review of Patient 20 ’ s “Initial Psychiatric Evaluation”, the initial psychiatric evaluation was dated and signed 8/1/2024 at 2:05 p.m. (more than 24 hours after admission). During a record review of Patient 20 ’ s “History and Physical”, the H&P was dated and signed 8/1/2024 at 3:43 p.m. (more than 24 hours after admission). During a record review of the facility’s “Medical Staff Rules & Regulations,” dated 2/6/2020, the rules and regulations indicated the following: “ ...6.3 History & Physical, 6.3-1 General, a. A complete history and physical examination shall be completed and signed within twenty-four (24) hours of the patient admission ... 6.3-2 Psychiatric Evaluations: An initial Psychiatric Evaluation must be completed within twenty-four (24) hours of admission to a Psychiatric care unit ...” During a review of the facility’s policy and procedure (P&P) titled, “History and Physical,” dated 9/2022, the P&P indicated the following: “Policy: The History and Physical must be completed within 24 hours of admission ...” During a review of the facility’s policy and procedure (P&P) titled, “Psychiatric Evaluation,” dated 9/2022, the P&P indicated the following: “Policy: The existence of a Psychiatric Consultation must be documented immediately in the progress notes, the initial psychiatric evaluation report must be completed within twenty-four (24) hours ...” 2. During a concurrent interview and record review on 8/8/2024 at 1:29 p.m. with the Nurse Manager 1 (NM 1), the NM 1 stated the following: Patient 21 Face Sheet (a document that provides a patient’s information at a quick glance) indicated Patient 21 was admitted 8/5/2024 at 4:34 p.m. Patient 21 ’ s “History and Physical” (H&P, a formal and complete assessment of the patient and the problem) was completed and dated 8/6/2024 at 8:31 p.m. The NM 1 verified Patient 20 ’ s H&P was not completed within 24 hours, per policy. The NM 1 further stated the following: Patient 21 ’ s H&P should have been completed within 24 hours. Patient 21 should be seen by a Medical Doctor within 24 hours to evaluate the patient for the need of inpatient care and start the plan of care. If patients are not seen within 24 hours, there could be a delay in care. During an interview on 8/9/2024 at 3:36 p.m. with the Chief Nursing Officer (CNO) and Chief Executive Officer (CEO), the CEO stated the following: The governing board has the ultimate responsibility over the entire hospital. It is the responsibility of the governing board to ensure physicians complete the H&P within 24 hours per policy. The CNO stated that physicians need to see the patients within 24 hours. During a record review of Patient 21 ’ s Face Sheet, the Face Sheet indicated Patient 21 was admitted to the facility on 8/5/2024 at 4:34 p.m. During a record review of Patient 21 ’ s “History and Physical”, the H&P was dated and signed 8/6/2024 at 8:31 p.m. (more than 24 hours after admission). During a record review of the facility’s “Medical Staff Rules & Regulations,” dated 2/6/2020, the rules and regulations indicated the following: “ ...6.3 History & Physical, 6.3-1 General, a. A complete history and physical examination shall be completed and signed within twenty-four (24) hours of the patient admission ...” During a review of the facility’s policy and procedure (P&P) titled, “History and Physical,” dated 9/2022, the P&P indicated the following: “Policy: The History and Physical must be completed within 24 hours of admission ...””

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility ’ s governing body (responsible for guiding the hospital ’ s long-term goals and policies and assists with strategic planning and decision-making) failed to assume full legal responsibility for implementing and monitoring policies governing the facility ’ s process of background check for all contracted staff members by not ensuring the contracted services perform background check on one of three sampled contracted services staff members (Mental Health Worker [MHW 1]) prior working at the facility. This deficient practice had the potential exposing patients to criminals and put patients safety at risk for abuse. Findings: During a concurrent interview and record review on 8/8/2024 at 4:07 p.m. with the Human Resources Coordinator (HRC), Mental Health Worker (MHW) 1 ’ s personnel file was reviewed. The personnel file indicated, there was no background check document in MHW 1 ’ s personnel file. HRC stated the following: background check was required for all employees prior working at the facility to make sure the employee was cleared with criminal background to prevent possible patient abuse. MHW 1 was hired on 8/2/2023 by the contracted company (CC 1) and background check should have been done for her (MHW 1). She (HRC) did not know why it was not done. During an interview on 8/8/2024 at 4:58 p.m. with the Director of Nursing (DON), DON stated background check was required for all employees prior starting at the facility. Background check was done for safety of patients to ensure no criminals working at the facility. During an interview on 8/9/2024 at 8:30 a.m. with the Director of Quality and Risk Management (DQRM), DQRM stated the following: MHW 1 was under the contracted company (CC 1). CC 1 was responsible to perform background check for its (CC 1) staff prior starting to work at the facility. The facility was also responsible to ensure the contracted services perform all the duties including background check. CC 1 did not perform background check for MHW 1 and this should not have happened. MHW 1 could potentially be a criminal and it would put patients ’ safety at risk. During an interview on 8/9/2024 at 3:06 p.m. with the Chief Executive Officer (CEO), CEO stated the following: governing body has the ultimate responsibility for the facility. The governing body oversaw contracted services and the facility ’ s human resources. Background check was required for all employees prior working at the facility to ensure safety of patients. During a concurrent interview and record review on 8/9/2024 at 3:39 p.m. with CEO, CC 1 ’ s “Clinical Services Agreement (contract),” dated 10/5/2022 was reviewed. The contract indicated, “[contract services] and its employees and representatives who render services at the hospital ’ s facility shall abide by all of its policies and procedures, including specifically (but not limited to) its anti-harassment and anti-discrimination policies.” CEO stated the CC1 and its employees need to abide to the facility ’ s policies and procedures. During a review of the facility ’ s policy and procedure (P&P) titled, “Human Resources 806 Background Investigations,” dated 10/2020, the P&P indicated, “All prospective new hires and rehires will have background investigations (BIs) conducted at the time of employment. Background investigations will include a review of prior employment and a criminal conviction review. Certain criminal records will be an automatic bar to employment ... State regulations may specify that the criminal conviction search be clear before hiring. If an unacceptable background or criminal history is found and the applicant has been hired, the job offer will be withdrawn. If employment has already commenced, the employee will be terminated immediately. Convictions for the following offenses, as well as others not listed, shall be automatic bars to employment with [the facility]. 1) Homicide (includes murder, capital murder, manslaughter, and criminal negligent homicide), 2) Kidnapping, aggravated kidnapping, false imprisonment, 3) Indecency with a child, 4) Sexual assault, 5) Aggravated assault, 6) Injury to a child, elderly individual or disabled individual, 7) Abandoning or endangering a child, 8) Aiding suicide, 9) Sale or purchase of a child, 10) Arson, 11) Robbery or aggravated robbery ... the facility will be responsible for contacting any other state agency as required by law. This may include the abuse registry and any licensing boards or bureaus. If state law requires a criminal conviction review through a state agency, those forms must be completed as well as the Human Resources Profile background check. All prospective employees will also be reviewed for Medicare sanctions by review of a recent cumulative sanctions report by the compliance officer of the facility. Anyone listed on the sanctions list will not be eligible for employment at [the facility] owned or managed facility.””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 36206 Based on interview and record review the facility failed to notify patient representatives, of patient-to-patient altercations (verbal or physical aggression) for two of 30 sampled patients (Patient 1 and 2), in accordance with the facility ’ s policy regarding patient-to-patient altercations. This deficient practice had the potential for patient representatives to be unaware of patient-to-patient altercations, and patient ’ s health status. Findings: During a review of Patient 1 ’ s Face sheet, the Face Sheet indicated Patient 1 was admitted to the facility on 7/6/2024 for severe psychosis (a mental disorder characterized by a disconnection from reality). During a review of Patient 1 ’ s nursing “Progress Note,” dated 7/12/2024 at 5:51 p.m., indicated the following. Patient (1) struck on back of head by peer (Patient 2) unprovoked, no bleeding noted, no LOC (loss of consciousness, or change in patient ’ s awareness) ...There was no documentation indicating that Patient 1 ’ s responsible party was notified. During a review of Patient 2 ’ s Face Sheet, the Face Sheet indicated Patient 2 was admitted to the facility on 6/4/2024 for agitation (very worried or upset and shows this in their behavior, movements, or voice). During a review of Patient 2 ’ s nursing “Progress Note,” dated 7/5/2024 at 2:41 p.m., the Progress Notes indicated the following. Patient (2) non-redirectable, high agitated ...yelling, striking out at peers (unknown) unprovoked ...Patient (2) stated “I felt threaten, so I hit her.” There was no documentation in the medical record that Patient 2 ’ s conservator was notified. During a review of Patient 2 ’ s nursing “Progress Note,” dated 7/12/2024 at 5:30 p.m., the Progress Note indicated the following. At 4:15 p.m., Patient (2) non-redirectable, high agitated ...yelling, struck out at female peer (Patient 1) with closed fist ... Patient 2 stating “she hit me, threw coffee at me, I didn ’ t start it.” ... There was no documentation in the medical record that Patient 2 ’ s conservator was notified. During a review of Patient 2 ’ s nursing “Progress Note,” dated 7/18/2024 at 5:35 p.m., the Progress Note indicated the following. At approximately 5:10 p.m., Patient (2) hit another patient in the head with a closed fist. The Patient (2) walked up to other patient (unknown) and despite 1:1 sitter (a non-licensed person who provides 1:1 constant care or observation) within arms ’ length away and attempting to hold his (Patient 2) arm back, Patient (2) pushed through the 1:1 sitter and hit the other patient (unknown) ... There was no documentation in the medical record that Patient 2 ’ s conservator was notified. During an interview on 8/8/2024 at 9:16 a.m., with Charge Nurse (CN) 1, CN 1 stated the following. Patient 1 and Patient 3 had an altercation in the Day/Dining Room during “coffee time,” at 4:15 p.m. CN 1 heard Patient 1 and 2 arguing. Mental Health Worker (MHW) 3 reported that Patient 1 threw coffee at Patient 2, and stated “he hit her (Patient 2 hit Patient 1),” around the head area. Patient 1 and 2 were separated immediately. Patient 2 had coffee dripping from his shift. CN 1 assessed Patient 1. CN 1 stated she did not notify Patient 1 ’ s representative of the incident. CN 1 stated that Patient 1 ’ s representative should have been notified. During an interview on 8/8/2024 at 10:27 a.m., with House Supervisor (HS) 1, HS 1 stated that when there is a patient-to-patient altercation, the family or patient representatives of both patients should be notified by patient ’ s primary nurse or the charge nurse. During an interview on 8/8/2024 at 10:27 a.m., with the Administrator (ADM), the ADM stated that family or patient representatives should be notified when patients are involved in an altercation, however, you should obtain permission from patient prior to notification. The ADM reviewed Patient 1 ’ s medical record and verified Patient 1 ’ s representative was not notified of the incident on 7/12/2024. During a concurrent interview and record review, on 8/8/2024 at 3:17 p.m., with Social Worker (SW) 1, SW 1 stated the following. Patient 2 was conserved (a law-appointed a guardian or protector) by family. Patient 2 was involved in 3 altercations, on 7/5/2024, 7/12/2024, and 7/18/2024. SW 1 verified that there was no documentation in the medical record indicating that Patient 2 ’ s family had been informed of the altercations. During a review of the facility ’ s policy and procedure (P&P) titled, “Patient -to-Patient Altercations,” dated 3/2019, the P&P indicated the following. if two patients are involved in an altercation, staff will ...Separate the patients ...Notify each patient ’ s representative ...”

“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: 48186 Based on observation, interview and record review, the facility failed to provide a safe environment for two of 30 sampled patients (Patients 17 and 19), when Patients 17 and 19, both on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation) for gravely disabled (GD, a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic needs),were left unmonitored on the behavioral health unit (an area of the hospital that provides mental health care and treatment), not in accordance with facility policy. This deficient practice had the potential for the patients to cause harm to themselves or each other. Findings: 1. During a concurrent observation and interview on 8/6/2024 at 3:50 p.m. with the Director of Nursing (DON), Patient 17 was observed in the activity room, with Patient 19, without staff monitoring. There was no staff observed in the activity room, directly outside or in the hallway. The DON stated the following: Patients should not be left in the activity room alone. There should be continuous monitoring of patients when in the activity room. There should have been a staff sitting directly outside of the activity room and there was not. It was important to monitor patients in the activity room for safety precautions in case there was a physical altercation. The patients in the activity room could have been a danger to themselves or others. During an interview on 8/6/2024 at 4:05 p.m. with the Certified Nursing Assistant 4 (CNA 4), the CNA 4 stated the following: She (CNA 4) was assigned to monitor the activity room from 3 p.m. – 7:00 p.m. she (CNA 4) left the activity room to assist another patient. When she (CNA 4) left the activity room, she (CNA 4) should have notified another staff to cover monitoring the activity room. Patients should not have been left in the activity room alone. She (CNA 4) was supposed to continuously monitor the activity room, while patients are in the room. She (CNA 4) was supposed to sit outside of the room in a chair or be in the activity room to monitor patients. While the patients were unmonitored, there could have been an argument, physical fight, or medical condition. During a concurrent interview and record review on 8/7/2024 at 3:19 p.m. with the Nurse Manager 1 (NM 1), the NM 1 stated the following: Patient 17 ’ s “Initial Psychiatric Evaluation,” dated 8/7/2024 at 9:05 a.m., indicated poor impulse control, a danger for safety and required supervision to prevent violent acting out. During a record review of Patient 17 ’ s Face Sheet, the Face Sheet (a document that provides a patient’s information at a quick glance) indicated Patient 17 was admitted to the facility on 8/6/2024 at 1:49 p.m. During a record review of Patient 17 ’ s “Initial Psychiatric Evaluation (comprehensive evaluation conducted by a qualified mental health physician)”, dated 8/7/2024 at 9:05 a.m., the Initial Psychiatric Evaluation indicated the following: Patient 20 was admitted to the facility on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation) for gravely disabled (GD, a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic needs), with a diagnosis of schizophrenia. The psychiatric evaluation further indicated Patient 17 “appears unable to control impulses to others, a danger for safety,” and “requires supervision to prevent violent acting out.” During a record review of Patient 17 ’ s “Interdisciplinary Care Plan,” dated 8/7/2024 at 7:16 a.m., the care plan indicated the following: “danger to self (DTS)/danger to others (DTO) Care Plan; Problem type: Actual; History: anxiety, paranoia (mental illness characterized by systematized delusions), impulsive unpredictable.” During a review of the facility’s policy and procedure (P&P) titled, “Activities Room Monitoring Psych Rehab,” dated 5/7/2022, the P&P indicated the following: “ ...2. Scope: This policy applies to all staff members, including clinical and non-clinical personnel, involved in the operation and supervision of the psych rehab activity room ... 3. Objectives: Ensure the safety of patients and staff ... 4. Monitoring Methods: Staff present immediately on the outside of the room... 4.1 Direct Supervision: Staff members will be present during all group activities ... monitor patient interactions, behavior, and safety ...” 1. During a concurrent observation and interview on 8/6/2024 at 3:50 p.m. with the Director of Nursing (DON), Patient 19 was observed in the activity room, with Patient 17, without staff monitoring. There was no staff observed in the activity room, directly outside or in the hallway. The DON stated the following: Patients should not be left in the activity room alone. There should be continuous monitoring of patients when in the activity room. There should have been a staff sitting directly outside of the activity room and there was not. It was important to monitor patients in the activity room for safety precautions in case there was a physical altercation. The patients in the activity room could have been a danger to themselves or others. During an interview on 8/6/2024 at 4:05 p.m. with the Certified Nursing Assistant 4 (CNA 4), the CNA 4 stated the following: She (CNA 4) was assigned to monitor the activity room from 3 p.m. – 7:00 p.m. she (CNA 4) left the activity room to assist another patient. When she (CNA 4) left the activity room, she (CNA 4) should have notified another staff to cover monitoring the activity room. Patients should not have been left in the activity room alone. She (CNA 4) is supposed to continuously monitor the activity room, while patients are in the room. She (CNA 4) is supposed to sit outside of the room in a chair to monitor or be in the activity room. While the patients were unmonitored, there could have been an argument, physical fight, or medical condition. During a concurrent interview and record review on 8/7/2024 at 3:35 p.m. with the Nurse Manager 1 (NM 1), the NM 1 stated the following: Patient 19 ’ s “Initial Psychiatric Evaluation,” dated 7/27/2024 at 11:29 a.m., indicated Patient 19 was a danger to self and others. During a record review of Patient 19 ’ s Face Sheet, the Face Sheet indicated Patient 19 was admitted to the facility on 7/26/2024 at 10:24 p.m. During a record review of Patient 19 ’ s “Initial Psychiatric Evaluation (comprehensive evaluation conducted by a qualified mental health physician)”, dated 7/27/2024 at 11:29 a.m., the Initial Psychiatric Evaluation indicated the following: Patient 19 was admitted to the facility with a diagnosis of schizophrenia, paranoid type. The psychiatric evaluation on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation) for gravely disabled (GD, a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic needs) and Danger to Others (DTO) further indicated Patient 19 “appears unable to control impulses to others, a danger for safety,” and “requires supervision to prevent violent acting out.” During a record review of Patient 19 ’ s “Interdisciplinary Care Plan,” dated 7/26/2024 at 11:52 p.m., the care plan indicated the following: “DTS/DTO Care Plan; Problem Type: Actual; DTS/DTO Problem: Violence: other-directed.” During a review of the facility’s policy and procedure (P&P) titled, “Activities Room Monitoring Psych Rehab,” dated 5/7/2022, the P&P indicated the following: “ ...2. Scope: This policy applies to all staff members, including clinical and non-clinical personnel, involved in the operation and supervision of the psych rehab activity room ... 3. Objectives: Ensure the safety of patients and staff ... 4. Monitoring Methods: Staff present immediately on the outside of the room... 4.1 Direct Supervision: Staff members will be present during all group activities ... monitor patient interactions, behavior, and safety ...””

“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: 36206 Based on interview and record review, the facility failed to follow its ’ policy regarding abuse when; 1. The facility failed to report allegations of physical abuse to the appropriate health care regulatory agency for one of 30 sampled patients (Patient 1). This deficient practice had the potential for the incidents not to be investigated by the regulatory agency, and places other patients at risk of harm or injury. 2. The facility failed to ensure a background check was performed on three of 10 sampled staff members (Mental Health Worker [MHW 1 and MHW 3] and Behavioral Health Assistant [BHA 1]) prior starting to work at the facility. This deficient practice had the potential exposing patients to criminals and put patients ’ safety at risk for abuse. Findings: 1. During a review of Patient 1 ’ s Face sheet, the Face Sheet indicated Patient 1 was admitted to the facility on 7/6/2024 for severe psychosis (a mental disorder characterized by a disconnection from reality). During a review of Patient 1 ’ s nursing “Progress Note,” dated 7/12/2024 at 5:51 p.m., the Progress Note indicated the following. Patient (1) struck on back of head by peer (Patient 2) unprovoked, no bleeding noted, no LOC (loss of consciousness, or change in patient ’ s awareness), ambulatory, able to make needs known. Vital signs WNL (within normal limits), PEERLA (pupils are equal, round, reactive to light and accommodation), grips intact, respirations even and unlabored, no external injury noted, denies any dizziness, given ice pack. Notified provider with no new orders at this time, just monitor patient. Will update provider of any changes. During a review of Patient 1 ’ s nursing “Progress Note,” dated 7/12/2024 at 10:06 p.m., the Progress Note indicated the following. At around 8:15 p.m., “Charge Nurse came inside after speaking with Patient 1 and Patient 1 ’ s family member ...Charge nurse informed that Patient 1 ’ s family member wanted Patient 1 to be sent to the Emergency Department (ED) for evaluation ...Patient 1 sent for evaluation of face and head. S/P (status post) head trauma secondary to getting punched ... During a review of Patient 2 ’ s Face Sheet, the Face Sheet indicated Patient 2 was admitted to the facility on 6/4/2024 for agitation (very worried or upset and shows this in their behavior, movements, or voice). During a review of Patient 2 ’ s nursing “Progress Note,” dated 7/12/2024 at 5:30 p.m., the Progress Note indicated the following. At 4:15 p.m., Patient (2) non-redirectable, high agitated ...yelling, struck out at female peer (Patient 1) with closed fist ... Patient 2 stating “she hit me, threw coffee at me, I didn ’ t start it.” ... During an interview on 8/8/2024 at 9:16 a.m., with Charge Nurse (CN) 1, CN 1 stated the following. On 7/12/2024 at 4:15 p.m., Patient 1 and Patient 2 had an altercation in the Day/Dining Room during “coffee time.” CN 1 heard Patient 1 and 2 arguing. Mental Health Worker (MHW) 3 reported that Patient 1 threw coffee at Patient 2 and stated “he hit her (Patient 2 hit Patient 1),” around the head area. Patient 1 and 2 were separated immediately by MHW 3. CN 1 assessed Patient 1 and vital signs were within normal limits and no visible injury was noted. CN 1 notified the provider of the incident. This incident could be considered as physical abuse. During an interview on 8/8/2024 at 11:01 a.m., with Mental Health Worker (MHW) 3 the following. On 7/12/2024 at approximately 4 p.m., MHW 3 was passing out coffee in the Day / Dining Room. Patient 1 called Patient 2 “the N word,” and thew coffee at Patient 2 ’ s upper chest area. Patient 2 “rushed” at Patient 1 and punched her with closed fist, does not recall the which part of the body was hit, or the number of times. MHW 3 immediately separated Patients 1 and 2. The incident happened so fast. MHW 3 check Patient 1 ’ s vital signs (blood pressure, heart rate, respiratory rate, and temperature) and informed Charge Nurse (CN) 1. Patient 1 stated she (Patient 1) was okay, no bruising or bleeding observed. During an interview on 8/9/2024 at 12:55 p.m. with the Director of Quality and Risk Management (DQRM), the DQRM stated the following. The incident on 7/12/2024 between Patient 1 and 2 was referred to Administration and was investigated. The DQRM learned of the incident on 8/6/2024 when DQRM returned from time off. The regulatory agency conducted an investigation 7/17/2024 due to a complaint. Patient 1 did not suffer any injuries and the case was closed. The incident was not reported to the regulatory agency. The DQRM verified that the facility ’ s policy and procedure indicated that cases of alleged abuse should be reported to the regulatory agency. The DQRM stated the facility ’ s practices does not match the facility ’ s policy. During a review of the facility ’ s policy and procedure (P&P) titled, “Patient -to-Patient Altercations,” dated 3/2019, the P&P indicated the following. if two patients are involved in an altercation, staff will ...Separate the patients ...Complete a Report/Accident form and document the incident findings, and any corrective measures ...Report incidents, findings, and corrective actions to appropriate agencies as outlined in out facility ’ s abuse reporting policy. During a review of the facility ’ s policy and procedure (P&P) titled, “Abuse – Management of Suspected Child, Adult, Disabled Person or Elderly Abuse, Neglect,” dated 3/8/2019, the P&P indicated the following. It is the policy of the Medical Center under guidance of applicable laws, that any person having reasonable cause to believe that any person is in the state of abuse, exploitation, or neglect shall report the information to the appropriate regulatory agency ...Cases of suspected sexual assault, physical abuse or neglect should be given priority ...All cases of suspected abuse / neglect must be reported to authorities ...A person, including an employee ...or other person associated with the department, who reasonably cause a person to believe that the physical or mental health or welfare of a patient of the department who is receiving medical services has been, is or will be adversely affected by abuse or neglect by any person shall, provide a mandatory report of information supporting the belief to the Department of Health, or the appropriate health care regulatory agency, by telephone, in writing, or by personal visit within 24-36 hours of alleged event ... 48212 2. During a concurrent interview and record review on 8/8/2024 at 4:07 p.m. with the Human Resources Coordinator (HRC), Mental Health Worker (MHW) 1 ’ s personnel file was reviewed. The personnel file indicated, there was no background check document in MHW 1 ’ s personnel file. HRC stated the following: background check was required for all employees prior working at the facility to make sure the employee was cleared with criminal background to prevent possible patient abuse. MHW 1 was hired on 8/2/2023 by the contracted company (CC 1) and background check should have been done for her (MHW 1). She (HRC) did not know why it was not done. During a review of MHW 3 ’ s personnel file, undated, MHW 3 ’ s personnel file indicated MHW 3 ’ s hire date of 3/4/2024 and there was no background check document in MHW 3 ’ s personnel file. During a review of BHA 1 ’ s personnel file, undated, BHA 1 ’ s personnel file indicated BHA 1 ’ s hire date of 10/23/2023 and there was no background check document in BHA 1 ’ s personnel file. During an interview on 8/8/2024 at 4:58 p.m. with the Director of Nursing (DON), DON stated background check was required for all employees prior starting at the facility. Background check was done for safety of patients to ensure no criminals working at the facility. During an interview on 8/9/2024 at 2:15 p.m. with HRC, HRC stated MHW 3 and BHA 1 were facility ’ s employees and the Human Resources department did not have the background check document for MHW 3 and BHA 1. During an interview on 8/9/2024 at 3:06 p.m. with the Chief Executive Officer (CEO), CEO stated background check was required for all employees prior working at the facility to ensure safety of patients. During a review of the facility ’ s policy and procedure (P&P) titled, “Human Resources 806 Background Investigations,” dated 10/2020, the P&P indicated, “All prospective new hires and rehires will have background investigations (BIs) conducted at the time of employment. Background investigations will include a review of prior employment and a criminal conviction review. Certain criminal records will be an automatic bar to employment ... State regulations may specify that the criminal conviction search be clear before hiring. If an unacceptable background or criminal history is found and the applicant has been hired, the job offer will be withdrawn. If employment has already commenced, the employee will be terminated immediately. Convictions for the following offenses, as well as others not listed, shall be automatic bars to employment with [the facility]. 1) Homicide (includes murder, capital murder, manslaughter, and criminal negligent homicide), 2) Kidnapping, aggravated kidnapping, false imprisonment, 3) Indecency with a child, 4) Sexual assault, 5) Aggravated assault, 6) Injury to a child, elderly individual or disabled individual, 7) Abandoning or endangering a child, 8) Aiding suicide, 9) Sale or purchase of a child, 10) Arson, 11) Robbery or aggravated robbery ... the facility will be responsible for contacting any other state agency as required by law. This may include the abuse registry and any licensing boards or bureaus. If state law requires a criminal conviction review through a state agency, those forms must be completed as well as the Human Resources Profile background check. All prospective employees will also be reviewed for Medicare sanctions by review of a recent cumulative sanctions report by the compliance officer of the facility. Anyone listed on the sanctions list will not be eligible for employment at [the facility] owned or managed facility.””

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d) Patient Rights: Confidentiality of Records This Standard is not met as evidenced by: 48186 Based on observation, interview and record review, the facility failed to ensure patient electronic health records (eHR, a digital version of a patient’s medical record) maintained secured, in one of three sampled units (Unit 3, medical surgical and behavioral health unit), when patient information on the workstation on wheels (WOW, a mobile computer) was left open and accessible for anyone to access in unit hallway. This deficient practice had the potential for unauthorized individuals to access patient ’ s protected health information. Findings: During a concurrent observation and interview on 8/6/2024 at 1:34 p.m. with the Director of Nursing (DON) in Unit 3, a workstation on wheels (WOW, a mobile computer) was observed open with electronic health records (eHR, a digital version of a patient’s medical record) unlocked and accessible in the unit hallway. The DON verified there was no staff in sight to safeguard the patient information on WOW. The DON stated the following: When not in use, staff are supposed to close the eHR. The eHR should be locked and protected to protect patient information. If the eHR is left open and unattended, anyone can access patient information which should be private for Health Insurance Portability and Accountability Act (HIPAA, regulates the use and disclosure of protected health information [PHI]) purposes. During an interview on 8/6/2024 at 1:40 p.m. with the Registered Nurse 7 (RN 7), the RN 7 verified the WOW was unattended and unlocked with patient information open and accessible by anyone. The RN 7 stated the following: The eHR should not be left unattended with open patient information. She (RN 7) is supposed to log in and out with a password to access the eHR. If the eHR is left open, anyone can access and see patient information. During a review of the facility’s policy and procedure (P&P) titled, “HIPAA Policies and Procedures,” dated 9/2022, the P&P indicated the following: “Policy: [the facility] to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), maintains that patient information must be kept private and confidential ...””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48186 Based on interview and record review, the facility failed to ensure one of 30 sampled patients (Patient 20) was reassessed by a Registered Nurse (RN) after Ativan (medication used to treat anxiety), Haldol (a medication used to treat mental/mood disorders) and Benadryl (a medication used to treat allergies that has sedative effects) were administered concurrently as emergency medications (immediate administration of psychotropic medications [medications used to treat mental health disorders] to a person to treat severe agitation and/or aggressive behaviors). This deficient practice had the potential for the medication to be ineffective or for medication adverse reactions not to be identified, which may cause a delay in care and interventions. Findings: During a record review of Patient 20 ’ s Face Sheet (a document that provides a patient’s information at a quick glance), the Face Sheet indicated Patient 20 was admitted to the facility on 7/31/2024 at 12:10 p.m. During a record review of Patient 20 ’ s “Initial Psychiatric Evaluation (comprehensive evaluation conducted by a qualified mental health physician)”, dated 8/1/2024 at 8:54 a.m., the initial psychiatric evaluation indicated the following: Patient 20 was admitted to the facility with a chief complaint of agitation (state of anxiety or nervous excitement) and aggression, and had a history of schizoaffective disorder, bipolar type (mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors). During a concurrent interview and record review on 8/7/2024 at 1:29 p.m. with the Nurse Manager 1 (NM 1), Patient 20 ’ s medical record was review and indicated the following: Patient 20 ’ s “Emergency Medication (immediate administration of psychotropic medications [medications used to treat mental health disorders] to a person to treat severe agitation and/or aggressive behaviors) Intervention (EMI) Assessment (to gather a patient ’ s health status) and Reassessment (to reevaluate a patient ’ s health status),” dated 8/1/2024 at 9:00 a.m., was completed by Licensed Vocational Nurse 3 (LVN 3). The NM 1 verified the EMI assessment and reassessment was not co-signed by a Registered Nurse (RN). During the same interview and record review on 8/7/2024 at 1:29 p.m. with the NM 1, the NM 1 stated the following: The EMI assessment and Reassessment is completed after a patient is given “emergency medications”, such as Ativan (medication used to treat anxiety), Haldol (a medication used to treat mental/mood disorders) and Benadryl (a medication used to treat allergies that has sedative effects) concurrently. The LVN can collect and enter data on the EMI assessment and Reassessment, after the administration of emergency medications. Patient 20 ’ s EMI assessment and Reassessment should have been co-signed by an RN, when LVN 3 collected and entered the data. The co-signature of the Registered Nurse would have indicated that the patient was reassessed by a Registered Nurse, to include a face-to-face (where the nurse physically assesses the patient) reassessment, within one hour of emergency medication administration. The EMI assessment and reassessment required the co-signature of the RN because was not in the scope of LVN 3 to reassess the patient. LVN 3 can only collect and enter the data. The NM 1 confirmed that the EMI assessment and reassessment did not have a place for the RN to co-sign. The NM 1 further confirmed the medical record did not indicate that a face-to-face was performed by an RN. During an interview on 8/8/2024 at 11:12 a.m. with the Director of Nursing (DON), the DON stated the following: The facility did not have a specific policy for the use of emergency medications and the facility used the “Restraint (any physical measure that immobilizes or reduces the ability to move freely) and Seclusion (to isolate in a room or space from which a person cannot willfully escape)” and “Psychotropic Medication (mental health medication) Use” policies, which included the use of emergency medications. After emergency medications are administered to a patient, the patient should have a face-to-face reassessment to assess patients physiological and the effects of the medication, per policy. The reassessment should occur within one hour of emergency medication administration, per policy by an RN. During a record review of Patient 20 ’ s “Electronic Medication Administration Record (eMAR, a record for the administration of medication to patients),” dated 8/1/2024, the eMAR indicated the following: On 8/1/2024 at 9:00 a.m., Benadryl 50mg/ml injection was administered to Patient 20 by intramuscular (within the muscle) injection. On 8/1/2024 at 9:00 a.m., Ativan 2mg injection was administered to Patient 20 by intramuscular injection. On 8/1/2024 at 9:00 a.m., Haldol 5mg injection was administered to Patient 20 by intramuscular injection. During a review of the facility’s policy and procedure (P&P) titled, “Restraint and Seclusion Policy” dated 3/9/2022, the P&P indicated the following: “Emergency Medication Intervention is a one-time order (which may be repeated if necessary) for one or more medications that is used as part of a patient ’ s standard medical or psychiatric (relating to mental illness) treatment and is administered within the standard dosage for the patient ’ s condition. This includes use of antipsychotic medications (used to treat psychosis [lose contact with reality]) to manage violent behavior ...” During a review of the facility’s policy and procedure (P&P) titled, “Psychotropic Medication (medications used to treat mental health disorders) Use,” dated 9/2019, the P&P indicated the following: “ ...Policy: ...E. Emergency Medication Intervention (EMI) injection shall be assessed and assessed by nursing staff in electronic Health Record (eHR, a digital version of a patient’s medical record) including ... conclusion assessment, and patient behavior face to face interview.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 47126 Based on observation, interview, and record review, the facility failed to ensure a care plan (a summary of a patient ’ s health conditions, specific care needs, and current treatment) was developed for two of 30 sampled patients (Patient 15 and Patient 26) when: 1. A care plan was not developed for Patient 15 ’ s medical diagnosis of epilepsy (seizures). This deficient had the potential for Patient 15 to be at risk for injury due to lack of appropriate nursing interventions for patients with epilepsy. 2. A care plan was not developed for Patient 26 ’ s medical diagnosis of anemia (not enough red blood cells to carry oxygen in the blood). This deficient practice had the potential for Patient 26 not receiving monitoring and evaluation for anemia and blood transfusion. Findings: 1. During a concurrent observation and interview on 8/7/24 at 9:16 a.m., with the Mental Health Worker (MHW) 4, in Patient 15 ’ s room, Patient 15 was sleeping on a mattress that was placed on the floor. MHW 4 stated Patient 15 was confused and lays on the floor without anything under him. MHW 4 further stated MHW 4 placed the mattress on the floor so Patient 15 would be laying on a barrier between himself and the floor. During a review of Patient 15 ’ s History and Physical (H&P), dated 8/4/24, the H&P indicated Patient 15 was admitted on 8/3/24 for Altered Mental Status (changes in awareness, movement and behavior). The H&P further indicated Patient 15 had a past medical history of hypertension (high blood pressure), epilepsy, and stroke. The H&P indicated, “Current Active Home Meds: ... KEPPRA [seizure medication] 500 MG [milligram] TAB [tablet] ...Plan ...Seizure Precautions ...” During a review of Patient 15 ’ s “Interdisciplinary Team Progress Note Nursing” (Nursing Note) dated 8/3/24, the Nursing Note indicated “Medical HX [History]: HTN [Hypertension], Epilepsy ...” During a review of Patient 15 ’ s physician ’ s order, dated 8/3/24, the physician ’ s order indicate “Nursing Name: Seizure Precautions ... Status New.” During a concurrent interview and record review on 8/8/24 at 3:42 p.m., with the Utilization Review Case Manager (URCM), Patient 15 ’ s active Nursing Care Plan was reviewed. URCM stated no seizure care plan was developed for Patient 15. During an interview on 8/8/24 at 4:03 p.m., with the Behavioral Health Unit Clinical Manager (CM) 1, CM 1 stated a seizure precaution care plan should be in place for patients with a medical diagnosis of epilepsy. CM 1 stated the care plan should include interventions to implement such as placing the mattress on the floor for precaution and to prevent injury, turning the patient to the side during an active seizure, and recording the duration of an active seizure. CM 1 further stated the care plan served as a communication tool for all floor staff to be aware of patients with history of seizures. During an interview on 8/9/24 at 10:56 a.m., with the Director of Nursing (DON), the DON stated it was expected that a care plan was in place for any active or potential health issues, and patients with a history of seizures to have a seizure care plan in place. During a review of the facility ’ s policy and procedure (P&P) titled “Multidisciplinary Plan of Care,” dated November 2019, the P&P indicated, “The admitting Licensed Nurse will initiate the care plan based on the admission assessment ...” During a review of the facility ’ s P&P titled “Hospital Plan for Provision of Care,” dated March 2019, the P&P indicated, “Patient Care Plan: [Facility Name] meets the identified needs of patients in a coordinated, interdisciplinary and systematic way that addresses the entire spectrum of care including the period before admission, during admission, hospitalization, before discharge, and at discharge. This interdisciplinary approach aims for consistency, continuity, and quality of care. Services flow continuously from assessment through treatment and reassessment.” 48212 2. During a review of Patient 26 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/31/2024, the H&P indicated Patient 26 was admitted to the facility with diagnoses of severe anemia (a condition marked by a deficiency of red blood cells or of hemoglobin [a component of red blood cells] in the blood, resulting in pallor and weariness). The H&P also indicated Patient 26 received blood transfusion at the facility. During an interview on 8/7/2024 at 2:17 p.m. with registered nurse (RN 1), RN 1 stated care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was developed upon admission by RN upon admission and update every shift to address patient ’ s current problem. During a concurrent interview and record review on 8/7/2024 at 3:28 p.m. with RN 1, Patient 26 ’ s “Interdisciplinary Care Plan,” dated 7/31/2024 was reviewed. The care plan indicated Patient 26 ’ s active care problems with acute pain, skin integrity, fall, hypertension and danger to self or others. RN 1 stated there was no care plan developed for Patient 26 to address his (Patient 26 ’ s) admitting diagnosis of anemia. RN 1 stated there should be care plan for anemia to provide nursing interventions including monitoring signs and symptoms of bleeding, and lab values including hemoglobin (a component of red blood cells) and hematocrits (volume percentage of red blood cells in blood) for anemia management. RN 1 stated without the care plan for anemia, nursing staff could not monitor and evaluate Patient 26 ’ s progress. During an interview on 8/9/2024 at 10:56 a.m. with the Director of Nursing (DON), DON stated care plan was a plan of treatment to identify problem and to provide interventions to address patients ’ active and potential problems. DON stated care plan was needed to evaluate patients ’ progress and to keep patients safe. During a review of the facility ’ s policy and procedure (P&P) titled, “Multidisciplinary Plan of Care,” dated 11/2019, the P&P indicated, “[facility] to develop a care plan foreach patient admitted at the hospital ... the plan will include problems/needs, goals and interventions ... the plan will serve to facilitate continuity, coordination and communication among team members ... the admitting licensed nurse will initiate the care plan based on admission assessment.” During a review of the facility ’ s policy and procedure (P&P) titled, “Hospital Plan for Provision of Care,” dated 3/2019, the P&P indicated, “Patient care plan. [the facility] meets the identified needs of patient in a coordinated, interdisciplinary and systematic way that addresses the entire spectrum of care including the period before admission, during admission, hospitalization, before discharge and at discharge.””

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure two of 10 sampled staff members (Mental Health Worker [MHW 3] and Behavior Health Assistant [BHA 1]) had a BLS (Basic Life Support, type of care that first-responders provide to anyone who is experiencing a cardiac or respiratory arrest) card in their personnel file. This deficient practice had the potential for the staff ’ s inability to identify and respond to a medical emergency if a patient suffers from a cardiac (heart) or respiratory arrest. Findings: During a concurrent interview and personnel file review on 8/9/2024 at 2:03 p.m., with the Human Resources Coordinator (HRC), the HRC stated the following. MHW 3 was hired on 3/4/2024. BHA 1 was hired on 10/23/2023. The HRC verified that MHW 3 and BHA 1 ’ s personnel file did not include a BLS card. The HRC stated that all clinical staff were required to have a BLS card. During an interview on 8/9/2024 at 3:15 p.m., with the Director of Nursing (DON), the DON stated all staff working on the patient care units were required to posses a BLS card to ensure staff are able to respond in an event of medical emergency. Human Resources Department should ensure all staff have posses a BLS card prior to starting their positions. During a review of MHW 3 ’ s”Job Description,” dated 3/4/2024, the Job Description indicated the following ... Demonstrates clinical competence in the provision of nursing care specific to adult patients ...Assist RN (registered nurse) in identification and treatment of significant change in patient ’ s physical and/or mental status ...Must possess a current BLS card ... During a review of BHA 1 ’ s “Job Description,” dated 10/23/2023, the Job Description indicated the following ... Demonstrates clinical competence in the provision of nursing care specific to adult patients ...Assist RN (registered nurse) in identification and treatment of significant change in patient ’ s physical and/or mental status ...Must possess a current BLS card ... During a review of the facility ’ s policy and procedure (P&P) titled, “HR 211 Certificates & Licenses,” dated 10/01/2020, indicated “It is a condition that employees in certain positions have and maintain a license, registration or certification to perform their jobs.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48186 1. Based on observation, interview and record review the facility failed to reassess (to reevaluate a patient ’ s health status) one of 30 sampled patients (Patient 19) after the administration of as needed medication, Ativan (a medication for anxiety), in accordance with policy and procedure. This deficient practice had the potential for the medication to be ineffective or for medication adverse reactions not to be identified, which may cause a delay in care and interventions. 2. Based on interview and record review, the facility failed to ensure nursing staff performed a proper risk assessment on three of 30 sampled patients (Patient 3, 29, and 30) in accordance with its policy and procedure for suicidal risk assessment. This deficient practice had the potential to result in nursing staff not recognizing patients ’ suicidal thoughts, and not providing interventions to prevent patients from harming self. Findings: 1. During a record review of Patient 19 ’ s Face Sheet (a document that provides a patient’s information at a quick glance), the Face Sheet indicated Patient 19 was admitted to the facility on 7/26/2024 at 10:24 p.m. During a record review of Patient 19 ’ s “Initial Psychiatric Evaluation (comprehensive evaluation conducted by a qualified mental health physician)”, dated 7/27/2024 at 11:29 a.m., the Initial Psychiatric Evaluation indicated the following: Patient 19 was admitted to the facility with a diagnosis of schizophrenia, paranoid type (a mental illness that causes a person to experience paranoia [delusions] and hallucinations [an experience involving the apparent perception of something not present]). During a record review of Patient 19 ’ s “Electronic Medication Administration Record (eMAR, a record for the administration of medication to patients),” dated 7/29/2024, the eMAR indicated the following: On 7/29/2024 at 4:41 a.m., Ativan (a medication for anxiety) 1mg tablet was administered to Patient 19 by mouth for anxiety. During a concurrent interview and record review on 8/7/2024 at 3:35 p.m. with the Nurse Manager 1 (NM 1), Patient 19 ’ s “As Needed Medication Report” indicated Patient 19 was reassessed by Registered Nurse 6 (RN 6) on 7/29/2024 at 6:38 a.m. The NM 1 confirmed the “as needed medication” report was to reassess (to reevaluate a patient ’ s health status) the Ativan given on 7/29/2024 at 4:41 a.m. The NM 1 verified the “as needed medication” reassessment was delayed for Patient 19. The NM 1 stated the following: Patient 19 should have been reassessed within one hour after the administration of as needed medications, such as Ativan. Patient 19 was reassessed late (approximately almost 2 hours after administration). As needed medications should be reassessed to ensure the medication was effective and to assess for adverse reactions. If patients are not reassessed timely after the administration of PRN medications, an adverse reaction may be missed. During an interview on 8/8/2024 at 11:50 a.m. with the Director of Nursing (DON), the DON stated the following: If a patient received an “as needed medication,” such as Ativan, the patient should be reassessed within 30 minutes to one hour after administration. The documentation of as needed medications should be documented on the “As Needed Medication Report” to assess the medication effectiveness, vital signs, adverse reactions, or side effects. The facility did not have a policy that specifically stated the timing of when as needed medications should be reassessed after administration. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration (Procedures & Timing of Administration),” dated 5/2024, the P&P indicated the following: “ ...C. Basic Safe Medication Practices ... viii. Right Response: To ensure that the drug led to the desired effect and document monitoring of the patient.” 48212 2a. During a review of Patient 29 ’ s “Psychiatric Initial Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 8/1/2024, the Psych Eval indicated, Patient 29 was admitted to the facility ’ s Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnosis of paranoid schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). The Psych Eval also indicated, Patient 29 was placed on a 5150-hold (a legal hold allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to self (harming self). During a concurrent interview and record review on 8/8/2024 at 11:40 a.m. with Registered Nurse (RN 1), Patient 29 ’ s “Behavioral Health Daily Assessment/ Suicidal Ideation, (shift assessment, head to toe assessment of the patient by nursing staff),” dated from 8/2/2024 to 8/3/2024 was reviewed. The shift assessment indicated “Question number 2 Current suicidal thoughts: Have you actually had any thoughts of killing yourself? On the Suicide Risk Level Section Level 1 (Low Suicide Risk) Suicidal Ideation Without Plan” was left blank on the following days: 8/2/2024 at 8:10 p.m. filled out by Licensed Vocational Nurse (LVN) 2 8/3/2024 at 10:15 a.m. filled out by LVN 1 RN 1 stated question number 2 was part of the suicide risk screening under shift assessment but LVN 1 and LVN 2 did not complete. They (LVN 1 and LVN 2) should ask Patient 29 question number 2 to assess if Patient 29 had any active plan for hurting self so that nursing staff could provide intervention to prevent Patient 29 from harming self. During an interview on 8/9/2024 at 10:53 a.m. with DON, DON stated the nursing staff will perform the suicide risk screening for all patients upon admission and every shift. DON stated the screening was done to identify potential risks and maintain safety for patients. DON stated question number 2 of suicide screening must be answered because it was part of the suicide risk screening. During a review of the facility ’ s policy and procedure (P&P) titled, “Patients at Risk for Suicide,” dated 7/2020, the P&P indicated, “it is the policy of [the facility] to provide a safe environment of patients who present with a primary diagnosis or an active complaint of an emotional or behavioral disorder ... the screen will determine ’ at risk status ’ and will assist with implementing appropriate levels of observation ... attachment: [name] suicide severity rating scale ... Ask questions 1 and 2. If both are negative, proceed to ’ Suicidal Behavior ’ section ... Question 1: Have you wished you were dead or wished you could go to sleep and not wake up? (answer yes or no) Question 2: Have you actually had any thoughts of killing yourself? (answer yes or no)” During a review of the facility ’ s policy and procedure (P&P) titled, “Assessment/ Re-assessment, Patient,” dated 3/2019, the P&P indicated, “it is the policy of [the facility] to conduct comprehensive, multidisciplinary assessment on each individual admitted to the hospital ... patients on legal holds must have accurate documentation that reflect patients ’ behavior. The documentation of the assessment and reassessment of patient behavior must be done every shift ...licensed nurse shift assessment is done every twelve (12) hours.” 2b. During a review of Patient 30 ’ s “Psychiatric Initial Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 8/1/2024, the Psych Eval indicated, Patient 30 was admitted to the facility ’ s Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnoses of major depression (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) without psychotic features (delusions and hallucinations) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). The Psych Eval also indicated, Patient 30 was placed on a 5150-hold (a legal hold allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for gravely disable (unable to take care self) and danger to others (harming other people). During a concurrent interview and record review on 8/8/2024 at 1:51 p.m. with Registered Nurse (RN 1), Patient 30 ’ s “Behavioral Health Daily Assessment/ Suicidal Ideation, (shift assessment, head to toe assessment of the patient by nursing staff),” dated from 8/4/2024 to 8/8/2024 was reviewed. The shift assessment indicated “Question number 2 Current suicidal thoughts: Have you actually had any thoughts of killing yourself? On the Suicide Risk Level Section Level 1 (Low Suicide Risk) Suicidal Ideation Without Plan” was left blank on the following days: 8/4/2024 at 9:36 p.m. filled out by Licensed Vocational Nurse (LVN) 4 8/8/2024 at 11:17 a.m. filled out by RN 5 RN 1 stated the suicide risk screening was incomplete. RN 1 stated it was part of standard assessment and should be completed. During an interview on 8/9/2024 at 10:53 a.m. with DON, DON stated the nursing staff will perform the suicide risk screening for all patients upon admission and every shift. DON stated the screening was done to identify potential risks and maintain safety for patients. DON stated question number 2 of suicide screening must be answered because it was part of the suicide risk screening. During a review of the facility ’ s policy and procedure (P&P) titled, “Patients at Risk for Suicide,” dated 7/2020, the P&P indicated, “it is the policy of [the facility] to provide a safe environment of patients who present with a primary diagnosis or an active complaint of an emotional or behavioral disorder ... the screen will determine ’ at risk status ’ and will assist with implementing appropriate levels of observation ... attachment: [name] suicide severity rating scale ... Ask questions 1 and 2. If both are negative, proceed to ’ Suicidal Behavior ’ section ... Question 1: Have you wished you were dead or wished you could go to sleep and not wake up? (answer yes or no) Question 2: Have you actually had any thoughts of killing yourself? (answer yes or no)” During a review of the facility ’ s policy and procedure (P&P) titled, “Assessment/ Re-assessment, Patient,” dated 3/2019, the P&P indicated, “it is the policy of [the facility] to conduct comprehensive, multidisciplinary assessment on each individual admitted to the hospital ... patients on legal holds must have accurate documentation that reflect patients ’ behavior. The documentation of the assessment and reassessment of patient behavior must be done every shift ...licensed nurse shift assessment is done every twelve (12) hours.” 2c. During a review of Patient 3 ’ s “Psychiatric Initial Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 7/23/2024, the Psych Eval indicated, Patient 3 was admitted to the facility ’ s Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) with diagnosis of schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions). The Psych Eval also indicated, Patient 3 was placed on a 5150-hold (a legal hold allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to others (harming other people). During a concurrent interview and record review on 8/8/2024 at 2:23 p.m. with Registered Nurse (RN 1), Patient 3 ’ s “Behavioral Health Daily Assessment/ Suicidal Ideation, (shift assessment, head to toe assessment of the patient by nursing staff),” dated 8/2/2024 was reviewed. The shift assessment indicated “Question number 2 Current suicidal thoughts: Have you actually had any thoughts of killing yourself? On the Suicide Risk Level Section Level 1 (Low Suicide Risk) Suicidal Ideation Without Plan” was left blank by Licensed Vocational Nurse (LVN) 5. RN 1 stated LVN 5 did not complete the suicide risk screening on the shift assessment. RN 1 stated incomplete suicide risk screening could place patients at risk for harming self. During an interview on 8/9/2024 at 10:53 a.m. with DON, DON stated the nursing staff will perform the suicide risk screening for all patients upon admission and every shift. DON stated the screening was done to identify potential risks and maintain safety for patients. DON stated question number 2 of suicide screening must be answered because it was part of the suicide risk screening. During a review of the facility ’ s policy and procedure (P&P) titled, “Patients at Risk for Suicide,” dated 7/2020, the P&P indicated, “it is the policy of [the facility] to provide a safe environment of patients who present with a primary diagnosis or an active complaint of an emotional or behavioral disorder ... the screen will determine ’ at risk status ’ and will assist with implementing appropriate levels of observation ... attachment: [name] suicide severity rating scale ... Ask questions 1 and 2. If both are negative, proceed to ’ Suicidal Behavior ’ section ... Question 1: Have you wished you were dead or wished you could go to sleep and not wake up? (answer yes or no) Question 2: Have you actually had any thoughts of killing yourself? (answer yes or no)” During a review of the facility ’ s policy and procedure (P&P) titled, “Assessment/ Re-assessment, Patient,” dated 3/2019, the P&P indicated, “it is the policy of [the facility] to conduct comprehensive, multidisciplinary assessment on each individual admitted to the hospital ... patients on legal holds must have accurate documentation that reflect patients ’ behavior. The documentation of the assessment and reassessment of patient behavior must be done every shift ...licensed nurse shift assessment is done every twelve (12) hours.””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 47126 Based on interview and record review, the facility failed to: 1. Ensure blood pressure medication was administered safely for one of 30 sampled patients (Patient 14) when Patient 14 was administered blood pressure medication without Patient 14 ’ s blood pressure or pulse rate being evaluated or assessed. This deficient practice had the potential for Patient 14 to experience serious side effects of low blood pressure or heart rate such as confusion, dizziness, blurry vision, weakness, or fainting. 2. Ensure antibiotics (medications used to treat infection) were given in a timely manner for two of 30 sampled patients (Patients 16 and 18) in accordance with the physician ’ s order (a doctor ’ s instructions for care and treatment) and the facility ’ s policy and procedure regarding medication administration, when: 2.a. Patient 16 ’ s vibramycin (medication used to treat infection) and augmentin (medication used to treat infection) were not administered timely. 2.b. Patient 18 ’ s gentamicin (medication used to treat infection) was not administered timely. These deficient practices resulted in a delay in treatment and had the potential for the antibiotics to be ineffective. Findings: 1. During a record review of Patient 14 ’ s History and Physical (H&P), dated 7/27/24, the H&P indicated Patient 14 was admitted on 7/27/24 for Schizoaffective exacerbation (symptoms of delusions, hallucinations, disorganized speech and behavior) and had a past medical history of chronic obstructive pulmonary disease (COPD: lung disease causing restricted airflow and breathing problems), hyperlipidemia (high cholesterol), and hypertension (HTN: high blood pressure). During a record review of Patient 14 ’ s physician ’ s order, dated 7/27/24, the physician ’ s order indicated “Coreg (a high blood pressure medication) 6.25 MG TAB [medication to lower blood pressure and heart rate, milligram – unit of weight] ...Frequency 2 times a day ... Care Plan: HTN Hold if SBP [systolic blood pressure: pressure in the veins when the heart pumps] below 110 or HR [heart rate] below 60 ...” During a concurrent interview and record review on 8/8/24 at 3:01 p.m., with the Utilization Review Case Manager (URMC), Patient 14 ’ s “electronic Medication Administration Record Report (eMAR),” dated from 7/27/24 to 8/8/24, was reviewed. The eMAR indicated the following for Coreg 6.25 mg tablet: On 7/28/24 for the 5:00 p.m. scheduled time - “Actual Time: 7/28/2024 17:22 [5:22 p.m.] ... Is Given: Yes,” however, no comment of blood pressure or pulse rate evaluated at time of medication administration. On 7/29/24 for the 7:00 a.m. scheduled time, “Actual Time: 7/29/2024 06:14 [6:14 a.m.] ... Is Given: Yes,” however, no comment of blood pressure or pulse rate evaluated at time of medication administration. On 7/31/24 for the 7:00 a.m. scheduled time, “Actual Time: 7/31/2024 06:06 [6:06 AM] ... Is Given: Yes,” however, no comment of blood pressure or pulse rate evaluated at time of medication administration. The URCM verified the eMAR indicated the blood pressure medication was documented as administered to Patient 14. Upon a subsequent interview and record review on 8/8/24 at 3:11 p.m., with the URMC, Patient 14 ’ s “Nursing Vital Signs (VS: measurements of the body ’ s most basic function which includes heart rate, breathing rate, temperature, and blood pressure),” dated from 7/28/24 to 8/8/24, was reviewed. The VS indicated the following: 7/28/24 at 5 p.m., no VS taken during the medication scheduled or administrated time. 7/29/24 at 6:07 a.m. “Unable to Obtain Vital Signs Due To: Pt. [patient] Refusal.” 7/31/24 at 6:09 a.m. “Comments: Patient refused vital signs.” The URCM stated there was no documentation on the VS or on the eMAR that Patient 14 ’ s blood pressure or pulse rate was evaluated or assessed prior to the administration of the blood pressure medication. The URCM stated the blood pressure medication should not be administered if a patient ’ s blood pressure was not assessed. The URCM further stated a patient ’ s current blood pressure may already be low and administering a blood pressure medication may lower the patient ’ s blood pressure to an unsafe level. The URCM also stated a patient ’ s blood pressure may be elevated and required further interventions in addition to blood pressure medication administration to address the high blood pressure. During an interview on 8/8/24, at 4:03 p.m., with the Behavioral Health Unit Clinical Manager (CM) 1, CM 1 stated the facility ’ s expectation was for the licensed nurse to not administer blood pressure medication if the patient ’ s blood pressure was not assessed or evaluated. CM 1 further stated the facility ’ s expectation was for the nurse to notify the attending physician if a patient refused to have their blood pressure assessed for blood pressure medication administration and follow what the physician orders. During a review of the facility ’ s policy and procedure (P&P) titled “Medication Administration (Procedures & Timing of Administration),” revised date May 2024, the P&P indicated “E. Use of Professional Judgment: Staff are expected to use their professional in organizing and prioritizing patient care work-loads to assure that medications are delivered in a safe and timely manner. In exercising such judgment, staff must take into account the following: ... 5. Prioritization of additional activities that may be required for particular drugs, such as vital signs assessments ... to ensure safe and timely medication administration.” 48186 2a. During a record review of Patient 16 ’ s Face Sheet, the Face Sheet (a document that provides a patient’s information at a quick glance) indicated Patient 16 was admitted to the facility on 8/2/2024 at 3:48 p.m. During a record review of Patient 16 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 8/3/2024 at 10:47 a.m., the H&P indicated the following: Patient 16 was admitted to the facility with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), complicated urinary tract infection (UTI, bacterial infection of the urinary tract [the kidneys, ureters, bladder, and urethra]), and multiple skin breakdowns with suspected infection consistent with cellulitis (deep infection of the skin caused by bacteria). During a review of Patient 16 ’ s physician ’ s orders (a doctor ’ s instructions for care and treatment), dated 8/3/2024 at 11:27 a.m., the order indicated to administer Vibramycin (medication used to treat infection) 100mg one tablet two times per day by mouth. During a review of Patient 16 ’ s physician ’ s orders, dated 8/5/2024 at 10:11 p.m., the order indicated to administer Augmentin medication used to treat infection) 500/125 mg one tablet three times per day by mouth. During a concurrent interview and record review on 8/7/2024 at 1:30 p.m. with the Nurse Manager 1 (NM 1), NM 1 verified Patient 16 had an order on 8/3/2024 for Vibramycin 100mg two times per day and an order for Augmentin 500/125mg three times per day. The NM 1 further verified the following doses Vibramycin and Augmentin were not administered to Patient 16 timely: Vibramycin 100mg tablet by mouth due at 9:00 p.m. was administered on 8/5/2024 at 10:00 p.m.; Vibramycin 100mg by mouth due at 9:00 p.m. was administered on 8/7/2024 at 10:24 p.m.; Vibramycin 100mg by mouth due at 9:00 a.m. was administered on 8/8/2024 at 10:05 a.m.; Augmentin 500/125mg tablet by mouth due at 8:00 a.m. was administered on 8/6/2024 at 8:49 a.m.; Augmentin 500/125mg tablet by mouth due at 12:30 p.m. was administered 8/6/2024 at 11:53 a.m.; Augmentin 500/125mg tablet by mouth due at 5:30 p.m. was administered on 8/6/2024 at 4:48 p.m.; Augmentin 500/125mg tablet by mouth due at 8:00 a.m. was administered on 8/7/2024 at 10:25 a.m.; Augmentin 500/125mg tablet by mouth due at 8:00 a.m. was administered 8/8/2024 10:09 a.m.; Augmentin 500/125mg tablet by mouth due at 5:30 p.m. was administered on 8/8/2024 at 4:43 p.m.; During the same interview and record review on 8/7/2024 at 1:30 p.m. with the NM 1, the NM 1 stated the following: Patient 16 ’ s antibiotics should have been given when due, within a 30-minute timeframe, and per the physician ’ s order. It is important to give antibiotic on-time to ensure the dose is therapeutic since antibiotics (medications used to treat infection) are time sensitive. If given too early or too late, the antibiotics may not reach therapeutic levels to treat infections. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration (Procedures & Timing of Administration),” dated 5/2024, the P&P indicated the following: “Policy: ... 3. Time-Critical Scheduled Medications: These are medications for which an early or late administration of greater than 30 minutes might cause harm or have a significant, negative impact on the intended therapeutic or pharmacological effect. The following medications must be administered at the EXACT time indicated when necessary, otherwise within 30 minutes before or after their scheduled dosing time, for a total window of 1 hour: i. Antibiotics ... H. Drug Administration Procedures:.. 2. Verify the drugs to be administered with prescriber’s order based on the 8 Rights of Safe Medication Practices ... v. Right Time.” 2b. During a record review of Patient 18 ’ s Face Sheet (a document that provides a patient’s information at a quick glance), the Face Sheet indicated Patient 18 was admitted to the facility on 7/24/2024 at 8:12 p.m. During a record review of Patient 18 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/25/2024 at 2:31 p.m., the H&P indicated the following: Patient 18 was admitted to the facility with diagnoses of extended spectrum beta-lactamase (ESBL, a strain of bacteria) urine, history of falls and hypotension (low blood pressure). During a review of Patient 18 ’ s physician ’ s orders (a doctor ’ s instructions for care and treatment), dated 8/1/2024 at 12:22 p.m., the order indicated to administer Gentamicin (medication used to treat infection) 80 mg one injection every 12 hours. During a review of Patient 18 ’ s physician ’ s orders, dated 8/5/2024 at 7:53 p.m., the order indicated to administer Gentamicin 80 mg one injection every 12 hours. During a concurrent interview and record review on 8/8/2024 at 10:41 a.m. with the Nurse Manager 1 (NM 1), NM 1 verified Patient 18 had an order on 8/1/2024 at 12:22 p.m. for Gentamicin 80mg every 12 hours, with a renewal order on 8/5/2024 at 7:53 a.m. The NM 1 further verified the following doses of Gentamicin were not administered to Patient 16 timely: Gentamicin 80mg intramuscular due at 9:00 p.m. was administered on 8/1/2024 at 8:11 p.m.; Gentamicin 80mg intramuscular due at 9:00 a.m. was administered on 8/4/2024 at 9:58 a.m.; Gentamicin 80mg intramuscular due at 9:00 p.m. was administered on 8/4/2024 at 8:08 p.m.; Gentamicin 80mg intramuscular due at 9:00 p.m. was administered on 8/5/2024 at 9:40 p.m.; Gentamicin 80mg intramuscular due at 9:00 a.m. was administered on 8/6/2024 at 11:16 a.m.; and Gentamicin 80mg intramuscular due at 9:00 a.m. was administered on 8/7/2024 at 10:10 a.m. During the same interview and record review on 8/8/2024 at 10:41 p.m. with the NM 1, the NM 1 stated the following: Patient 18 ’ s Gentamicin should have been given when due, within a 30-minute timeframe, and per the physician ’ s order. It is important to give Gentamicin on-time to ensure the dose is therapeutic since Gentamicin is time sensitive. If Gentamicin is given too early or too late, it may not reach therapeutic levels to treat infection. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration (Procedures & Timing of Administration),” dated 5/2024, the P&P indicated the following: “Policy: ... 3. Time-Critical Scheduled Medications: These are medications for which an early or late administration of greater than 30 minutes might cause harm or have a significant, negative impact on the intended therapeutic or pharmacological effect. The following medications must be administered at the EXACT time indicated when necessary, otherwise within 30 minutes before or after their scheduled dosing time, for a total window of 1 hour: i. Antibiotics ... H. Drug Administration Procedures: ... 2. Verify the drugs to be administered with prescriber’s order based on the 8 Rights of Safe Medication Practices ... v. Right Time ...””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 36206 Based on observation, interview, and record review, the facility failed to ensure medical records were complete and accurate for two of 30 sample patients (Patient ’ s 1 and 2). Patient 1 ’ s vital signs were not documented in the medical record. Patient 2 ’ s gender and height were inaccurate. This deficient had the potential to affect treatment plans and the inability to detect changes in the patient 1 ’ s condition. Findings: During a review of Patient 1 ’ s Face sheet, indicated Patient 1 was admitted to the facility on 7/6/2024 for severe psychosis (a mental disorder characterized by a disconnection from reality). During a review of Patient 1 ’ s nursing “Progress Note,” dated 7/12/2024 at 5:51 p.m., indicated the following. Patient (1) struck on back of head by peer unprovoked, no bleeding noted, no LOC (loss of consciousness, or change in patient ’ s awareness) ...Vital signs (blood pressure, heart rate, respiratory rate, temperature) WNL (within normal limits) ... During a review of Patient 1 ’ s “Vital Signs Flowsheet,” dated 7/12/2024, no vital signs were documented correlating with the Progress Notes dated 7/12/2024 at 5:51 p.m., regarding vital signs WNL. During a concurrent interview and record review, on 8/7/2024 at 11:37 a.m., with the Utilization Review Case Manager (URCM), the URCM stated the following. URCM verified there were no vital signs documented in the flowsheets that correlated with the Progress Notes dated 7/12/2024 at 5:51 p.m. The URCM stated vital signs should be documented to identify changes in patient ’ s condition. During a review of the facility ’ s policy and procedure titled, “Vital Signs,” dated 3/19/2019, the P&P indicated vital signs shall be recorded in the EMR (Electronic medical record) under the Vital signs ’ flowsheet. During a tour of the East Unit on 8/7/2024 at 8:41 a.m., Patient 2 was observed in his room, lying on the bed, calm, awake and alert. Patient 2 was a male and approximately 6 feet tall. During a review of Patient 2 ’ s H&P (H&P, a formal and complete assessment of the patient and the problem), dated 6/5/2024 at 12:15 p.m., the H&P indicated Patient 2 was a female ...who was displaying aggressive behavior and repeatedly assaulting staff ...She conveyed no complaints during my encounter ... During a review of Patient 2 ’ s “Admission Assessment,” dated 6/4/2024 at 5:20 p.m., the Admission Assessment indicated Patient 2 ’ s height was 60 inches (152 cm or 5 feet). During a concurrent interview and record review on 8/8/2024 at 11:30 a.m., with Clinical Manager (CM) 1 and the Administrator (ADM) of the Behavior Health (BH), CM 1 and the ADM verified the “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 6/5/2024, was inaccurate because it indicated Patient 2 was a female, when in fact, Patient 2 is a male. In addition, CM 1 and the ADM verified that Patient 2 ’ s nursing “Admission Assessment,” dated 6/4/2024 indicated Patient 2 was 60 inches tall (5 feet). The ADM and CM 1 stated that Patient 2 was approximately 6 feet tall. The ADM and CM 1 stated that medical records should be accurate. During a review of the facility ’ s policy and procedure (H&P) titled, “History and Physical,” dated 9/2022, the P&P indicated the following. The History and Physical ... should contain adequate information to support the diagnosis and treatment plans. This information should be comprehensive enough to inform a surgeon, consultant, or other practitioner of all the precautions to be taken during treatment. The Medical History include the following criteria at minimum: including, Patient ’ s Sex ... During a review of the facility ’ s policy and procedure (H&P) titled, “Chart Completion,” dated 9/2022, the P&P indicated the following...The process utilized for calculating/counting incomplete medical records and determining delinquent status must comply with all applicable federal, state, accrediting agency ...The Health Information Services Director/Manager is responsible for overseeing the accuracy and completeness of these processes.”

“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: 48212 Based on observation, interview and record review, the facility failed to ensure its staff to adhere to the facility ’ s infection control program in accordance to its policy and procedure when: Two staff members (Mental Health Worker [MHW 1] and Certified Nursing Assistant [CNA 1]) did not perform hand hygiene when entering patient rooms, before and after patient care; There were 2 bottle of body wash, a wash cloth in the bathroom and a open box of facial tissue on top the bedside cabinet and a piece of dried food left in the bedside table tray in one unoccupied patient room; One CNA (CNA 2) did not wear personal protective equipment (PPE, worn to prevent or minimize exposure to hazards) when entering a contact isolation room; and Six staff not N95 respirator (N95, respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) fit tested upon hired and annually. This deficient practice had the potential to result in putting patients and staff at risk for transmissions of infections within the facility. Findings: During a concurrent observation and interview on 8/6/2024 at 1:36 p.m. with the Mental Health Worker (MHW 1) in a patient ’ s (Patient 25 ’ s) room, MHW 1 walked into Patient 25 ’ s room holding a heating pad, MHW 1 put gloves on before applying heating pad to Patient 25 ’ s abdomen then took off the gloves and threw the gloves into the trash can. MHW 1 stated she (MHW 1) did not perform hand hygiene (a term used to cover both hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers) before and after touching Patient 25. MHW 1 stated wearing gloves could not replace performing hand hygiene. During an interview on 8/6/2024 at 1:43 p.m. with the Director of Nursing (DON), DON stated the expectation was for staff to perform hand hygiene before entering patient ’ s room, before and after touching patient to prevent spread of infection. During a concurrent observation and interview on 8/6/2024 at 1:47 p.m. with the Certified Nursing Assistant (CNA 1) in a patient ’ s (Patient 26 ’ s) room, CNA 1 walked into Patient 26 ’ s room and walked out of Patient 26 ’ s room without performing hand hygiene. CNA 1 stated, “I should ’ Gel in and gel out (applying alcohol-based hand sanitizer when entering and leaving patient ’ s room) ’ but I did not do it.” During an interview on 8/9/2024 at 11:42 a.m. with the Director of Infection Control (IC 1), IC 1 stated the following: all staff needed to perform hand hygiene because dirty hands can transmit disease. Hand hygiene is priority. Staff needed to perform hand hygiene before and after contacting patients, before applying gloves and after removing gloves. During a review of the facility ’ s policy and procedure (P&P) titled, “Hand Hygiene,” dated 11/2022, the P&P indicated, “effective hand hygiene in order to prevent transmission of bacteria, germs and infections ... the purpose of hand hygiene is to remove dirt, organic materials, and transient microorganisms from the hands and wrists and to prevent the transfer of organisms to other people. Hand hygiene is the single most effective methods of preventing spread of infectious microorganisms ... All personnel will use the hand-hygiene techniques ... hands must be cased for by hand washing with soap and water or by hand antisepsis with alcohol based hand rubs ...before and after patient contact ... before applying gloves ...after removing gloves.” During a concurrent observation and interview on 8/6/2024 at 2:10 p.m. with the Director of Nursing (DON) in an unoccupied patient room (RM 1), there were 2 bottle of body wash, a wash cloth in the bathroom and a open box of facial tissue on top the bedside cabinet. DON stated the following: those items should not be in an unoccupied patient room. There was a patient in RM 1 but was discharged yesterday (8/5/2024). RM 1 was unoccupied since then. Environmental Services (EVS) Staff was responsible for cleaning the patients room after patient was discharged. During a concurrent observation and interview on 8/6/2024 at 2:24 p.m. with the EVS staff (EVS 1) in RM 1, there were a piece of dried food left in the bedside table tray. EVS 1 stated the bedside table tray was dirty. EVS 1 stated the EVS staff was responsible for cleaning the bedside table tray from last night (8/5/2024) after the patient was discharged. During an interview on 8/9/2024 at 9:40 a.m. with the EVS supervisor (EVSS), EVSS stated the following: EVS staff was responsible to clean and disinfect the room after patient was discharged. There should not be any body wash bottles, and wash cloth left in the bathroom. All used items should be thrown away. The EVS staff should also clean and disinfect the bedside table tray. There should be no piece of food left in the bedside table tray. During a review of the facility ’ s policy and procedure (P&P) titled, “Environmental Decontamination and Terminal Cleaning,” dated 11/2022, the P&P indicated, “the Environmental Services Department has the responsibility for the reduction of the level of microorganisms in the hospital environment and to ensure the infectious agents do not become disseminated, so as to provide a safe environment for all who enter it, be they patients, employees and visitors ... terminal cleaning ... the thorough cleaning of a patient room following discharge to remove germs ...remove soiled linen ...discard open facial tissue boxes ...clean and wipes down all tables, nightstands and rolling tables.” During a concurrent observation and interview on 8/6/2024 at 3:11 p.m. with Certified Nursing Assistant (CNA 2) at a patient ’ s (Patient 27 ’ s) room, there was a sign indicating “Contact Precaution” outside Patient 27 ’ s room and CNA 2 walked into Patient 27 ’ s without any personal protective equipment (PPE, worn to prevent or minimize exposure to hazards). CNA 2 stated, “I have to put on PPE when entering isolation room but I did not.” During a concurrent interview and record review on 8/8/2024 at 11:05 a.m. with registered nurse (RN 1), Patient 27 ’ s “physician order (orders written by physicians to direct care and treatment),” dated 8/3/2024 was reviewed. The physician order indicated contact isolation. RN 1 stated contact isolation is a type of transmission-based precaution in which staff should wear PPE including gloves and gown upon entering Patient 27 ’ s room to prevent transmission of disease. During a concurrent interview and record review on 8/9/2024 at 10:59 a.m. with the Director of Nursing (DON), the facility ’ s “Contact Precaution” sign, undated, was reviewed. The sign indicated, “wear gloves and gown when entering room.” DON stated the expectation was for all staff to follow facility ’ s transmission-based precaution protocol. DON stated the staff needed to follow the isolation sign posted outside patient room and to wear proper PPE including wearing gloves and gown when entering room to prevent spread of infection. During a review of the facility ’ s policy and procedure (P&P) titled, “Isolation Precaution,” dated 11/2022, the P&P indicated, “contact precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient ’ s environment ... Healthcare personnel caring for patient on contact precaution wear a gown and gloves for all interactions that may involve with the patient or potentially contaminated areas in the patient ’ s environment.” During a concurrent interview and record review on 8/8/2024 at 2:47 p.m. with the Human Resources Coordinator (HRC), Certified Nursing Assistant (CNA) 3 ’ s personnel file was reviewed. The personnel file indicated, CNA 3 ’ s hire date of 5/29/2024 and there was no N95 respirator (N95, respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) fit test document in CNA 3 ’ s personnel file. HRC stated the following: the N95 respirator fit test was not done upon hired. N95 respirator fit test was done by cardiopulmonary department. Human Resource department did not keep record for employees N95 respirator fit test record. During a concurrent interview and record review on 8/8/2024 at 3:03 p.m. with HRC, the personnel files for charge nurse (CN 1), registered nurse (RN 2), licensed vocation nurse (LVN 1), and mental health worker (MHW 1 and MHW 2) were reviewed. The personnel files indicated the followings: CN 1 date of hire: 3/5/2019 with no N95 respirator fit test record RN 2 date of hire: 3/29/2021 with no N95 respirator fit test record LVN 1 date of hire: 11/5/2023 with no N95 respirator fit test record MHW 1 date of hire: 8/2/2023 with no N95 respirator fit test record MHW 2 date of hire: 7/14/2022 with no N95 respirator fit test record HRC stated Human Resource department did not have all employees N95 respirator fit test record. During an interview on 8/8/2024 at 4:13 p.m. with the Director of Quality and Risk Management (DQRM), DQRM stated there was no system in place at this moment to keep track which employee was N95 respirator fit tested. During an interview on 8/9/2024 at 10:17 a.m. with the Cardiopulmonary Supervisor (CPS), CPS stated the following: N95 respirator fit test was required for employees so that they could wear N95 respirator properly when taking care of airborne precaution (prevent transmission of infectious agents that remain infectious over long distances when suspended in the air) patients to prevent getting sick and spread of infections. Cardiopulmonary department did not keep a log to keep track which employee had received N95 respirator fit test and when N95 respirator fit test was done. CPS stated, “as of this time, we cannot tell which staff is N95 respirator fit tested and who is due for fit test.” During an interview on 8/9/2024 at 11:27 a.m. with the Director of Infection Control (IC 1), IC 1 stated Cardiopulmonary Department and Human Resources Department were responsible for performing and keeping records of N95 respirator fit test for employees. IC 1 stated there was policy and procedure in placed for the facility to follow. IC 1 stated N95 respirator fit test was required for registered nurses, licensed vocational nurses, certified nursing assistants, mental health workers, respiratory therapists, laboratory technicians and housekeeping staff upon hired and annually. During a review of the facility ’ s policy and procedure (P&P) titled, “Tuberculosis [TB, a serious illness that mainly affects the lungs. It can spread when a person with the illness coughs or sneezes to put tiny droplets with the germs into the air] Exposure Plan,” dated 11/2022, the P&P indicated, “[the facility] is committed to maintaining an injury and illness free workplace and is making every efforts to protect patients, visitors and employees from tuberculosis, and other aerosol transmissible disease ... proper fit of N95 respirators is essential ... all fit testing will be performed by qualified individuals who have been appropriately trained. All personnel using respirators must be fit tested prior to use. Personnel in the following departments will also be fit tested on annual basis: medical surgical (general patient population hospitalized for various causes such as illness and surgery), surgery, housekeeping ...””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 36206 Based on interview and record review the facility failed to ensure the Condition of Participation for Governing Body was met as evidenced by: 1. The Governing Body failed to ensure its Contracted Clinic performed all necessary tests (such as EKG [electrocardiogram, a recording of the heart’s electrical activity] and Chest X-ray [a test that creates an image of the heart, lungs, and bones]) prior to admitting one of 30 sampled patients (Patient 1) to the facility and failed to ensure Patient 1 met the criteria for admission to the facility, in accordance with the facility’s policy and procedure regarding criteria for admission. This deficient practice had the potential for Patient 1 to have medical complications (such as cardiac arrest [when the heart stops beating]) that the facility may not be able to handle, making it unsafe to admit Patient 1. (Refer to A-0083) 2. The Governing Body failed to ensure an onsite physician (a physician who is physically present at the facility) was readily available for one of 30 sampled patients (Patient 1), who was experiencing a medical emergency (low blood pressure and low heart rate). This deficient practice resulted in the nursing staff handling a medical emergency for Patient 1 without a physician physically present to evaluate Patient 1’s condition including Patient 1’s responses to interventions and give direction to nursing staff. This deficient practice also resulted in Patient 1’s death. (Refer to A- 0093) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36206 Based on observation, interview and record review the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by: 1. The facility failed to ensure that patient rights (ethical principles that apply to patient care; informs patient of their autonomy over medical decisions and rights as a patient in the hospital. Example: right to participate in decision-making regarding treatment plan, etc.) information and conditions of admissions (COA- a form that outlines the patient’s obligations for hospital services received, including the duty to pay for services rendered) information was provided for one of 30 sampled patients (Patient 26). This deficiency resulted in Patient 26 not being informed of his (Patient 26) rights as a patient, which may result in Patient 26 not being involved in the treatment plan and may cause delay in the patient’s (Patient 26) recovery. (Refer to A-0117) 2. The facility failed to assess for environmental safety risks (such as ligature [anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation] risks) to identify potential hazards for patients at risk of harm to themselves or others for two of 30 sampled patients (Patient 15 and Patient 16). Both patients (Patient 15 and Patient 16) were admitted to the facility on a 5150-hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) due to danger to self and others. This deficient practice had the potential to compromise Patient 15’s and Patient 16’s health and safety due to the lack of proper environmental safety checks, to assess for presence of ligature risks, conducted by the facility, which may result in patient harm and/or death via hanging or strangulation (external pressure applied to the neck, by any means, that obstructs the blood flow and/or airflow) using available cords in the patient room. (Refer to A- 0144) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 36206 Based on interview and record review the facility failed to ensure the Condition of Participation for Quality Assurance Performance Improvement (QAPI) was met as evidenced by: 1. The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI, a process used to ensure services are meeting quality standards and assuring care reaches a certain level) department analyze and provide measurable data to track the facility’s rapid response (a process for working with a rapidly declining patient) and code blue (patient with an unexpected cardiac or respiratory arrest [when the heart stops beating] requiring resuscitation [methods used to restart the heart and lungs when they stop working]) events for one of two sampled patients (Patient 1). This deficient practice resulted in the facility’s inability to assess and monitor its staff performance including effectiveness of staff intervention in a rapid response and/or code blue event as evidenced by staff not following the facility’s rapid response/code blue protocols (standard procedures to be followed and implemented during a medical emergency) which led to Patient 1’s death. (Refer to A- 0273) 2. The facility failed to perform a root cause analysis (RCA, a structured, facilitated team process to identify the root cause of an event that resulted in an undesired outcome and develop corrective actions) on the facility’s rapid response (a process for working with a rapidly declining patient) and code blue (patient with an unexpected cardiac or respiratory arrest [when the heart stops beating] requiring resuscitation [methods used to restart the heart and lungs when they stop working]) events for one of one sampled patient (Patient 1). This deficient practice resulted in the facility’s inability to identify potential system or process changes that could improve performance or improve patient safety and prevent any undesired outcome such as Patient 1’s death or prevent harm and/or death to other patients admitted to the facility. (Refer to A- 0286) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments, thus compromising patient safety.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 36206 Based on interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to ensure completion of training and competency check (an assessment tool which checks and determines the skill of a staff) for four of four sampled nursing staff (House Supervisor [HS] 1, Registered Nurses [RNs] 2, 3 and 4) regarding their role in a rapid response (a process for working with a rapidly declining patient) call for one of 30 sampled patients (Patient 1). This deficient practice resulted in nursing staff (HS 1, RN 2, RN 3, and RN 4) not knowing how to manage a rapid response team call properly as evidenced by nursing staff failing to render supportive medical management for one of 30 sampled patients (Patient 1) during a rapid response call which led to Patient 1’s condition to further deteriorate into a code blue (patient with an unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]), which eventually resulted in Patient 1’s death. (Refer to A- 0397) 2. Nursing staff failed to adhere and follow rendering supportive medical management for low oxygen saturation (measures the amount of oxygen in the blood) levels, low blood pressure, and low heart rate during a rapid response (a process for working with a rapidly declining patient) event and also failed to analyze the heart rhythm (when the heart beats too quickly or too slowly) and deliver a shock (using an electrical charge to stop the heart’s abnormal rhythm by a defibrillator [a device that can detect an abnormal heart rhythm and applies an electric charge [shock] or current to the heart to restore a normal heartbeat]) for one of 30 sampled patients (Patient 1) during a Code blue (patient with an unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]), in accordance with the facility’s policy and procedure regarding Advanced Cardiac Life Support (ACLS, a set of life-saving protocols and skills that goes beyond the basic life support [such as CPR, Cardiopulmonary Resuscitation - an emergency procedure consisting of chest compressions and artificial ventilation, a means of assisting or stimulating breathing]) guidelines. This deficient practice resulted in Patient 1’s condition to further worsen and resulted in Patient 1’s death. (Refer to A- 0398) 3. Nursing staff failed to perform vital signs (VS, temperature, blood pressure, pulse, respiratory rate, and pain) check every four (4) hours and failed to address and report abnormal vital signs to the physician for one of 30 sampled patients (Patient 1). This deficient practice had the potential for changes in Patient 1’s condition to go unidentified by staff and Patient 1’s needs not being addressed in the event of a change of condition, which may result in patient harm and/or death. (Refer to A- 0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment and resulted in Patient 1’s death.”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility’s Governing Body failed to ensure its Contracted Clinic performed all necessary tests (such as EKG [electrocardiogram, a recording of the heart’s electrical activity] and Chest X-ray [a test that creates an image of the heart, lungs, and bones]) and clearance prior to admitting one of 30 sampled patients (Patient 1) to the facility and failed to ensure Patient 1 met the criteria for admission to the facility, in accordance with the facility’s policy and procedure regarding criteria for admission. This deficient practice had the potential for Patient 1 to have medical complications (such as cardiac arrest [when the heart stops beating]) that the facility may not be able to handle, making it unsafe to admit Patient 1. Findings: During a review of Patient 1’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/07/2023 at 10:06 p.m., the H&P indicated the following: Patient 1 was admitted to the facility on 12/6/2023 on a 5150-Hold (72-hour, involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) for being a danger to others and agitated (a feeling of irritability or severe restlessness) behavior. Patient 1’s diagnosis included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucinations [sensing things such as visions, sounds or smells that seem real but are not]), morbid obesity (over 100 pounds over your recommended weight), type 2 diabetes (high blood sugar), hypertension (high blood pressure), and seizures (medical condition that happens due to uncontrolled activity in the brain). During a review of Patient 1’s “Vital Signs (include temperature, blood pressure, heart rate, respiratory rate),” record dated 12/14/203 at 8 a.m., the Vital Signs record indicated Patient 1 weighed 460 pounds (lbs., a unit of measurement) During a review of Patient 1’s “Nutrition Assessment,” dated 12/14/2023 at 9:44 a.m., the Nutrition Assessment indicated the following: Patient 1 weighed 460 lbs. and was 68 inches tall. Body Mass Index (a measure of body fat based on height and weight): 69.94 (over 40 indicates morbid obesity). During a concurrent interview and review of Patient 1’s medical record on 1/08/2024 at 2:53 p.m., with Registered Nurse (RN) 1, RN 1 stated Patient 1 was admitted to the facility on 12/06/2023 to the Medical Surgical Unit (serves the general patient population hospitalized for various cases such as surgery, etc.) from the facility’s Contracted Clinic (Clinic), located on the second (2nd) floor of the building. RN 1 stated Patient 1 was on a 5150 Hold for being a danger to others and agitation (a feeling of irritability or severe restlessness). RN 1 stated Patient 1 weighed 460 pounds (lbs.) and was morbidly obese. RN 1 stated patients were medically cleared by the Clinic prior to admission. The medical clearance included an electrocardiogram (EKG, a recording of the heart’s electrical activity) and a chest x-ray (a test that creates an image of the heart, lungs, and bones). RN 1 verified that an EKG and a chest X-ray were not performed by the Clinic prior to clearing Patient 1 for admission. RN 1 verified that on 12/16/2023, Patient 1’s health declined, and Patient 1 expired on 12/16/2023 at 6:20 a.m. During a concurrent interview and review of Patient 1’s medical record on 1/11/2024 at 12:38 p.m., with House Supervisor (HS) 2, HS 2 verified Patient 1’s documented weight was 460 lbs. HS 2 also verified Patient 1 had multiple co-morbidities (existence of more than one disease or condition within the body at the same time), including diabetes and hypertension. HS 2 stated patients who weigh 460 lbs. should not be admitted to the facility because their (referring to the patients) health can decline very quickly. HS 2 stated Patient 1 should not have been admitted to the facility because the facility does not have the capability to address the patient’s (Patient 1) condition if the patient suffers from complications of morbid obesity along with Patient 1’s multiple co-morbidities. During an interview on 1/11/2024 at 2:20 p.m., with Physician (MD) 1, in the Contracted Clinic, MD 1 stated the Clinic medically cleared patients prior to admitting the patients to the facility. Medical clearance included an EKG and a chest X-ray for all the patients. MD 1 stated Patients who weigh 460 lbs. and have co-morbidities (such as hypertension and diabetes) should not be admitted to the facility. During a review of the facility’s policies and procedure (P&P) titled, “Admission Criteria,” dated 3/2022, the P&P indicated the following: Purpose: To provide guidelines for admission to the Psychiatric Unit that conforms to the laws of California. Procedure: ...Patients must be medically cleared before they are admitted to the psychiatric unit ...Conditions that may prevent admission but are not limited to the following: ...Morbid Obesity (over 100 pounds over your ideal body weight). During a review of the facility’s “Service Agreement,” between the facility and the Contracted Clinic (Company or Clinic), dated 10/2023, the Service Agreement indicated the following: “Applicable Standards. Company and its staff agree that the Services shall be performed in compliance with all applicable standards set forth by law or ordinance or established by the rules and regulations of any federal, state, or local agency, department, commission, association or other pertinent governing, accrediting, or advisory body, including the Joint Commission (an agency that oversees quality improvement and patient safety in health care), Healthcare Facilities Accreditation Program or other accrediting agencies, having authority to set standards for health care facilities. Exhibit A: Services and Fees: Medical Clearance ...””

“EMERGENCY SERVICES CFR(s): 482.12(f)(2) If emergency services are not provided at the hospital, the governing body must assure that the medical staff has written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility’s Governing Body failed to ensure an onsite physician (a physician who is physically present at the facility) was readily available for one of 30 sampled patients (Patient 1), who was experiencing a medical emergency (low blood pressure and low heart rate). This deficient practice resulted in the nursing staff handling a medical emergency for Patient 1 without a physician physically present to evaluate Patient 1’s condition including Patient 1’s responses to interventions and give direction to nursing staff. This deficient practice also resulted in Patient 1’s death. On 1/09/2024 at 4:35 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Nursing Officer (CNO), Vice President of Operations (VPO), Pharmacy Manager (Pharm M), Chief Strategist Officer (CSO), and the Director of Quality & Risk Management (DQRM). Prior to 1/8/2024, the facility failed to provide an on-site physician to be readily available for a patient (Patient 1) experiencing a medical emergency during the night shift. Patient 1 was admitted to the facility on 12/6/2023 on a 5150-Hold (72-hour, involuntary hold- a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) for being a danger to others and agitated (a feeling of irritability or severe restlessness) behavior. Patient 1’s diagnosis included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucinations [sensing things such as visions, sounds or smells that seem real but are not]), morbid obesity (over 100 pounds over your recommended weight), type 2 diabetes (high blood sugar), hypertension (high blood pressure), and seizures (medical condition that happens due to uncontrolled activity in the brain). On 12/16/2023 at 5:45 a.m., a Rapid Response (a process for working with a rapidly declining patient) was called for Patient 1, who was found unresponsive (unconscious and possibly dead or dying). In addition, Patient 1’s blood pressure (BP) was 60/35 (low, normal is 120/80) millimeters of mercury (mmHg, a unit of measurement), heart rate was 32 (Normal range 60 - 100), and oxygen saturation level (measures the amount of oxygen in the blood) was 48 % (normal is 90 - 100 %). No interventions addressing the abnormal vital signs (includes temperature, blood pressure, heart rate, respiratory rate) were documented during the Rapid Response. Nursing staff were not able to establish an intravenous (IV, into the vein) line, despite multiple attempts. The House Supervisor (HS 1) contacted a physician, by telephone, who ordered a stat (immediate) EKG (electrocardiogram, a recording of the heart’s electrical activity) and Code Blue (patient with an unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]). A Code Blue was called at 5:50 a.m., when CPR (cardiopulmonary resuscitation, an emergency procedure consisting of chest compressions and artificial ventilation [a means of assisting or stimulating breathing]) and assisted breathing were started. IV insertion efforts were still unsuccessful, and the facility was unable to administer emergency medications. There was no documentation that a provider (physician) arrived onsite at the facility to lead the Code Blue, assist with emergency IV access, or interpret the EKG results. At 5:59 a.m., the paramedics arrived and took over CPR. At 6:20 a.m., CPR was terminated and Patient 1 expired (died). There was no policy or process in place to provide on-site physician coverage overnight, to care for patients experiencing a medical emergency. On 1/11/2024 at 5:23 p.m., the IJ was removed in the presence of the CNO, DQRM, Chief Executive Officer (CEO), and Administration (ADM) after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record reviews. The IJ Removal Plan indicated that the facility’s Governing Body would ensure ongoing compliance and provide oversite for all hospital activities including 24-hour onsite physician coverage. The facility had a contract agreement with an on-site clinic to provide on-site physician coverage during the day shift from 9 a.m. to 9 p.m. The facility amended its contract agreement with the clinic to include 24-hour physician coverage by adding on-site physician coverage to respond to Rapid Reponses and Code Blues during the night shift from 9 p.m. to 9 a.m., effective 1/10/2024. The facility’s Rules & Regulations were updated to include an on-site physician, from the contracted clinic, who would be available for 24-hours a day, 7 days a week. Physician responsibilities included medical evaluation, assessment of patient’s condition, interventions, and recommendations for the plan of care. The on-site physician must be prepared to respond promptly to emergencies including code blues, rapid responses, or other critical situations. The physicians are also required to provide consultations, prescribe medications if needed, and document all interactions and clinical decisions in the electronic medical record. In addition, the facility implemented its policy titled, “Hospital Plan for Provision of Care,” to include 24 hour 7 days a week clinic on-site physician. All healthcare providers were expected to comply with this policy. Findings: During a review of Patient 1’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/07/2023 at 10:06 p.m., the H&P indicated the following: Patient 1 was admitted to the facility on 12/6/2023 on a 5150-Hold (72-hour, involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) for being a danger to others and agitated (a feeling of irritability or severe restlessness) behavior. Patient 1’s diagnosis included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucinations [sensing things such as visions, sounds or smells that seem real but are not]), morbid obesity (over 100 pounds over your recommended weight), type 2 diabetes (high blood sugar), hypertension (high blood pressure), and seizures (medical condition that happens due to uncontrolled activity in the brain). During a review of Patient’s 1’s nurses note titled, “Interdisciplinary (comprise of the physician, nurse, respiratory therapist, etc. Involved in the care of a patient) Team Progress Note,” dated 12/16/2023 at 5:45 a.m., the Interdisciplinary Team Progress Note indicated a Rapid Response (a process for working with a rapidly declining patient) was called for Patient 1 due to Patient 1 found unresponsive (unconscious and possibly dead or dying) with the following vital signs: Blood pressure (BP) 60/35 (normal 120/80) millimeters of mercury (mmHg, a unit of measurement), heart rate (HR) 32 (normal 60 - 100) and oxygen saturation level (sp02, measures the amount of oxygen circulating in the blood) 48% (normal 90 - 100), respirations were not documented. Rapid response (a process for working with a rapidly declining patient) was called. There was no documentation to indicate that Patient 1 was provided with supportive medical management (includes interventions such as face mask to deliver oxygen, intravenous [IV, into the vein] fluids, etc.) for the low saturation, low BP, and low HR. During a review of Patient’s 1’s nurses note titled, “Nursing Progress Note,” dated 12/16/2023 at 5:47 a.m., the Nursing Progress Note indicated that the facility was not able to establish the Intravenous (IV, into the vein) access on Patient 1 despite of numerous attempts during the Rapid Response. During a review of Patient’s 1’s nurses note titled, “Progress Note,” dated 12/16/2023, at 9:10 a.m., the Progress Note indicated, the house supervisor (HS 1) contacted the Nurse Practitioner (NP), and then the Medical Doctor (MD). MD gave a telephone order for a stat (immediate) EKG (electrocardiogram, a recording of the heart’s electrical activity) and code blue (patient with an unexpected cardiac or respiratory arrest [when the heart stops beating] requiring resuscitation [methods used to restart the heart and lungs when they stop working]). There was no documentation that NP or MD arrived on-site to the facility to evaluate Patient 1’s condition and guide the nursing staff with interventions to address Patient 1’s medical emergency. During a review of Patient 1’s CPR (Cardiopulmonary Resuscitation, an emergency procedure consisting of chest compressions and artificial ventilation [a means of assisting or stimulating breathing]) Record,” dated 12/16/2023, the CPR record indicated the Code Blue was initiated at 5:50 a.m., because Patient 1 was in asystole (no heart-beat or flatline) and assisted breathing (use of devices to help a patient breathe) was provided; at 5:50 a.m., IV access insertion was still unsuccessful. At 5:51 a.m. (6 minutes after the Rapid Response was initiated) 9-1-1 was called; at 5:58 a.m., code blue team continued CPR. At 5:59 a.m., paramedics arrived and took over CPR. At 6:20 a.m., CPR terminated and Patient 1 expired (died). The Code Blue for Patient 1 was initiated by Licensed Vocational Nurse (LVN) 1. During an interview on 1/9/2024 at 11:11 a.m., RN 1 stated the House Supervisor leads the code blue team if a physician is not available. During an interview on 1/9/2024, at 10:00 a.m., with the Chief Nursing Officer (CNO), the CNO stated, if a rapid response is called on a patient, the primary physician is notified. The CNO stated, during the Code Blue, staff should begin CPR, activate the ACLS (Advance Cardiac Life Support, a set of life-saving protocols and skills that goes beyond the basic life support [such as CPR]) protocol and call the on-call physician for further orders. Primary MD had to be informed of the patient’s change of condition. The CNO further stated, the On-Call (means physician is available to work when called) physician is called for the orders and is expected to come on-site for further treatment. The CNO also stated, prior to 1/8/2024, the facility did not have an on-site physician to cover the night shift hours from 11:00 p.m. to 7:00 a.m., since November 2022 when the Intensive Care Unit (ICU, a specialized unit that cares for patients that require critical medical care) closed. The Rapid Response and the Code Blue for Patient 1 happened between 11:00 p.m. and 7:00 a.m. when there was no on-site physician present at the facility. This was verified by the CNO during an interview. During an interview on 1/9/2024 at 11:20 a.m., with the Chief of Staff (COS), the COS stated physicians take on- call telephone calls. There was no on-site physician at night and the physicians taking on- call telephone calls at night were not present on-site. During an interview on 1/9/2024 at 11:40 a.m., with the Chief Medical Officer (MD 2), the MD 2 stated the on-call schedule prepared by the facility was on-call physician schedule for phone calls and not in-person on-call which meant there was no on-site physician available at night to respond to medical emergencies. The physicians only take phone calls from the nursing staff and orders are given over the phone when there is a medical emergency. There was no policy or process in place to provide on-site physician coverage overnight, to care for patients in the facility requiring care for medical emergencies. This was verified by the CNO during an interview.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 48186 Based on interview and record review, the facility failed to ensure that patient rights (ethical principles that apply to patient care; informs patient of their autonomy over medical decisions and rights as a patient in the hospital. Example: right to participate in decision-making regarding treatment plan, etc.) information and conditions of admissions (COA- a form that outlines the patient’s obligations for hospital services received, including the duty to pay for services rendered) information was provided for one of 30 sampled patients (Patient 26). This deficiency resulted in Patient 26 not being informed of his (Patient 26) rights as a patient, which may result in Patient 26 not being involved in the treatment plan and may cause delay in the patient’s (Patient 26) recovery. Findings: During a review of Patient 26’ Face Sheet (a document that gives a patient’s information at a quick glance), dated 1/4/2024, the Face Sheet indicated Patient 26 was admitted on 1/4/2024 at 9:00 p.m. with diagnoses of mental illness (changes in emotion, thinking or behavior), angry outbursts, and aggressive behavior. During a review of Patient 26’ “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/5/2024 at 1:19 p.m., the H&P indicated Patient 26 had a past medical history of Alzheimer’s disease (a brain disorder that slowly affects a person’s memory and thinking skills), major depression (a serious medical illness that affects how someone feels, the way they think and how they act), schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucinations [sensing things such as visions, sounds or smells that seem real but are not]) and psychosis (severe mental condition affecting thought processes and emotions, requiring hospitalization). The H&P further indicated Patient 26 was able to participate in a “review of systems (series of questions asked by a physician to identify signs and/or symptoms the patient may be experiencing).” The H&P did not indicate Patient 26 was unable to make independent decisions regarding medical care. During a review of Patient 26’ Psychiatric Evaluation (comprehensive evaluations conducted by qualified mental health physician), dated 1/5/2024 at 10:28 a.m., Patient 26’ Psychiatric Evaluation indicated Patient 26 was admitted to the facility under a 5150 hold (72-hour, involuntary hold- a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) due to being a danger to others. During a review of Patient 26’ psychosocial assessment (an evaluation of a person’s mental health, social status, and functional capacity within the community), dated 1/5/2024 at 12:25 p.m., Patient 26’s psychosocial assessment indicated Patient 26 had no learning barriers (anything that prevents a learner from being fully engaged in the learning process) identified. During a concurrent interview and record review on 1/11/2024 at 11:18 a.m. with the Behavioral Health Director (BHD), Patient 26’ medical records indicated Patient 26’ admissions forms (forms signed when admitted to the hospital), including the Conditions of Admission (COA- a form that outlines the patient’s obligations for hospital services received, including the duty to pay for services rendered) and Patient’s Rights (ethical principles that apply to patient care; informs patient of their autonomy over medical decisions and rights as a patient in the hospital. Example: right to participate in decision-making regarding treatment plan, etc.) forms, were not signed by Patient 26. BHD said the admission forms which included the COA, and the Patient Rights forms, were not signed by Patient 26 to indicate acknowledgement and receipt. BHD stated that when patients were on a 5150 hold, they (referring to patients) can make decisions for themselves, if they were assessed to have the capability such as in the case of Patient 26. BHD also said if patients can make decisions for themselves, they should be provided with and sign their own admission forms such as the COA and the Patient Rights form. BHD further stated that on admission, patients should be informed of their patient rights. During a concurrent interview and record review on 1/11/2024 at 1:05 p.m. with Social Worker 1 (SW 1), SW 1 stated, when a patient was admitted, it was the social workers responsibility to meet with the patient and perform a psychosocial assessment. SW 1 confirmed that Patient 26’ psychosocial assessment indicated Patient 26 had the ability to make independent decisions. SW 1 confirmed that Patient 26 should have signed the admission forms independently which included information regarding his (Patient 26) patient rights. During an interview on 1/11/2024 at 2:13 p.m. with Admitting Clerk 1 (AC 1), AC 1 stated that upon admission, patients were registered by the admitting clerk. AC 1 stated the admitting clerk’s duties were to gather information and obtain signatures for admission paperwork, including the conditions of admission and patient rights forms. AC 1 stated the admission paperwork was forwarded to the social worker for follow up. AC 1 stated it was the responsibility of the social worker to review the admission paperwork submitted by the admitting clerk and follow up with the patient to ensure the patients received and signed their admission forms and informed of their patient rights if capable of doing so. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights: Rights of Involuntary Patients 5150,” dated March 2019, the P&P indicated: “Policy: It is the policy ...to exhibit and adhere to the rights of involuntary patients as defined by the State of California ... Procedure: 3. All patients receiving involuntary inpatient mental health services have the right to be informed verbally and in writing within twenty-four (24) hours of admission, in the person’s primary language, in simple, non-technical terms, of their rights ...””

“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: 46238 Based on observation, interview, and record review, The facility failed to assess for environmental safety risks (such as ligature [anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation] risks) to identify potential hazards for patients at risk of harm to themselves or others for two of 30 sampled patients (Patient 15 and Patient 16). Both patients (Patient 15 and Patient 16) were admitted to the facility on a 5150-hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) due to danger to self and others. This deficient practice had the potential to compromise Patient 15’s and Patient 16’s health and safety due to the lack of proper environmental safety checks, to assess for presence of ligature risks, conducted by the facility, which may result in patient harm and/or death via hanging or strangulation (external pressure applied to the neck, by any means, that obstructs the blood flow and/or airflow) using available cords in the patient room. Findings: 1a. During a review of Patient 15’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/28/2023, the H&P indicated, Patient 15 was admitted to the facility’s medical/surgical (serves the general patient population hospitalized for various cases such as surgery, etc.) floor (a dual psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] and medical unit, for patients with psychiatric and medical health conditions) for a psychiatric treatment for increasing psychosis (severe mental condition affecting thought processes and emotions, requiring hospitalization). During a review of Patient 15’s Psychiatric Evaluation (Psych Eval, thorough mental health assessment), dated 12/28/2023, the Psychiatric Evaluation indicated, Patient 15 was admitted on 5150 hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others), endorsing homicidal ideation (a thought pattern characterized by the desire to kill another person or persons, along with a mental plan for a method of doing it) to assault (attack violently). During an observation on 1/8/2024, at 3:30 p.m., in Patient 15’s room, Patient 15 was observed in bed, with privacy curtain pulled over visual field, preventing the line of sight (a level of observation wherein the patient remains in staff view at all times) from staff. During a concurrent observation and interview on 1/8/2024 at 3:22 p.m. with Chief Nursing Officer (CNO), Patient 15’s room was observed. Multiple ligature (anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) risk points were identified: an electric cord on bed, electric cords behind television exposed, call light with a long cord placed on Patient 15’s bed, empty laundry basket with plastic liner parked inside the room, multiple door knobs, shoes with shoelaces, and the emergency pull cord in the bathroom were identified. The CNO stated, electric cords should be removed for psychiatric patients because this is not safe and CNO also stated maintenance should be called to remove the ligature risks. During an interview on 1/8/2024 at 3:22 p.m. with the CNO, the CNO stated, the facility uses medical surgical units located on the 6th and 7th floors for patients with psychiatric and medical conditions alike. The CNO further stated, most patients on the 6th and 7th floors were psychiatric patients and multiple patients were on a 5150 hold or a 5250 hold (a law that allows a patient with mental, emotional and behavioral issues to be detained for 14 days involuntarily for stabilization treatment [interventions to address mental health]). The CNO stated, there were safety rounds (patient rounding, a best practice intervention to ensure patient safety) that were done by the assigned mental health workers every 15 minutes to check on patients, but there was no ligature risk assessment including the removal of ligatures that was done during those safety rounds. During an interview on 1/8/2024 at 3:35 p.m. with Registered Nurse (RN 2), the RN 2 stated, the safety checks were conducted by mental health workers at every 15 minutes intervals, but the RN 2 further stated this safety check was not the primary nurse’s duty to oversee the rounds for safety checks and the documentation by the mental health workers. The RN 2 also said, actively suicidal patients required a one-to-one (1:1 - consist of one-to-one staff observation with a patient never farther away at arm’s length at all times) order for a sitter and patients with aggressive behavior were monitored by the mental health workers during the safety rounds. The RN 2 was not able to identify potential environmental hazards in patients’ rooms. During an interview on 1/8/2023 at 3:55 p.m. with mental health worker (MHW) 1, the MHW 1 was not able to identify ligature risks in the environment when conducting safety checks. MHW 1 stated, “I do round (patient rounding, a best practice intervention to ensure patient safety) on patients every 15 minutes and document observations and patients’ whereabouts.” However, MHW 1 was not able to verbalize that the presence of ligature risks in the patients’ rooms were part of what was being observed during patient rounding. MHW 1 stated that the observations conducted only included observing what the patient was doing and does not include observing/checking the environment for any potential hazards that the patients can use to harm themselves or others. During a concurrent interview and record review on 1/10/2024 at 2:25 p.m. with the facility’s case manager (CM), Patient 15’s record titled, “Patient Round Sheet,” dated 1/7/2024 to 1/8/2024, was reviewed. The record indicated, on 1/8/2024 and 1/9/2024, the mental health worker (MHW) did not mark Patient 15’s level of precautions (Level II: standard every 15 minutes round checks; or Level III: patient requires constant observation) and no measures indicating what precautions (safety precautions) were implemented for Patient 15, were marked. On 1/7/2024, the MHW marked both Level II and Level III, for Patient 15. The CM stated only one level of precautions must be marked for a patient, as well as measures/interventions implemented, based on precautions identified for the patient during safety rounds checks. The CM further stated, the MHU may need further training on conducting patient safety round checks. During a concurrent interview and record review on 1/10/2024 at 2:25 p.m. with the Case manager (CM), Patient 15’s medical record, dated 12/28/203 to 1/9/2023 was reviewed. The record indicated, no documentation of environment safety assessment for Patient 15 was documented anywhere in the records. During an interview on 1/12/2024 at 1:24 p.m. with the Chief Nursing Officer (CNO), the CNO stated, there were many ligature risks in patients’ room on the 6th and 7th floors because the floors were designed as medical floors, not psychiatric floors; however, the majority of patients admitted to these floors were psychiatric patients and many of the patients were on a hold for danger to self or others. The CNO further stated, patients can hurt themselves or others with ligature points and therefore, the environmental hazards needed to be identified and removed during safety checks. The CNO further stated, no ligature risk reduction training was ever provided to staff working in the facility and the facility did not have a process for safety risks assessment to be conducted by the staff to identify hazards and environmental risks to provide safety to patients at risk for harm to themselves or others. During a review of the facility’s policy and procedure (P&P) titled, “Ligature Risk Reduction/Mental Health Environment of Care Check List,” dated 10/02/2023, the P&P indicated, “Inpatient psychiatric medical and psychiatric units, must achieve a ligature-resistant environment to promote safety for patients at risk of harm to themselves or others. Systematic environmental assessments using the facility assessment tool for the purpose of eliminating factors that could contribute to the attempted suicide (ending own life) or harm of a patient or staff members. Ligature risk points are defined as anything that could be used to create a sustainable attachment point, such as cord, rope, or other materials, for hanging or strangulation. Common points include doorknobs, handles, hooks, window frames, belts, sheets, towels, shoelaces.” 1b. During a review of Patient 16’s History and Physical (H&P, a formal and complete assessment of the patient and the problem) ), dated 1/5/2024, the H&P indicated, Patient 16 was admitted for a psychiatric (a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders) management to the facility’s medical/surgical (serves the general patient population hospitalized for various cases such as surgery, etc.) floor (a dual psychiatric and medical floor, for patients with psychiatric disorders and medical health conditions) for a psychiatric treatment for increasing psychosis (severe mental condition affecting thought processes and emotions, requiring hospitalization) due to aggression toward others. Patient 16 was placed on a 5150 Hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others). During a review of Patient 16’s psychiatric evaluation (Psych eval, thorough mental health evaluation), dated 1/5/2024, the Psychiatric Evaluation indicated, Patient 16 was placed on 5150 hold due to risk of striking out at others and required psychiatric treatment. The Psychiatric evaluation further indicated, Patient 16 had no regard for safety and required supervision to prevent violent acting out. During a review of Patient 16’s medical record titled, “Nursing Assessment,” dated 1/5/2024, the Nursing Assessment record indicated, Patient 16 had poor insight (deficit of the capacity of Judgment), poor eye contact (avoidance of looking at someone directly in the eye), poor judgement (inability to make appropriate decisions), and irritable mood (feeling of agitation as a result of mental health condition). The record further indicated, Patient 1 was alert and oriented to self only. During an interview on 1/8/2024 at 3:35 p.m. with Registered Nurse (RN 2), RN 2 stated, the safety checks were conducted by mental health workers at every 15 minutes intervals, but the RN 2 further stated this was not the primary nurse’s duty to oversee the rounds (patient rounding, a best practice intervention to ensure patient safety) for safety checks and the documentation by the mental health workers. The RN 2 also stated, actively suicidal patients required a one-to-one (1:1- consist of one-to-one staff observation with a patient never farther away at arm’s length at all times) order for a sitter and patients with aggressive behavior were monitored by the mental health workers during the safety rounds. The RN 2 was not able to identify potential environmental hazards in patients’ rooms. During an interview on 1/8/2023 at 3:55 p.m. with mental health worker (MHW) 1, the MHW 1 was not able to identify ligature risks in the environment when conducting safety checks. MHW 1 stated, “I do round (patient rounding, a best practice intervention to ensure patient safety) on patients every 15 minutes and document observations and patients’ whereabouts.” However, MHW 1 was not able to verbalize that the presence of ligature risks in the patients’ rooms were part of what was being observed during patient rounding. MHW 1 stated that the observations conducted only included observing what the patient was doing and does not include observing/checking the environment for any potential hazards that the patients can use to harm themselves or others. During a concurrent interview and record review on 1/10/2024 at 2:25 p.m. with the facility’s case manager (CM), Patient 16’s record titled, “Patient Round Sheet,” dated 1/7/2024 to 1/8/2024, was reviewed. The record indicated, on 1/8/2024 and 1/9/2024, the mental health worker (MHW) did not mark Patient 16’s level of precautions (Level II: standard every 15 minutes round checks; or Level III: patient requires constant observation) and no measures indicating what precautions (safety precautions) were implemented for Patient 16, were marked. On 1/7/2024, the MHW marked both Level II and Level III, for Patient 16. The CM stated only one level of precautions must be marked for a patient, as well as measures implemented, based on precautions identified for the patient during safety rounds checks. The CM further stated, the MHW may need further training on conducting patient safety round checks. During an interview and concurrent record review on 1/11/2024, at 11:17 a.m., with the case manager (CM), Patient 16’s medical record (MR) dated 1/5/2024 to 1/8/2024 was reviewed. The MR contained no record of environmental safety screening. The CM stated, the facility does not have an assessment tool to screen for and identify environmental hazards. During an interview on 1/11/2024 at 2:14 p.m. with facility supervisor (HS 2), the HS 2 stated, environmental safety checks on both 6th & 7th medical/surgical floors, should be conducted, but there was nothing that can be done about the ligature (anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) risks. The HS 2 further stated, if a patient was actively suicidal, a 1:1 sitter may be assigned, otherwise, the staff does frequent rounding which was done by the mental health workers for safety and nurses conduct routine behavior assessment for each patient. During an interview on 1/11/2024 at 2:14 p.m. with facility supervisor (HS 2), the HS 2 was not able to state what was meant by Level II and Level III precautions (Level II: standard every 15 minutes round checks; or Level III: patient requires constant observation) documented on “Patient Round Sheet” and stated, mental health workers should know. During an interview on 1/12/2024 at 1:24 p.m. with the Chief Nursing Officer (CNO), the CNO stated, there were many ligature risks in patients’ room on the 6th and 7th floors because the floors were designed as medical floors, not psychiatric floors; however, the majority of patients admitted to these floors were psychiatric patients and many of the patients were on a hold for danger to self or others. The CNO further stated, patients can hurt themselves or others with ligature points and therefore, the environmental hazards needed to be identified and removed during safety checks. The CNO further stated, no ligature risk reduction training was ever provided to staff working in the facility and the facility did not have a process for safety risks assessment to be conducted by the staff to identify hazards and environmental risks to provide safety to patients at risk for harm to themselves or others. During a review of the facility’s policy and procedure (P&P) titled, “Ligature Risk Reduction/Mental Health Environment of Care Check List,” dated 10/02/2023, the P&P indicated, “Inpatient psychiatric medical and psychiatric units, must achieve a ligature-resistant environment to promote safety for patients at risk of harm to themselves or others. Systematic environmental assessments using the facility assessment tool for the purpose of eliminating factors that could contribute to the attempted suicide or harm of a patient or staff members. Ligature risk points are defined as anything that could be used to create a sustainable attachment point, such as cord, rope, or other materials, for hanging or strangulation. Common points include doorknobs, handles, hooks, window frames, belts, sheets, towels, shoelaces.””

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure its Quality Assurance and Performance Improvement (QAPI, a process used to ensure services are meeting quality standards and assuring care reaches a certain level) department analyze and provide measurable data to track the facility’s rapid response (a process for working with a rapidly declining patient) and code blue (patient with an unexpected cardiac or respiratory arrest [when the heart stops beating] requiring resuscitation [methods used to restart the heart and lungs when they stop working]) events for one of two sampled patients (Patient 1). This deficient practice resulted in the facility’s inability to assess and monitor its staff performance including the effectiveness of staff intervention in a rapid response and/or code blue event as evidenced by staff not following the facility’s rapid response/code blue protocols (standard procedures to be followed and implemented during a medical emergency) which led to Patient 1’s death. Findings: During a review of Patient 1’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/07/2023 at 10:06 p.m., the H&P indicated the following: Patient 1 was admitted to the facility on 12/6/2023, on a 5150-hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others)) due to danger to others and agitated (a feeling of irritability or severe restlessness) behavior. Patient 1’s admission diagnoses included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucination [sensing things such as visions, sounds or smells that seem real but are not]), type 2 diabetes (high blood sugar), hypertension (high blood pressure), seizure (medical condition that happens due to uncontrolled activity in the brain), and morbid obesity (weight over 100 pounds over the recommended weight). During a review of Patient’s 1’s nurses note titled, “Interdisciplinary Team Progress Note,” dated 12/16/2023 at 5:45 a.m., the Interdisciplinary (comprise of the physician, nurse, respiratory therapist, etc. Involved in the care of a patient) Team Progress Note indicated a Rapid Response (a process for working with a rapidly declining patient) was called for Patient 1 due to Patient 1 found unresponsive (unconscious and possibly dead or dying) with the following vital signs: Blood pressure (BP) 60/35 (normal 120/80) millimeters of mercury (mmHg, a unit of measurement), heart rate (HR) 32 (normal 60 - 100) and oxygen saturation level (sp02, measures the amount of oxygen in the blood) 48% (normal 90 - 100), respirations were not documented. Rapid response was called. There was no documentation to indicate that Patient 1 was provided with supportive medical management for the low saturation, low BP, and low HR. During a review of Patient 1’s CPR (cardiopulmonary resuscitation, an emergency procedure consisting of chest compressions and artificial ventilation [a means of assisting or stimulating breathing]) Record,” dated 12/16/2023, the CPR record indicated that a Code Blue (patient with an unexpected cardiac or respiratory arrest [when the heart stops beating] requiring resuscitation [methods used to restart the heart and lungs when they stop working]) was initiated at 5:50 a.m., because Patient 1 was in asystole (no heart-beat or flatline) and assisted breathing was provided; at 5:50 a.m., IV (intravenous, into the vein) access insertion was still unsuccessful. At 5:51 a.m., (6 minutes after the Rapid Response was initiated) 9-1-1 was called; at 5:58 a.m., code blue team continued CPR. At 5:59 a.m., paramedics arrived and took over CPR. At 6:20 a.m., CPR terminated and Patient 1 expired (died). During a concurrent interview and review of Patient 1’s nurses notes, on 01/10/2024, at 11:18 a.m., with the House supervisor (HS) 1, HS 1 confirmed that HS 1 responded to Patient 1’s rapid response called on 12/16/2023 at 5:45 a.m. with arrival time at 5:47 a.m. Upon arrival, Patient 1 was unresponsive and was on oxygen with 2 liters per minute via nasal canula (a device used to deliver supplemental oxygen). HS 1 stated Patient 1’s heart rate of 32 and spO2 (oxygen saturation) of 48% were out of range. Nursing staff attempted to insert IV in anticipation for IV fluids and emergency medications but were unsuccessful. HS 1 stated Code Blue was activated due to no pulse, no blood pressure and no respiration; at 5:49 a.m., Physician called back with orders to insert an IV line, intubate (a process of inserting a plastic tube into a patient’s airway to assist with breathing) the patient, continue CPR, and give Epinephrine (a hormone used to restore heart rhythm) 1 mg every 3 minutes. HS 1 stated Patient 1 was connected to the vital signs machine which monitored blood pressure and heart rate. Then nursing staff connected Patient 1 to a defibrillator (a device that applies an electric charge to the heart to restore a normal heartbeat). HS 1 stated, Patient 1 “had no pulse and was flat line for 10 minutes before the fire department’s arrival.” HS 1 stated the fire department arrived at 5:59 a.m. Upon arrival of fire department, the fire department staff took over CPR and established an intraosseous (IO, an emergency route for fluid and drug delivery) access on Patient 1’s left shin. In addition, the fire department administered total of 3 doses of Epinephrine. CPR was terminated and Patient 1 was pronounced dead by the fire department at 6:20 a.m. In addition, on 01/10/2024, at 11:30 a.m., HS 1 reviewed Patient 1’s cardiac “Rhythm Strip (a record of the electrical activity of the heart),” dated 12/16/2023 at 5:59 a.m. and Patient 1’s Code Blue cardiac rhythm strips dated 12/16/2023 at 5:52 a.m. and at 6:01 a.m. were reviewed. HS 1 stated she (HS 1) was the team leader for the Code Blue. HS 1 interpreted the rhythm strip after the Code Blue was over. HS 1 stated the cardiac rhythm at 5:52 a.m. and 6:01 a.m. indicated ventricular fibrillation (a life-threatening heart rhythm). HS 1 further stated with this rhythm, the patient should be shocked (shock, using an electrical charge to stop the heart’s abnormal rhythm by a defibrillator). HS 1 stated the shock should have been delivered at 5:52 a.m. for Patient 1, but no shock was delivered during the code blue. HS 1 further stated the EKG completed on 12/16/2023 at 5:59 a.m. was never sent to a physician for interpretation. During a review of the facility’s Quality Council “2023 Risk Management Incident Dashboard (dashboard, a summary of different, but related data sets, presented in a way that makes the related information easier to understand),” dated 11/1/2023, the dashboard indicated, there were seven cases of “mortality (death)/code blue/rapid (responses)” in 2022 and nine cases of “mortality/code blue/rapid (responses)” up to third quarter in 2023. This was verified by the Director of Quality and Risk Management (DQRM) during an interview. During an interview on 1/12/2024 at 2:53 p.m. with the Director of Quality & Risk Management (DQRM), DQRM stated code blue historical data was presented in a summary fashion but not aggregated (to collect into one) and not broken down into analytical data. There was no review of code blue events to analyze if protocol was followed, and no review of the outcome from the code blue. DQRM further stated Quality Assessment and Performance Improvement did not provide oversight to rapid response and code blue events. During a record review of the facility’s policy and procedure (P&P) titled, “Rapid Response Team,” dated 2023, the P&P indicated, “A copy of the Rapid Assessment Team (RAT) record ... will also be sent to the Quality Improvement Coordinator, who will measure and trend the utility and effectiveness of the interventions employed.” During a record review of the facility’s 2023 Hospital Performance Improvement Plan, dated 2023, the Hospital Performance Improvement Plan indicated, “the primary goal is to provide a comprehensive Performance Improvement Program that will coordinate and integrate all performance improvement activities hospital wide to assure that the highest achievable safe and quality of care is delivered to the patient ...the organization collects data on measures as outlined by regulatory agencies and as needed to evaluate the services provided by the organization ... at a minimum the organization collects data on these measures: outcomes related to resuscitation (methods used to restart the heart and lungs when they stop working) ... on an ongoing basis, the data collected is analyzed to provide information about the facility and the systems within.””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to perform a root cause analysis (RCA, a structured, facilitated team process to identify the root cause of an event that resulted in an undesired outcome and develop corrective actions) on the facility’s rapid response (a process for working with a rapidly declining patient) and code blue (patient with an unexpected cardiac or respiratory arrest [when the heart stops beating] requiring resuscitation [methods used to restart the heart and lungs when they stop working]) events for one of one sampled patient (Patient 1). This deficient practice resulted in the facility’s inability to identify potential system or process changes that could improve performance or improve patient safety and prevent any undesired outcome such as Patient 1’s death or prevent harm and/or death to other patients admitted to the facility. Findings: During a review of Patient 1’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/07/2023 at 10:06 p.m., the H&P indicated the following: Patient 1 was admitted to the facility on 12/6/2023, on a 5150-hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) due to danger to others and agitated (a feeling of irritability or severe restlessness) behavior. Patient 1’s admission diagnoses included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucination [sensing things such as visions, sounds or smells that seem real but are not]), type 2 diabetes (high blood sugar), hypertension (high blood pressure), seizure (medical condition that happens due to uncontrolled activity in the brain), and morbid obesity (weight over 100 pounds over the recommended weight). During a review of Patient’s 1’s nurses note titled, “Interdisciplinary Team Progress Note,” dated 12/16/2023 at 5:45 a.m., the Interdisciplinary (comprise of the physician, nurse, respiratory therapist, etc. Involved in the care of a patient) Team Progress Note indicated a Rapid Response (a process for working with a rapidly declining patient) was called for Patient 1 due to Patient 1 found unresponsive (unconscious and possibly dead or dying) with the following vital signs: Blood pressure (BP) 60/35 (normal 120/80) millimeters of mercury (mmHg, a unit of measurement), heart rate (HR) 32 (normal 60 - 100) and oxygen saturation level (sp02, measures the amount of oxygen in the blood) 48% (normal 90 - 100), respirations were not documented. Rapid response was called. There was no documentation to indicate that Patient 1 was provided with supportive medical management for the low saturation, low BP, and low HR. During a review of Patient 1’s CPR (cardiopulmonary resuscitation, an emergency procedure consisting of chest compressions and artificial ventilation [a means of assisting or stimulating breathing]) Record,” dated 12/16/2023, the CPR record indicated that a Code Blue (patient with an unexpected cardiac or respiratory arrest [when the heart stops beating] requiring resuscitation [methods used to restart the heart and lungs when they stop working]) was initiated at 5:50 a.m., because Patient 1 was in asystole (no heart-beat or flatline) and assisted breathing was provided; at 5:50 a.m., IV (intravenous, into the vein) access insertion was still unsuccessful. At 5:51 a.m., (6 minutes after the Rapid Response was initiated) 9-1-1 was called; at 5:58 a.m., code blue team continued CPR. At 5:59 a.m., paramedics arrived and took over CPR. At 6:20 a.m., CPR terminated and Patient 1 expired (died). During a concurrent interview and review of Patient 1’s nurses notes, on 01/10/2024, at 11:18 a.m., with the House supervisor (HS) 1, HS 1 confirmed that HS 1 responded to Patient 1’s rapid response called on 12/16/2023 at 5:45 a.m. with arrival time at 5:47 a.m. Upon arrival, Patient 1 was unresponsive and was on oxygen with 2 liters per minute via nasal canula (a device used to deliver supplemental oxygen). HS 1 stated Patient 1’s heart rate of 32 and spO2 (oxygen saturation) of 48 % were out of range. Nursing staff attempted to insert IV in anticipation for IV fluids and emergency medications but were unsuccessful. HS 1 stated Code Blue was activated due to no pulse, no blood pressure and no respiration; at 5:49 a.m., Physician called back with orders to insert an IV line, intubate (a process of inserting a plastic tube into a patient’s airway to assist with breathing) the patient, continue CPR, and give Epinephrine (a hormone used to restore heart rhythm) 1 milligram (mg- a unit of measurement) every 3 minutes. HS 1 stated Patient 1 was connected to the vital signs machine which monitored blood pressure and heart rate. Then nursing staff connected Patient 1 to a defibrillator (a device that applies an electric charge to the heart to restore a normal heartbeat). HS 1 stated, Patient 1 “had no pulse and was flat line (represents cessation of mechanical activity of the heart) for 10 minutes before the fire department’s arrival.” HS 1 stated the fire department arrived at 5:59 a.m. Upon arrival of the fire department, the fire department staff took over CPR and established an intraosseous (IO, an emergency route for fluid and drug delivery) access on Patient 1’s left shin. In addition, the fire department administered total of 3 doses of Epinephrine. CPR was terminated and Patient 1 was pronounced dead by the fire department at 6:20 a.m. In addition, on 01/10/2024, at 11:30 a.m., HS 1 reviewed Patient 1’s cardiac “Rhythm Strip (a record of the electrical activity of the heart),” dated 12/16/2023 at 5:59 a.m. and Patient 1’s Code Blue cardiac rhythm strips dated 12/16/2023 at 5:52 a.m. and at 6:01 a.m. were also reviewed. HS 1 stated she (HS 1) was the team leader for the Code Blue. HS 1 interpreted the rhythm strip after the Code Blue was over. HS 1 stated the cardiac rhythm at 5:52 a.m. and 6:01 a.m. indicated ventricular fibrillation (a life-threatening heart rhythm). HS 1 further stated with this rhythm, the patient should be shocked (shock, using an electrical charge to stop the heart’s abnormal rhythm by a defibrillator). HS 1 stated the shock should have been delivered at 5:52 a.m. for Patient 1, but no shock was delivered during the code blue. HS 1 further stated the EKG completed on 12/16/2023 at 5:59 a.m. was never sent to a physician for interpretation. During an interview on 1/12/2024 at 2:53 p.m. with the Director of Quality & Risk Management (DQRM), DQRM stated no root cause analysis (RCA, a structured, facilitated team process to identify the root cause of an event that resulted in an undesired outcome and develop corrective actions) was done for rapid response and code blue events in 2023. DQRM further stated root cause analysis is important because it could point out the root cause problem of the event so that the team can address the issue by providing intervention and education for staff as needed. DQRM also said that there was no RCA done for the code blue incident involving Patient 1. During a record review of the facility’s policy and procedure (P&P) titled, “Rapid Response Team,” dated 2023, the P&P indicated, “A copy of the Rapid Assessment Team (RAT) record ... will also be sent to the Quality Improvement Coordinator, who will measure and trend the utility and effectiveness of the interventions employed.” During a record review of facility’s 2023 Hospital Performance Improvement Plan (a process used to ensure services are meeting quality standards and assuring care reached a certain level) dated 2023, the Hospital Performance Improvement Plan indicated, “Performance Improvement activities will track and trend data on critical patient safety indicators including, but not limited to, medical errors and adverse patient events (an event that resulted in an undesirable outcome such as death) and provide feedback and education throughout the hospital ... discuss the root cause analysis (RCA) and failure mode and effects analysis (FMEA, a step-by-step approach to identify all possible failures in a process).””

“MEDICAL STAFF RESPONSIBILITIES - H&P CFR(s): 482.22(c)(5)(i) [ The bylaws must:] Include a requirement that-- (i) A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(5)(iii) of this section. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified individual in accordance with State law and hospital policy. This Standard is not met as evidenced by: 48186 Based on interview and record review, the facility failed to ensure that a History & Physical (H&P, a formal and complete assessment of the patient and the problem) was completed and documented within 24 hours of admission for one of 30 sampled patients (Patient 24). Likewise, the facility also failed to ensure that a Psychiatric (a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders) Evaluation (a mental health assessment performed by a Physician used to determine a person’s mental state and guide recommendations) was completed within 24 hours of an order written for a psychiatric consult and document completion of the Psychiatric Evaluation within 24 hours of the consultation for one of 30 sampled patients (Patient 24) in accordance with the facility’s policy and procedure regarding completion of a History and Physical and consultation orders. This deficient practice had the potential to result in delayed diagnoses, medical treatments, and/or medications for Patient 24, which may worsen Patient 24’s medical and psychiatric conditions. Findings: During a review of Patient 24’s Face Sheet (a document that gives a patient’s information at a quick glance), the Face Sheet indicated Patient 24 was admitted on 12/29/2023 at 4:18 p.m. with diagnoses of dehydration (not enough water in the body) and hypernatremia (when the concentration of sodium [helps maintain a normal blood pressure and regulates the body’s fluid balance] in blood is abnormally low). During a review of Patient 24’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/31/2023 at 5:07 a.m., the H&P indicated Patient 24 was admitted to the facility due to multiple medical and psychiatric (a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders) conditions. During a review of Patient 24’s Physicians Orders, dated 12/29/2023 at 4:58 p.m., the Physicians Orders indicated, Patient 24 had an order for a Psychiatric Consult (mental health assessment by a psychiatrist [mental health physician]). During a review of Patient 24’s Psychiatric Progress Note, dated 1/1/2024 at 8:52 p.m., the Psychiatric Progress Note indicated Patient 24 had a diagnosis of schizoaffective disorder (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucinations [sensing things such as visions, sounds or smells that seem real but are not]), Bipolar type (a mental illness that can affect your thoughts, mood and behavior). During a concurrent interview and record review of Patient 24’s medical record on 1/11/2024 at 10:30 a.m. with the Behavioral Health Director (BHD), BHD verified Patient 24’s H&P was completed after 24 hours of admission (completed on 12/31/2023 while Patient 24 was admitted on 12/29/2023). BHD stated that Patient 24 was admitted initially as a medical patient. BHD said that the H&P was important because it sets up the plan of care that is used as a reference point for the care of a patient. Likewise, BHD verified there was an order for a psychiatric consult on 12/29/2023 and stated this should have been completed within 24 hours of the ordered date and time. Instead, the psychiatric consult was completed on 1/1/2024 (3 days [72 hours] after the psychiatric consult was ordered on 12/29/2023 by the primary medical doctor). BHD stated that a delay in the psychiatric consult can result in a delay in care for Patient 24 who needed psychiatric care. During an interview on 1/12/2024 at 1:24 p.m. with the Chief Nursing Officer (CNO), CNO stated that if there was an order for a psychiatric consult, the patient must be seen by a psychiatrist within 24 hours. CNO stated that if this was not completed, the patient may not get the proper treatment and the patient’s psychiatric condition may get worse. During a review of the facility’s policy and procedure (P&P) titled, “History and Physical,” dated 9/2022, the P&P indicated: “Policy: The History and Physical must be completed within 24 hours of admission and should contain adequate information to support the diagnosis and treatment plan. This information should be comprehensive enough to inform a surgeon, consultant, or other practitioner of all the precautions to be taken during treatment.” During a review of the facility’s policy and procedure (P&P) titled, “Consultations,” dated 9/2020, the P&P indicated: “Policy: ...as a courtesy consultants have twenty-four (24) hours to accept or decline a case. The existence of the consultation request must be documented in the patient’s chart. Procedure: The Consultation Report must be completed within twenty-four (24) hours of accepting a case and include the following criteria at a minimum: 1. Patient name 2. Medical Record Number 3. Age 4. Sex 5. Date of Admission, Consultation, Operation, etc. 6. Name of referring physician 7. Name of Consultant 8. Reason for Consultation 9. Current History 10. Past Medical History 11. Examination of the patient if applicable 12. Diagnosis and recommendations 13. Treatments, orders, and dispositions.””

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure completion of training and competency check (an assessment tool which checks and determines the skill of a staff) for four of four sampled nursing staff (House Supervisor [HS] 1, Registered Nurses [RNs] 2, 3 and 4) regarding their role in a rapid response (a process for working with a rapidly declining patient) call for one of 30 sampled patients (Patient 1) This deficient practice resulted in nursing staff (HS 1, RN 2, RN 3, and RN 4) not knowing how to manage rapid response team call properly as evidenced by nursing staff failing to render supportive medical management for one of 30 sampled patients (Patient 1) during a rapid response call which led to Patient 1’s condition to further deteriorate into a code blue (patient with an unexpected cardiac or respiratory arrest [when the heart stops beating] requiring resuscitation [methods used to restart the heart and lungs when they stop working]), which eventually resulted in Patient 1’s death. Findings: During a review of Patient 1’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/07/2023 at 10:06 p.m., the H&P indicated the following: Patient 1 was admitted to the facility on 12/6/2023, on a 5150-hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) due to danger to others and agitated (a feeling of irritability or severe restlessness) behavior. Patient 1’s admission diagnoses included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucination [sensing things such as visions, sounds or smells that seem real but are not]), type 2 diabetes (high blood sugar), hypertension (high blood pressure), seizure (medical condition that happens due to uncontrolled activity in the brain), and morbid obesity (weight over 100 pounds over the recommended weight). During a review of Patient’s 1’s nurses note titled, “Interdisciplinary Team Progress Note,” dated 12/16/2023 at 5:45 a.m., the Interdisciplinary (comprise of the physician, nurse, respiratory therapist, etc. Involved in the care of a patient) Team Progress Note indicated a Rapid Response (a process for working with a rapidly declining patient) was called for Patient 1 due to Patient 1 found unresponsive (unconscious and possibly dead or dying) with the following vital signs: Blood pressure (BP) 60/35 (normal 120/80) millimeters of mercury (mmHg, a unit of measurement), heart rate (HR) 32 (normal 60 - 100) and oxygen saturation level (sp02, measures the amount of oxygen in the blood) 48% (normal 90 - 100), respirations were not documented. Rapid response was called. There was no documentation to indicate that Patient 1 was provided with supportive medical management for the low saturation, low BP, and low HR. During a review of Patient 1’s CPR (cardiopulmonary resuscitation, an emergency procedure consisting of chest compressions and artificial ventilation [a means of assisting or stimulating breathing]) Record,” dated 12/16/2023, the CPR record indicated that a Code Blue was initiated at 5:50 a.m., because Patient 1 was in asystole (no heart-beat or flatline) and assisted breathing was provided; at 5:50 a.m., IV (intravenous, into the vein)access insertion was still unsuccessful. At 5:51 a.m., (6 minutes after the Rapid Response was initiated) 9-1-1 was called; at 5:58 a.m., code blue team continued CPR. At 5:59 a.m., paramedics arrived and took over CPR. At 6:20 a.m., CPR terminated and Patient 1 expired (died). During a concurrent interview and record review on 01/12/2024 at 10:37 a.m. with the Human Resources Coordinator (HRC), the facility’s orientation record (orientation pathway, a process to ensure that staff receive consistent information regarding facility policies, procedures, standards, and documentation) titled, “Orientation Pathway Charge Nurse/Support Registered Nurse, Medication Nurse, Licensed Vocation Nurse, Licensed Psychiatric Technician” was reviewed for HS 1 and RN 4. The HRC stated the orientation pathway was completed as the nursing staff received training and demonstrate skills listed. HRC verified that rapid response topic was not included in the orientation pathway. HRC stated the role of the rapid response team should be included in the orientation pathway section 5 “responding to Emergency Codes.” During an interview on 01/12/2024 at 10:52 a.m. with HRC, HRC stated the orientation pathway was not done for RN 3. During a concurrent interview and record review on 01/12/2024 at 11:03 a.m. with HRC, contracted Registered Nurse (RN 2) 2’s orientation record titled, “orientation/contract list registry,” dated 12/23/2023, was reviewed. HRC stated that the role of the rapid response team was not included in the orientation record. During an interview on 01/12/2024 at 1:41 p.m. with Chief Nursing Officer (CNO), CNO stated the role of the rapid response team should be part of the orientation so nursing staff would know how to respond to rapid response calls including knowledge of what to do such as provision of supportive medical management (airway support and CPR). During a review of the facility’s policy and procedure (P&P) titled, “Rapid Response Team,” dated 2023, the P&P indicated, “Guidelines for better patient care through a collaborative interdisciplinary team approach for clinical support, expert assessment, early intervention, and stabilization of patients. Also, to prevent further clinical deterioration or cardiopulmonary arrest to all patients ... Respiratory and nursing will be in-serviced upon hire and annually on the Rapid Assessment Team.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure the following: 1. Nursing staff failed to adhere and follow rendering supportive medical management for low oxygen saturation (measures the amount of oxygen in the blood) levels, low blood pressure, and low heart rate during a rapid response (a process for working with a rapidly declining patient) event and also failed to analyze the heart rhythm (when the heart beats too quickly or too slowly) and deliver a shock (using an electrical charge to stop the heart’s abnormal rhythm by a defibrillator [a device that can detect an abnormal heart rhythm and applies an electric charge [shock] or current to the heart to restore a normal heartbeat]) for one of 30 sampled patients (Patient 1) during a Code blue (patient with an unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]), in accordance with the facility’s policy and procedure regarding Advanced Cardiac Life Support (ACLS, a set of life-saving protocols and skills that goes beyond the basic life support [such as CPR, Cardiopulmonary Resuscitation - an emergency procedure consisting of chest compressions and artificial ventilation, a means of assisting or stimulating breathing]) guidelines. This deficient practice resulted in Patient 1’s condition to further worsen and resulted in Patient 1’s death. 2. Nursing staff failed to perform vital signs (VS, temperature, blood pressure, pulse, respiratory rate, and pain) check every four (4) hours and failed to address and report abnormal vital signs to the physician for one of 30 sampled patients (Patient 1). This deficient practice had the potential for changes in Patient 1’s condition to go unidentified by staff and Patient 1’s needs not being addressed in the event of a change of condition, which may result in patient harm and/or death. On 1/11/2024 at 10:05 a.m., the survey team called a 2nd Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Director of Quality and Risk Management (DQRM), Chief Nursing Officer (CNO), Chief Executive Officer (CEO), and the Medical Staff Manager (MSM). The facility failed to ensure nursing staff adhered to BLS (Basic Life Support, use of CPR [cardiopulmonary resuscitation, an emergency procedure consisting of chest compressions and artificial ventilation [a means of assisting or stimulating breathing]) and ACLS (Advance Cardiac Life Support, a set of life-saving protocols and skills that goes beyond the basic life support) guidelines, and rendered supportive medical management for low oxygenation levels, low blood pressure and heart rate during a Rapid Response (a process for working with a rapidly declining patient) and Code Blue (patient with an unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]) for Patient 1. Patient 1 was admitted to the facility on 12/6/2023 on a 5150-Hold (72-hour, involuntary hold- a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) for being a danger to others and agitated (a feeling of irritability or severe restlessness) behavior. Patient 1’s diagnosis included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucinations [sensing things such as visions, sounds or smells that seem real but are not]), morbid obesity (over 100 pounds over your recommended weight), type 2 diabetes (high blood sugar), hypertension (high blood pressure), and seizures (medical condition that happens due to uncontrolled activity in the brain). On 12/16/2023 at 5:45 a.m., a Rapid Response (a process for working with a rapidly declining patient) was called for Patient 1, who was found unresponsive (unconscious and possibly dead or dying). In addition, Patient 1’s blood pressure (BP) was 60/35 (low, normal is 120/80) millimeters of mercury (mmHg, a unit of measurement), heart rate was 32 (Normal range 60 - 100), and oxygen saturation level (measures the amount of oxygen in the blood) was 48 % (normal is 90 - 100 %). No interventions addressing the abnormal vital signs (include temperature, blood pressure, heart rate, respiratory rate) were documented during the Rapid Response. Nursing staff were not able to establish an IV (intravenous, into the vein) line, despite multiple attempts. The House Supervisor (HS 1) contacted a physician, by telephone, who ordered a stat (immediate) EKG (electrocardiogram, a recording of the heart’s electrical activity) and Code Blue (patient with an unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]). A Code Blue was called at 5:50 a.m., due to no pulse, no respirations. CPR (cardiopulmonary resuscitation, an emergency procedure consisting of chest compressions and artificial ventilation [a means of assisting or stimulating breathing]) and assisted breathing were started. IV insertion efforts were still unsuccessful, and the facility was unable to administer emergency medications. Patient 1 was connected to a defibrillator (a device that can detect an abnormal heart rhythm and applies an electric charge [shock] or current to the heart to restore a normal heartbeat). An EKG was performed. There was no documentation that Patient 1’s heartbeat was analyzed by the defibrillator, nurse, or physician to determine whether Patient 1 required continued chest compressions or a shock to restore the heartrate. At 5:59 a.m., the paramedics arrived and took over CPR. At 6:20 a.m., CPR was terminated and Patient 1 expired. During an interview, the House Supervisor (HS 1) stated she (HS 1) reviewed the heart monitoring strips from the defibrillator after the code blue was over. HS 1 interpreted Patient 1’s heart rhythm strips as ventricular fibrillation (a life-threatening heart rhythm, that can be triggered from a heart attack) and stated Patient 1 should have been shocked. HS 1 stated the shock should have been delivered at 5:52 a.m., per ACLS guidelines. On 1/12/2024 at 4:42 p.m., the 2nd IJ was removed in the presence of the CNO, DQRM, and CEO after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record reviews. The IJ Removal Plan included the following: On-site 24-hour physician support to respond to Rapid Responses and Code Blues, Mock code (a simulation exercise with a mannequin that mimics real life clinical situations to improve response times and efficiency) education and training, Code blue education and reminders: including assessments and recognition, CPR, Defibrillation (use of a device that can detect an abnormal heart rhythm and applies an electric charge [shock] or current to the heart to restore a normal heartbeat), Airway Management and Breathing, Medication Administration, Rhythm Assessment and Monitoring, Team Communication and Roles ...Documentation. In addition, the Plan included Rapid Response Training for responsibilities for non-licensed and licensed staff who identify the significant change in patient’s condition. This includes notifying other staff members, staying with the patient, and immediate assessment of the patient until the Rapid Response Team takes over the process. The facility mandates that all registered nurses stay current with ACLS guidelines and receive regular training. The facility obtained an intraosseous (process of injecting medications, fluids, and blood products directly into the marrow [a soft, fatty tissue inside the bone] of the bone) vascular device to be used in the event of a code where IV access is difficult to obtain, in order to administer emergency medications. In addition, the facility updated and implemented the following policies: 1. 1/9/2024 - Code Blue - updated to include standing orders (written protocols that authorize designated members of the health care team such as nurses to complete certain clinical tasks without having to first obtain a physician order) and documentation. 2. 1/9/2024 - Rapid Response - updated to include signs and symptoms including criteria for RRT (Rapid Response Team) activation. 3. 1/10/2024 - Hospital Plan for Provision of Care- implemented (includes 24-hours 7 days a week clinic on-site physician) 4. 1/11/2024 - Policy implemented- Responsibilities of On Call/Clinic On-Site Physician Coverage Findings: 1. During a review of Patient 1’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/07/2023 at 10:06 p.m., the H&P indicated the following: Patient 1 was admitted to the facility on 12/6/2023, on a 5150-hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) due to danger to others and agitated (a feeling of irritability or severe restlessness) behavior. Patient 1’s admission diagnoses included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucination [sensing things such as visions, sounds or smells that seem real but are not]), type 2 diabetes (high blood sugar), hypertension (high blood pressure), seizure (medical condition that happens due to uncontrolled activity in the brain), and morbid obesity (weight over 100 pounds over the recommended weight). During a review of Patient’s 1’s nurses note titled, “Interdisciplinary Team Progress Note,” dated 12/16/2023 at 5:45 a.m., the Interdisciplinary (comprise of the physician, nurse, respiratory therapist, etc. Involved in the care of a patient) Team Progress Note indicated a Rapid Response (a process for working with a rapidly declining patient) was called for Patient 1 due to Patient 1 found unresponsive (unconscious and possibly dead or dying) with the following vital signs: Blood pressure (BP) 60/35 (normal 120/80) millimeters of mercury (mmHg, a unit of measurement), heart rate (HR) 32 (normal 60 - 100) and oxygen saturation level (sp02, measures the amount of oxygen in the blood) 48% (normal 90 - 100), respirations were not documented. Rapid response was called. There was no documentation to indicate that Patient 1 was provided with supportive medical management for the low saturation, low BP, and low HR. During a review of Patient’s 1’s nurses note titled, “Nursing Progress Note,” dated 12/16/2023 at 5:47 a.m., the Nursing Progress Note indicated that the facility was not able to establish the Intravenous (IV, into the vein) access on Patient 1 despite of numerous attempts during the Rapid Response. During a review of Patient’s 1’s nurses note titled, “Progress Note,” dated 12/16/2023, at 9:10 a.m., Patient 1’s Progress Note indicated, the house supervisor contacted the Nurse Practitioner (NP), and then the Medical Doctor (MD). MD gave a telephone order for a stat (immediate) EKG (electrocardiogram, a recording of the heart’s electrical activity) and code blue (patient with an unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]). During a review of Patient 1’s CPR (cardiopulmonary resuscitation, an emergency procedure consisting of chest compressions and artificial ventilation [a means of assisting or stimulating breathing]) Record,” dated 12/16/2023, the CPR record indicated that a Code Blue was initiated at 5:50 a.m., because Patient 1 was in asystole (no heart-beat or flatline) and assisted breathing was provided; at 5:50 a.m., IV (intravenous, into the vein) access insertion was still unsuccessful. At 5:51 a.m., (6 minutes after the Rapid Response was initiated) 9-1-1 was called; at 5:58 a.m., code blue team continued CPR. At 5:59 a.m., paramedics arrived and took over CPR. At 6:20 a.m., CPR terminated and Patient 1 expired (died). During a concurrent interview and review of Patient 1’s nurses notes, on 01/10/2024, at 11:18 a.m., with the House supervisor (HS) 1, HS 1 confirmed that HS 1 responded to Patient 1’s rapid response called on 12/16/2023 at 5:45 a.m. with arrival time at 5:47 a.m. Upon arrival, Patient 1 was unresponsive and was on oxygen with 2 liters per minute via nasal canula (a device used to deliver supplemental oxygen). HS 1 stated Patient 1’s heart rate of 32 and spO2 (oxygen saturation) of 48 % were out of range. Nursing staff attempted to insert IV in anticipation for IV fluids and emergency medications but were unsuccessful. HS 1 stated Code Blue was activated due to no pulse, no blood pressure and no respiration; at 5:49 a.m., Physician called back with orders to insert an IV line, intubate (a process of inserting a plastic tube into a patient’s airway to assist with breathing) the patient, continue CPR, and give Epinephrine (a hormone used to restore heart rhythm) 1 milligram (mg- a unit of measurement) every 3 minutes. HS 1 stated Patient 1 was connected to the vital signs machine which monitored blood pressure and heart rate. Then nursing staff connected Patient 1 to a defibrillator (a device that applies an electric charge to the heart to restore a normal heartbeat). HS 1 stated, Patient 1 “had no pulse and was flat line (represents the cessation of the mechanical activity of the heart) for 10 minutes before the fire department’s arrival.” HS 1 stated the fire department arrived at 5:59 a.m. Upon arrival of fire department, the fire department staff took over CPR and established an intraosseous (IO, an emergency route for fluid and drug delivery) access on Patient 1’s left shin. In addition, the fire department administered total of 3 doses of Epinephrine. CPR was terminated and Patient 1 was pronounced dead by the fire department at 6:20 a.m. On 01/10/2024, at 11:30 a.m., HS 1 reviewed Patient 1’s cardiac “Rhythm Strip (a record of the electrical activity of the heart),” dated 12/16/2023 at 5:59 a.m. and Patient 1’s Code Blue cardiac rhythm strips dated 12/16/2023 at 5:52 a.m. and at 6:01 a.m. were also reviewed. HS 1 stated she (HS 1) was the team leader for the Code Blue. HS 1 interpreted the rhythm strip after the Code Blue was over. HS 1 stated the cardiac rhythm at 5:52 a.m. and 6:01 a.m. indicated ventricular fibrillation (a life-threatening heart rhythm). HS 1 further stated with this rhythm, the patient should be shocked (shock, using an electrical charge to stop the heart’s abnormal rhythm by a defibrillator). HS 1 stated the shock should have been delivered at 5:52 a.m. for Patient 1, but no shock was delivered during the code blue. HS 1 further stated the EKG completed on 12/16/2023 at 5:59 a.m. was never sent to a physician for interpretation. During an interview on 1/10/2023 at 10:10 a.m., with the Respiratory Therapist (RT) 1, RT 1 stated he (RT 1) responded to a Rapid Response on 12/16/2023 for Patient 1. Upon arrival at 5:50 a.m., Patient 1 was unresponsive, not breathing, and without a pulse. Staff was “bagging” (using a self-inflating bag to deliver ventilation) Patient 1 and chest compressions had already been started. RT 1 placed defibrillator pads on Patient 1 and connected Patient 1 to the defibrillator. A code blue was called. 911 was called. RT 1 stated that during the Code Blue, there was no pause in chest compressions to allow the defibrillator to analyze Patient 1’s cardiac rhythm strip, nor did RT 1 hear the defibrillator prompt the staff to deliver a shock. RT 1 stated a shock was not delivered during the Code Blue. During a review of the Facility’s policy and procedure (P&P) titled, “Rapid Response Team,” dated 02/2023, the P&P indicated, “The RN and RCP (Respiratory Care Practitioner) will perform a patient assessment to determine the status of the patient. Based on findings, the identified RN leader may institute ACLS (Advanced Life Support) measures and applicable standardized procedures to assist a patient emergent situation.” During a review of the Facility’s policy and procedure (P&P) titled, “Cardiopulmonary Emergencies Code Blue,” dated 3/2022, the P&P indicated, “it is the responsibility of all personnel discovering a cardiopulmonary emergency to follow the hospital policy of initiating a ‘code blue’ ... The Code Blue standing orders per ACLS Guideline can be followed by ACLS-certified nurses and cardiopulmonary personnel during the code ... When the on-call physician is not present, the House Supervisor, then Charge Nurse will act as the Code Blue Team Leader ... ACLS protocol will be adhered to during the Code Blue. The “Adult Cardiac Arrest Algorithm (a set of step-by-step instructions to complete a task)” indicated, Start CPR, give oxygen and attach monitor/defibrillator, for rhythm ventricular fibrillation (VF) or pulseless Ventricular tachycardia (a type of life- threatening cardiac rhythm), shock the patient.” 2. During a review of Patient 1’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/07/2023 at 10:06 p.m., the H&P indicated the following: Patient 1 was admitted to the facility on 12/6/2023, on a 5150-hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) due to danger to others and agitated (a feeling of irritability or severe restlessness) behavior. Patient 1’s admission diagnoses included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucination [sensing things such as visions, sounds or smells that seem real but are not]), type 2 diabetes (high blood sugar), hypertension (high blood pressure), seizure (medical condition that happens due to uncontrolled activity in the brain), and morbid obesity (weight over 100 pounds over the recommended weight). During a review of Patient 1’s “Vital Signs (VS- temperature, blood pressure, pulse, respiratory rate, and pain),” record dated 12/06/2024 to 12/16/2023, the Vital Signs record indicated the following: Normal vital signs ranges: Blood pressure (BP), 90/60 to 120/80. Resting heart rate (HR), 60 to 100 beats per minute. Respiratory Rate (RR), 12 to 18 breaths per minute. Oxygen saturation (O2 sat, measures the amount of oxygen in the blood), 95 % to 100 %. Body Temperature (Temp), 97.8 degrees Fahrenheit (F, a unit of measurement) to 99 degrees F or 36.5 degrees Celsius (C, a unit of measurement) to 37.2 degrees C. On 12/06/2023 at 9:36 p.m., BP 162/83 (high), HR 78, RR 18, O2 sat 95 %, Temp was not documented, Pain No. On 12/07/2023 at 1:17 a.m., BP 165/75 (high), HR 82, RR 18, O2 sat 94 % (low), Temp was not documented, Pain No On 12/07/2023 at 8 a.m., BP 154/70 (high), HR 82, RR 16, O2 sat 93 % (low) on room air, Temp 97.9 F, Pain 0. On 12/07/2023 at 4 p.m., BP 167/87 (high), HR 77, RR 18, O2 sat 94 % (low) on room air, Temp 98.4 F, Pain was not documented. Provider notified of abnormal values: Not Applicable. On 12/07/2023 at 8:13 p.m., BP 171/83 (high), HR 78, RR 18, O2 sat 95 %, Temp 97.8 F, Pain was not documented. On 12/07/2023 at 8:54 p.m., BP 131/69, HR 76, RR 17, O2 sat 90 % (low), Temp 97.4, Pain: No. Nurse notified of abnormal values: No On 12/08/2023 at 8 a.m., BP 144/77, HR 86. RR 16, O2 sat 96 %, on room air, Temp 97.7 F, Pain: 0 On 12/08/2023 at 12:06 p.m., BP 131/69, HR 102 (high), RR 18, O2 sat 93 % (low) on room air, Pain: 0, Provider notified of abnormal values: Not Applicable. On 12/08/2023 at 4 p.m., BP 154/75 (High), HR 97, RR 18, O2 sat 93 % (low) on room air, Temp 97.6, Pain: 0, Provider notified of abnormal values: Not Applicable. On 12/08/2023 at 8:31 p.m., BP 140/66, HR 92, RR 18, O2 sat 92 % (low), Temp 97.7 F, Pain: No, Nursing notified of abnormal values: Not Applicable. On 12/08/2023 at 12:08 a.m., BP 140/70, HR 96, RR 18, O2 sat 92 % (low), Temp 97.5, Pain: No, Nursing notified of abnormal values: No Applicable On 12/08/2023 at 4:07 a.m., BP 145/74, HR 94, RR 18, O2 sat 90 % (low), Temp 97.4 F, Pain: No, Nurse notified of abnormal values: Not Applicable. On 12/09/2023 at 8:17 a.m., BP 138/70, HR 72, RR 18, O2 sat 95 %, Temp 98.1, Pain: No On 12/09/2023 at 4:41 p.m., BP 140/63, HR 74, RR 18, O2 sat 94 % (low), Temp 97.7 F, Pain was not documented. On 12/10/2023 at 12:09 a.m., BP 132/64, HR 67, RR 18, O2 sat 92 % (low), Temp 97 F, Pain was not documented. Nurse notified of abnormal values: Not Applicable. On 12/10/2023 at 4:15 a.m., BP 127/74, HR 75, RR 148, O2 sat 90 % (low), Temp 97.6 F, Pain: No. Nurse notified of abnormal values: Not Applicable. On 12/10/2023 at 8:28 p.m., BP 155/69 (High), HR 74, RR 18, O2 sat 93 % (low), Temp 97.3 F, Pain: No. Nurse notified of abnormal values: Not Applicable. On 12.11.2023 at 8:48 p.m., BP 141/78 (High), HR 73, RR 17, O2 sat 94 % (low), Temp 97.1, Pain: No On 12/12/2023 at 12 p.m., BP 130/77, HR 62, RR 18, O2 sat 94 % (low) on room air, Temp 97.8 F, Pain No. On 12/12/2023 at 12:15 a.m., BP 128/63, HR 76, RR 18, O2 sat 94 % (low), Temp 97.1 F, Pain: No On 12/14 /2023 at 8 a.m., BP 136/63, HR 83, RR 18, O2 sat 92 % (low), Temp 98 F, Pain: No On 12/14/2023 at 8:54 p.m., BP 154/68 (high), HR 109 (high), RR 18, O2 sat 92 % (low), Temp was not documented, Pain: No On 12/15/2023 at 12:21 a.m., BP 138/87 (high), HR 101 (high), RR 18, O2 sat 92 % (low), Temp was not documented, Pain: No 12/15/2023 at 4 a.m., no vital signs were documented. 12/15/2023 at 8 a.m., no vital signs were documented. 12/15/2023 at 12 p.m., no vital signs were documented. 12/15/2023 at 4 p.m., no vital signs were documented. On 12/15/2023 at 8:12 p.m., BP 155/68 (High), HR 95, RR 18, O2 sat 91 % (low), Temp 98.2 F, Pain; was not documented. On 12/16/2023 at 12:07 a.m., BP 139/86 (high), HR 82, RR 18, O2 sat 91 % (low), Temp 98.4 F, Pain was not documented. On 12/16 /2023 at 3:56 a.m., BP 128/82, HR 86, RR 18, O2 sat 98% on room air, Temp 98.6 F, Pain: 0 During a concurrent interview and review of Patient 1’s Vital Signs Record, on 1/9/2023 at 11:38 a.m., with registered nurse (RN) 1, RN 1 stated Patient 1 was located in the Medical Surgical Unit (serves the general patient population hospitalized for various cases such as surgery, etc.) and vital signs should be done every four (4) hours. RN 1 reviewed the vital signs for Patient 1 from 12/15/2023 to 12/16/2023 and verified Patient 1 had abnormal vital signs. The blood pressure and heart rate were high. The oxygen saturation was low. The vital signs were not done every 4 hours. RN 1 also reviewed the nursing notes and stated that the abnormal vital signs were not reported to the physician. RN 1 said the nurse assigned to Patient 1 should have notified the physician “if the vital signs are out of range to “fix” the vital signs and prevent a change in the patient’s condition such as worsening of clinical condition.” During a review of the facility’s policy and procedure (P&P) titled, “Vital signs,” dated 3/2022, the P&P indicated the following: “Vital signs i.e., Temperature, Pulse Rate, Respiratory Rate, Blood Pressure, Pain, Oxygen saturation shall be performed routinely ...Vital signs will be taken per unit routine unless otherwise ordered by the physician ...MS (Medical Surgical, serves the general patient population hospitalized for various cases such as surgery, etc.) and Telemetry (a unit in the hospital where patient’s undergo continuous cardiac [heart rate and rhythm] monitoring) - every four (4) hours and charted on Vital Signs record and M/S Flow sheet (8 a.m., 12 p.m., 4 p.m., 8 p.m.,) ...Any vital signs which are outside normal limits or are unusual for that patient, are to be reported to the patient’s nurse who will evaluate the situation and report to the physician if this is indicated.””