Resnick Neuropsychiatric Hospital at UCLA

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45774 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Patient Rights as evidenced by: 1. The facility failed to ensure patient safety practices requirements unique to the behavioral health facility (an inpatient unit that provides treatment and therapy for people who have mental, emotional, and behavioral disorders) were consistently followed for one of 35 sampled patients (Patient 4) when the facility staff did not follow the facility ’ s policy and procedures (P&Ps) for Patient 4 observation monitoring every 15 minutes and for screening of contraband items on Patient 4 or in Patient 4 ’ s room. The deficient practice resulted in Patient 4 making a suicide attempt with a belt and an upturned bedside table (a table, usually found in a hospital, that can hold patient ’ s belongings or food trays, and can be positioned to be placed in front of a patient if the patient is lying in bed), a code blue (an emergency alert signaling that a patient is experiencing a critical, life-threatening event) being called, a transfer to GACH (General Acute Care Hospital) 1 ’ s ICU (intensive care unit, a specialized hospital department that provides high-level care for critically ill patients), and taken off life support (the use of specialized equipment to maintain a person ’ s essential functions, such as breathing) two weeks later resulting in Patient 4 ’ s death. (Refer to A-0144) The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 45774 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by: 1.The facility failed to ensure facility staff performed every 15 minute observations (observations ordered for every patient at the facility, performed by an assigned staff member with the patient ’ s location and behavior documented electronically via an iPad) for three out of 35 patients (Patient 1, Patient 4, Patient 30) in accordance with the facility ’ s policy and procedure regarding patient observation. The deficient practice resulted in Patient 4 having a suicide attempt, subsequently resulting in Patient 4 ’ s death two weeks later. The deficient practice also had the potential to cause miscommunication among healthcare providers and place patients at risk for missed interventions, delays in treatment, or incorrect treatments for Patient 1 and Patient 30. (Refer to A-0398) 2.The facility failed to ensure two of 35 sampled patients (Patient 25 and Patient 27), were administered the correct pain medication for the type of pain patient experienced. This deficient practice had the potential to result in inadequate pain control, untreated or worsening pain, and delayed symptom relief. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“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: 45774 Based on observation, interview, and record review, the facility failed to ensure patient safety practices requirements unique to the behavioral health facility (an inpatient unit that provides treatment and therapy for people who have mental, emotional, and behavioral disorders) were consistently followed for one of 35 sampled patients (Patient 4) when the facility staff did not follow the facility ’ s policy and procedures (P&Ps) for Patient 4 observation monitoring every 15 minutes and for screening of contraband items on Patient 4 or in Patient 4 ’ s room. The deficient practice resulted in Patient 4 making a suicide attempt with a belt and an upturned bedside table (a table, usually found in a hospital, that can hold patient ’ s belongings or food trays, and can be positioned to be placed in front of a patient if the patient is lying in bed), a code blue (an emergency alert signaling that a patient is experiencing a critical, life-threatening event) being called, a transfer to GACH (General Acute Care Hospital) 1 ’ s ICU (intensive care unit, a specialized hospital department that provides high-level care for critically ill patients), and taken off life support (the use of specialized equipment to maintain a person ’ s essential functions, such as breathing) two weeks later resulting in Patient 4 ’ s death. On 4/15/2026 at 1:42 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 Director of Quality Management and Rehabilitative Services (DQM), the Chief Medical Officer (CMO), the covering Chief Nurse Manager (NM 1), the Occupational Therapist, Registered and Licensed - Quality Management (QM), the Director of Utilization Management (UMD), and the Clinical Regulatory Affairs Specialist (CRAS). The facility failed to provide a safe environment for care when the every 15 minute patient observations were not performed in accordance to the facility ’ s policy and procedure and when Patient 4 used two contraband (materials, articles, or goods that patients are prohibited from having in their possession because the items may present a risk to safety and security in the facility) items, a belt and a bedside table, in a suicide attempt (a self-directed and potentially damaging behavior with any intent to die as a result of the action). As a result, Patient 4 was found by facility staff in his room with a belt ligature (an object used for tying or binding something tightly) around Patient 4 ’ s neck. This led to a code blue being called for Patient 4. Patient 4 was revived (restored to life or consciousness) and transported to GACH 1 ’ s ICU. Patient 4 suffered hypoxia (lack of oxygen) to the brain. Two weeks later, Patient 4 ’ s family made the decision to remove Patient 4 from life support and allowed Patient 4 to expire. On 4/17/2026 at 12:35 p.m., the IJ was removed in the presence of the Assistant Nurse Manager for 4 West [one of three nursing units in the facility] (ANM 2), the Clinical Regulatory Affairs Specialist (CRAS), the Director of Utilization Management (UMD), the Nurse Manager for 4 North [one of three nursing units in the facility] (NM 2), the Assistant Nurse Manager for 4 East [one of three nursing units in the facility] (ANM 3), Nurse Manager for 4 East (NM 1), the Nurse Manager for 4 West (NM 3), the Electroconvulsive Therapy [ECT, a medical procedure for severe, treatment-resistant mental illnesses like depression (a serious mental health disorder characterized by persistent sadness, loss of interest in activities, and low energy) and bipolar disorder (a mental health condition characterized by intense shifts in mood , energy, and activity levels, ranging from extreme highs to severe lows)] Nurse Manager (NM 4), the Chief Medical Officer (CMO), the Chief Medical and Quality Officer UCLA Health System (CMQO), the Director of Quality Management and Rehabilitative Services (DQM), and the Occupational Therapist, Registered and Licensed - Quality Management (QM). The elements of the IJ Removal Plan (interventions to correct the deficient practices) were verified and confirmed by the survey team while onsite through observations, interviews, and record reviews. The IJ Removal Plan indicated: Effective 1/29/2026, all bedside tables were removed from the facility. Beginning February 5, 2026 to March 10, 2026, Nursing Leadership and Nursing Transformation Leadership Committee, have revised the “Nursing Admission Procedures: Inpatient Services,” Policy, revised on 2/10/2026, 2/18/2026, and 2/24/2026, to eliminate duplications and increase consistency and standardize workflows and procedures. Effective 3/20/2026, a revised “Patient Belongings Form,” revised on 2/24/2026, was introduced. The updated form includes designated sections for clothing, valuables, jewelry, contraband (including ligature risk items), Activities of Daily Living (ADLs, items used to assist in daily activities, such as a cane or walker) products, and miscellaneous items. Effective 3/29/2026, a second staff person participates in the patient belongings (the items a patient arrived to the facility with, which may include clothing and other objects) check on admission, requiring both staff to sign the document. Effective 4/10/2026, the Chief Nursing Officer (CNO) sent a notice to all nursing staff requiring completion of the new policy regarding belongings check and contraband removal, verified by a staff member ’ s attestation (evidence of proof). Effective 4/10/2026, a standardized workflow for belongings check and contraband screening was implemented, requiring the signature of the two staff members performing the checks. Effective 4/15/2026, a random sample of every 15 minute observation checks will be monitored by the hospital and/or unit leaders from all three units to verify quality every 15 minute observations checks are conducted by staff per policy. The staff will: visually observe patient and if patient is awake, staff member will have a verbal interaction or check-in with patient; if patient is using the bathroom, staff will visually observe patient ’ s face or head; if patient is asleep, the staff will assess breathing and check for the full rise and fall of the chest; ensure patient bathroom doors are locked if applicable; monitoring will also occur during the audits to verify accuracy of patient location and behavior. The random audits will include 10 day and 10 night shifts per month in each of the 3 units. Effective 4/15/2026, facility leadership developed an internal audit tool to perform unannounced, random direct observations compliance with the policy requiring two staff members to conduct a comprehensive search of patient belongings, including screening for contraband. Effective 4/15/2026, an internal audit tool was implemented to monitor the policy requirement of two staff members to conduct a comprehensive search of patients belongings, including screening for contraband. Effective 4/15/2026, Environmental Safety Rounds (periodic and mandatory inspections of a facility to proactively identify potential hazards) are to be conducted each shift by two staff members to proactively identify and mitigate (make less severe, serious, or painful) potential safety risks. Effective 4/16/2026, unannounced and random observations of newly admitted patients will be performed on 10 day and 10 night shifts, per month in all 3 units, to monitor belongings and contraband screening process. Effective 4/16/2026, the facility staff will receive in-service education during their next scheduled shift reviewing the facility ’ s policy “Patient Observation and Safety Check/Contraband Competency Assessment.” Staff must demonstrate competency by direct observation or return demonstration. Staff will be provided with a summary document of “key reminders and updates” for the policy. In-service education will occur each shift until 100% of staff have been retrained. Effective 4/16/2026, Any contraband identified after patient admission is reported daily to the Leadership Safety and Operations Huddle. (Nursing Education is developing) Nursing Education is developing a contraband identification simulation exercise for staff. Audit findings will be presented at the Performance Improvement and Patient Safety Council (PIPSC) monthly. Findings: During a review of Patient 4 ’ s “Inpatient Admission Note,” dated 1/16/2026, the admitting note indicated Patient 4 was admitted to the facility voluntarily on 1/16/2026 with an admission diagnosis of bipolar 1 disorder [a serious mental health condition characterized by at least one manic (a state of abnormally elevated energy and frantic activity) episode that lasts at least seven days and is severe enough to require hospitalization] with psychotic features [the patient experiences a loss of contact from reality, such as hallucinations (sensing things not there) or delusions (false beliefs)], worsening anxiety (feelings of tension, worried thoughts, with physical changes such as an increased heart rate or sweating) with significant financial stressors, strong support from multiple family members, and a recent discharge from the facility one week prior to readmission on 1/16/2026. The 1/16/2026 admitting note indicated Patient 4 had made vague statements such as “no way out ...unsolvable ...” but denied any active suicidal ideation [SI, thoughts or ruminations about dying by suicide, ranging from passive desires to be dead to active, specific planning] (no intent/plan). The admitting note indicated Patient 4 had a history of suicide attempt by driving into an oncoming car in 2015. The admitting note indicated Patient 4 had a CSSRS (Columbia-Suicide Severity Rating Scale, a tool used to assess suicide risk by asking simple questions about suicidal thoughts and behaviors, with 0 points indicating no risk, 1-2 points indicating low risk, 3 or more points indicating moderate to high risk) score of 0 in the outpatient setting and the physician ’ s Suicide Risk and Assessment, dated 1/16/2026, indicated: Baseline chronic (a long-term period) risk: Moderately elevated baseline risk. Acute (a short-term period) risk: Not clearly elevated above their baseline. “At present, the patient does not meet criteria for involuntary [against his will] psychiatric hold; his passive [without active response or resistance] SI is fleeting [lasting a short period to time], ego-dystonic [thoughts, impulses, or behaviors that are inconsistent with an individual ’ s values or personalities, causing distress, guilt, or anxiety], and accompanied by clear protective factors; he denies HI [homicidal ideation, thoughts, planning, or intent to harm or kill another person].” During a review of Patient 4 ’ s Nursing Flow Sheets (a form in an electronic medical record that collects all the necessary data and displays it for easier review), dated 1/16/2026 and 1/17/2026, the flow sheets indicated Patient 4 ’ s CSSRS as Low Risk for both days. During a review of Patient 4 ’ s physician ’ s (MD) 1 order, dated 1/16/2026, the order indicated “Routine observation (every 15 minute checks).” A review of Patient 4 ’ s MD 1 ’ s orders for the dates of admission 1/16/2026 to 1/17/2026 indicated there was no order for a bedside table. During an interview on 4/13/2026 at 2:20 p.m. with 4 North Nurse Manager (NM) 2, NM 2 stated 15 minute observations were documented using a 2 component electronic device system. The first component was a wristband, called a beacon, worn by a facility patient. The second component was an iPad held by the facility staff. NM 2 stated a staff member would approach the patient, approximately 6 feet away but could be as far as 15 feet away, and the beacon would connect with iPad electronically. Facility staff would enter on the iPad the patient ’ s location and visually observe and enter a patient ’ s behavior. During a concurrent interview and record review on 4/14/2026 at 4:21 p.m. with CMO and DQM of Patient 4 ’ s Behavioral Health Patient Observation Sheet by Clinical Care Partner (CCP) 3 every 15 minute observations, dated 1/17/2026 at 11:12 a.m., 11:25 a.m., 11:38 a.m., and 11:53 a.m., the documented observations indicated Patient 4 ’ s location was the facility ’ s Day Room [a room used for meals, group therapy (a small group of patients will meet with a mental health therapist), occupational therapy (therapy to address physical, emotional, and social needs to improve quality of life), and other activities] and Patient 4 ’ s behavior was GR (Group Therapy session). During same interview and record review, the video footage dated 1/17/2026 and time stamped 10:56 a.m. to 11:46 a.m. of area Patient 4 was located, Patient 4 was observed to not be in Day Room after 10:58 a.m. but rather Patient 4 was observed in hallway outside of Patient 4 ’ s room and entering and exiting his room. During the same interview and record review, CCP 3 was observed on video to document Patient 4 ’ s locations and behaviors on an electronic device without determining visually Patient 4 ’ s behavior or location. During an interview on 4/14/2026 at 5:00 p.m. with DQM, DQM stated, “It is not the rounding I expected.” DQM further stated, “The expectation is you look in, see if the patient is safe, not necessarily have an interaction. You see and record.” During an interview on 4/14/2026 at 5:00 p.m. with CMO, CMO stated, “You can look in, but you actually have to look in to see what is going on.” During a review of Patient 4 ’ s nursing note dated 1/17/2026 at 11:37 a.m., the note indicated Patient 4 was found in his private room, not in the facility ’ s Day Room as documented in the CCP 3 ’ s notes, by a staff member with a belt around Patient 4 ’ s neck and an upturned bedside table used as fixed height object. During a review of Patient 4 ’ s Cardiopulmonary Arrest Record/Order, dated 1/17/2026, the Record indicated a code blue event recognized time was 11:36 a.m. and the crash cart (a wheeled container carrying medicine and equipment for use in emergency situations) brought to Patient 4 ’ s room at 11:37 a.m. Time elapsed was from one to one and half minutes from time Patient 4 ’ s event was recognized to the time crash cart was brought to Patient 4 ’ s room. Patient 4 was transported to GACH 1 ’ s ICU at 12:10 p.m. During a review of Patient 4 ’ s Discharge Summary addendum, dated 2/23/2026, the addendum indicated Patient 4 was sent out and admitted to GACH 1 ’ s ICU on 1/17/2026 after resuscitation (the process of reviving someone from unconsciousness or apparent death), was intubated (inserting a tube into a patient ’ s airway for breathing), and on 2/23/2026 later taken off life support with the cause of death including but not limited to: respiratory failure (a serious condition that makes it difficult to breath on your own), cardiac arrest (a condition where the heart suddenly and unexpectedly stops breathing), anoxic brain damage and injury (a serious, non-traumatic injury caused by a total lack of oxygen to the brain, leading to widespread brain cell death within minutes). During an interview on 4/14/2026 at 9:39 a.m. with DQM, DQM stated the expectation for a patient upon arrival is for the admitting nurse to complete a thorough belongings check. DQM stated for Patient 4 ’ s 1/16/2026 admission to facility, the nurse failed to confiscate (take or seize with authority) the contraband of a belt, cellphone, and wallet. DQM stated she was not aware whose responsibility it was to remove the bedside table found in Patient 4 ’ s room, with DQM stating the bedside table was probably left over from the previous occupant of Patient 4 ’ s room. During an interview on 4/14/2026 at 9:39 a.m. with CMO and DQM, DQM stated the expectation for every 15-minute checks is for the facility employee to visually observe the patient and to make eye contact with patient if patient is not asleep. During an observation on 4/14/2026, at 10:57 a.m., of CCP 2 making every 15-minute rounds, CCP 2 was observed to perform the 15-minute checks without making eye contact or verbal contact with 6 out of 7 patients. Durning a concurrent observation and interview on 4/14/2026 at 4:21 p.m. with the Director (DQM) of Quality Management and Chief Medical Officer (CMO), the facility ’ s security footage outside of Patient 4 ’ s room, date-stamped 1/17/2026 from 10:56 a.m. to 11:46 p.m., was reviewed. The following was observed in the footage: 1. 10:56 a.m. Clinical Care Partner (CCP) 3 with iPad (device used to document patient location and activity) was sitting at desk in chair with monitor, in hallway outside of Patient 4 ’ s room. 2. 10:58 a.m. Patient 4 entered his room. Patient 4 closed his door. 3. 11:02 a.m. Patient 4 left his room, looked into the day room through the day room ’ s window, walked past his (Patient 4) room door, CCP 3, with iPad in hand, looked at Patient 4. 4. 11:03 a.m. Patient 4 walked back to his room. 5. 11:04 a.m. CCP 3 sat back in chair outside Patient 4 ’ s room. 6. 11:10 a.m. Patient 4 left his room, CCP 3 glanced at Patient 4 but did not reach for iPad. 7. 11:11 a.m. Patient 4 walked back to his room, CCP 3 and another Clinical Care Partner spoke but iPad was not used. 8. 11:15 a.m. CCP 3 went down hallway with iPad and out of view camera view. 9. 11:16 a.m. CCP 3 walked past rooms, including Patient 4 ’ s room, with iPad, appearing to document, and was not observed to have looked in rooms. 10. 11:17 a.m. CCP 3 sat down in chair in hallway outside of Patient 4 ’ s room. 11. 11:18 a.m. CCP 4 and CCP 3 spoke with each other. Patient 4 ’ s door moving but not opening fully. 12. 11:19 a.m. CCP 4 looked briefly into Patient 4 ’ s door window. CCP 4 then walked away out of sight. 13. 11:30 a.m.: CCP 3 took iPad. CCP 3 walked past Patient 4 ’ s room (and other room visible in the video), stood approximately one foot away from door. CCP 3 did not look into rooms or door windows. CCP 3 appeared to document on iPad Patient 4 ’ s status and location. 14. 11:34 a.m.: Patient 4 ’ s door slightly opened from the inside, Patient 4 ’ s head was only partially visible and was not visible for very long. Patient 4 did not exit his room. Patient 4 closed his door, remaining inside his room. 15. 11:35 a.m.: CCP 3 made a very subtle but not full glance to patient ’ s door. 16. 11:43 a.m. CCP 3 took the iPad, walked down hallway to made rounds, not looking into patient rooms and keeping approximately one foot away from each door CCP 3 observed. 17. 11:44 - 11:45 a.m.: Unit Secretary (US) approached and entered Patient 4 ’ s room, immediately ran out of room, alerted staff to a situation. Several facility staff, being alerted, approached to assess and begin a code blue. 18. 11:46 a.m. CCP 3 returned to area outside of Patient 4 ’ s room. During an interview on 4/14/2026 at 5:00 p.m. with DQM, DQM stated, “It is not the rounding I expected.” DQM further stated, “The expectation is you look in, see if the patient is safe, not necessarily have an interaction. You see and record.” During an interview on 4/14/2026 at 5:00 p.m. with CMO, CMO stated, “You can look in, but you actually have to look in to see what is going on.” During a review on 4/16/2026 of Patient 4 ’ s Admitting Personal Belongings checklist, dated 1/16/2026, the belongings checklist indicated Patient 4 ’ s belongings did not include a belt, either kept by Patient 4 or confiscated by staff. During a review of the facility ’ s policy and procedure (P&P) titled “Admission/Contraband Screening/Search Guideline,” last revised 5/16/2025, the P&P indicated the following: 1. Contraband: Any other items found by staff to be a harm or danger to patient. 2. Upon admission a patient ’ s admission body/belongings search must be completed within an hour of patient arriving on the unit. When the patient arrives on the unit all personal belongings will be removed from the patient ’ s person and locked into their personal locker. This includes clothing, electronic devices. 3. One staff member checks clothes for contraband. Patient ’ s clothing, shoes (and insoles), and socks will be patten down, pockets checked, ... 4. Backpacks, purses, suitcases and similar items will have all items removed and all compartment checked. 5. When patient belongings are checked, they will be checked by at least one staff member. All items will be catalogued on the paper patient belongings sheet or in electronic health record. 6. Contraband items include not limited to: Belts and belt buckles. During a review of the facility ’ s P&P titled, “Nursing Observation of Patients,” dated 5/25/2022, the P&P indicated the following: 1. Patients will be assessed with the level of observation order by the physician and the RN will initiate and/or increase the level of observation, based on the RN ’ s professional judgement. 2. Routine observation – all patients will be visually observed every 15 minutes. 3. Constant eyesight (CE) – used for unpredictable patients must always be visually observed by staff. 4. When rounding and the patient is awake, the staff member should have a verbal interaction or check-in with the patient, i.e., “I am rounding, is there anything you need?””

“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: 38310 Based on observation, interview, and record review, the facility ’ s Quality Assurance Performance Improvement team (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) failed to fully analyze the cause of an adverse patient event (preventable, serious and unambiguous occurrence or error at a healthcare facility that is universally or largely preventable and should never occur) when it failed to conduct a thorough root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution) for one of 35 sampled patients (Patient 4) when Patient 4 attempted suicide (a self-directed and potentially injurious behavior with an intent to die as a result of the action) in order to ensure there was proper observation or monitoring provided for patients who are placed on every 15-minute observations) monitoring in the facility (a behavioral health hospital, inpatient unit that provided treatment and therapy for patients who have mental, emotional and behavioral disorders). This deficient practice had the potential for similar adverse patient events to recur, placing patients requiring 15-minute observations at risk for serious injury or harm. Findings: During a review of Patient 4 ’ s “Inpatient Admission Note,” dated 1/16/2026, the admitting note indicated Patient 4 was admitted to the facility voluntarily on 1/16/2026 with an admission diagnosis of bipolar 1 disorder [a serious mental health condition characterized by at least one manic (a state of abnormally elevated energy and frantic activity) episode that lasts at least seven days and is severe enough to require hospitalization] with psychotic features [the patient experiences a loss of contact from reality, such as hallucinations (sensing things not there) or delusions (false beliefs)], worsening anxiety (feelings of tension, worried thoughts, with physical changes such as an increased heart rate or sweating) with significant financial stressors, strong support from multiple family members, and a recent discharge from the facility one week prior to readmission on 1/16/2026. The 1/16/2026 admitting note indicated Patient 4 had made vague statements such as “no way out ...unsolvable ...” but denied any active suicidal ideation [SI, thoughts or ruminations about dying by suicide, ranging from passive desires to be dead to active, specific planning] (no intent/plan). The admitting note indicated Patient 4 had a history of suicide attempt by driving into an oncoming car in 2015. The admitting note indicated Patient 4 had a CSSRS (Columbia-Suicide Severity Rating Scale, a tool used to assess suicide risk by asking simple questions about suicidal thoughts and behaviors, with 0 points indicating no risk, 1-2 points indicating low risk, 3 or more points indicating moderate to high risk) score of 0 in the outpatient setting and the physician ’ s Suicide Risk and Assessment, dated 1/16/2026, indicated: Baseline chronic (a long-term period) risk: Moderately elevated baseline risk. Acute (a short-term period) risk: Not clearly elevated above their baseline. “At present, the patient does not meet criteria for involuntary [against his will] psychiatric hold; his passive [without active response or resistance] SI is fleeting [lasting a short period to time], ego-dystonic [thoughts, impulses, or behaviors that are inconsistent with an individual ’ s values or personalities, causing distress, guilt, or anxiety], and accompanied by clear protective factors; he denies HI [homicidal ideation, thoughts, planning, or intent to harm or kill another person].” During a review of Patient 4 ’ s physician ’ s (MD) 1 order, dated 1/16/2026, the order indicated “Routine observation (every 15 minute checks).” During a review of Patient 4 ’ s “Behavioral Health – Patient Observation Sheet” by Clinical Care Partner (CCP) 3, dated 1/17/2026 at 11:12 a.m., 11:25 a.m., 11:38 a.m., and 11:53 a.m., the documented observations indicated Patient 4 ’ s location was the facility ’ s Day Room [a room used for meals, group therapy (a small group of patients will meet with a mental health therapist), occupational therapy (therapy to address physical, emotional, and social needs to improve quality of life), and other activities] and Patient 4 ’ s behavior was GR (Group Therapy session). During a record review of Patient 4 ’ s nursing note dated 1/17/2026 at 11:37 a.m., the note indicated Patient 4 was found in his private room, not in the facility ’ s Day Room as documented in the CCP 3 ’ s notes, by a staff member with a belt around Patient 4 ’ s neck and an upturned bedside table used as fixed height object. During a concurrent interview and record review on 4/14/2026 at 9:39 a.m. with DQM, the RCA regarding Patient 4 ’ s suicide attempt, dated 1/23/2026, was reviewed. The RCA indicated three factors were found to have a role in Patient 4 ’ s suicide attempt: Belongings check not performed and contraband not removed in Patient 4 ’ s room according to policy; the bedside table was found to be in Patient 4 ’ s room with no order for a bedside table; and there were discrepancies in every 15 minute observations/rounds. The RCA indicated the corrective actions as: standardizing belongings process and contraband identification during admission process and disposal of all overbed rolling tables (bedside tables) in facility. The DQM stated surveillance footage of Patient 4 ’ s every 15 minute observations was not viewed as part of the RCA process. During a concurrent observation and interview on 4/14/2026 at 4:21 p.m. with the Director (DQM) of Quality Management and Chief Medical Officer (CMO), the facility ’ s security footage, date-stamped 1/17/2026 from 10:56 a.m. to 11:46 p.m., was reviewed. The following was observed in the footage: 1. 10:56 a.m. Clinical Care Partner (CCP) 3 with iPad (device used to document patient location and activity) sitting at desk in chair with monitor, in hallway outside of Patient 4 ’ s room. 2. 10:58 a.m. Patient 4 entered his room. Patient 4 closed his door. 3. 11:02 a.m. Patient 4 left his room, looked into the day room through the day room ’ s window, walked past his (Patient 4) room door, CCP 3, with iPad in hand, looked at Patient 4. 11:03 a.m. Patient 4 walked back to his room. 5. 11:04 a.m. CCP 3 sat back in chair outside Patient 4 ’ s room. 6. 11:10 a.m. Patient 4 left his room, CCP 3 glanced at Patient 4 but did not reach for iPad. 7. 11:11 a.m. Patient 4 walked back to his room, CCP 3 and another Clinical Care Partner spoke but iPad was not used. 8. 11:15 a.m. CCP 3 went down hallway with iPad and out of view camera view. 9. 11:16 a.m. CCP 3 walked past rooms, including Patient 4 ’ s room, with iPad, appearing to document, and was not observed to have looked in rooms. 10. 11:17 a.m. CCP 3 sat down in chair in hallway outside of Patient 4 ’ s room. 11. 11:18 a.m. CCP 4 and CCP 3 spoke with each other. Patient 4 ’ s door moving but not opening fully. 12. 11:19 a.m. CCP 4 looked briefly into Patient 4 ’ s door window. CCP 4 then walked away out of sight. 13. 11:30 a.m.: CCP 3 took iPad. CCP 3 walked past Patient 4 ’ s room (and other room visible in the video), stood approximately one foot away from door. CCP 3 did not look into rooms or door windows. CCP 3 appeared to document on iPad Patient 4 ’ s status and location. 14. 11:34 a.m.: Patient 4 ’ s door slightly opened from the inside, Patient 4 ’ s head was only partially visible and was not visible for very long. Patient 4 did not exit his room. Patient 4 closed his door, remaining inside his room. 15. 11:35 a.m.: CCP 3 made a very subtle but not full glance to patient ’ s door. 16. 11:43 a.m. CCP 3 takes the iPad, walks down hallway to made rounds, not looking into patient rooms and keeping approximately one foot away from each door CCP 3 observed. 17. 11:44 - 11:45 a.m.: Unit Secretary (US) approached and entered Patient 4 ’ s room, immediately ran out of room, alerted staff to a situation. Several facility staff, being alerted, approached to assess and begin a code blue. 18. 11:46 a.m. CCP 3 returned to area outside of Patient 4 ’ s room. After viewing the video/security footage, DQM stated, “It is not the rounding I expected.” DQM further stated, “The expectation is you look in, see if the patient is safe, not necessarily have an interaction. You see and record.” DQM verified three separate Patient 4 observations and documentations were made by CCP 3 on Patient 4 ’ s “Behavioral Health – Patient Observation Sheet” at 11:15 a.m., 11:30 a.m., and at 11:43 a.m., during which CCP did not have a visual sighting of Patient 4 in accordance with the facility ’ s policy regarding observations. During an interview on 4/16/2026 at 3:00 p.m. with Quality Management (QM) 1 [a member of the QAPI Committee], QM 1 stated, the choice to not include the video/security footage of the hallway outside of Patient 4 ’ s room was a committee choice. QM 1 stated, “If the video request is tied to an event, we can request to view. There may have been a choice to include the video in the investigation. If we suspected there was a need, we would watch the video.” During a review of the facility ’ s “Quality and Performance Improve Plan 2025 – 2026,” the Plan indicated, “Focus ...Principles and Methodology: Understand causes. Analyze the process to identify causes of the variations.” During a record review of the facility ’ s policy and procedure (P&P) titled, “Nursing Observation of Patients,” dated 5/25/2022, the P&P indicated the following: 1. Patients will be assessed with the level of observation order by the physician and the RN will initiate and/or increase the level of observation, based on the RN ’ s professional judgement. 2. Routine observation – all patients will be visually observed every 15 minutes. 3. Constant eyesight (CE) – used for unpredictable patients must always be visually observed by staff. 4. When rounding and the patient is awake, the staff member should have a verbal interaction or check-in with the patient, i.e., “I am rounding, is there anything you need?””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 45774 Based on observation, interview, and record review, the facility failed to ensure facility staff performed every 15 minute observations (observations ordered for every patient at the facility, performed by an assigned staff member with the patient ’ s location and behavior documented electronically via an iPad) for three out of 35 patients (Patient 1, Patient 4, and Patient 30) in accordance with the facility ’ s policy and procedure regarding patient observation. The deficient practice resulted in Patient 4 having a suicide attempt, subsequently resulting in Patient 4 ’ s death two weeks later. The deficient practice also had the potential to cause miscommunication among healthcare providers and place patients at risk for missed interventions, delays in treatment, or incorrect treatments for Patient 1 and Patient 30. Findings: During a record review of Patient 1 ’ s Inpatient Admission Note, dated 4/08/2026, the note indicated Patient 1 was admitted on 4/08/2026 for suicidal ideation (thoughts about considering or planning a suicide) with undisclosed plan. The note indicated Patient 1 had a past medical history of polysubstance abuse disorder [a complex, often fatal condition characterized by addiction to or misuse of two or more substances (drugs or alcohol)] and substance induced psychosis (a temporary mental health condition characterized by hallucinations, delusions, or disorganized thinking caused by the ingestion, misuse, or withdrawal of substances like drugs, alcohol, or medications). During a review of Patient 4 ’ s “Inpatient Admission Note,” dated 1/16/2026, the admitting note indicated Patient 4 was admitted to the facility voluntarily on 1/16/2026 with an admission diagnosis of bipolar 1 disorder [a serious mental health condition characterized by at least one manic (a state of abnormally elevated energy and frantic activity) episode that lasts at least seven days and is severe enough to require hospitalization] with psychotic features [the patient experiences a loss of contact from reality, such as hallucinations (sensing things not there) or delusions (false beliefs)], worsening anxiety (feelings of tension, worried thoughts, with physical changes such as an increased heart rate or sweating) with significant financial stressors, strong support from multiple family members, and a recent discharge from the facility one week prior to readmission on 1/16/2026. The 1/16/2026 admitting note indicated Patient 4 had made vague statements such as “no way out ...unsolvable ...” but denied any active suicidal ideation [SI, thoughts or ruminations about dying by suicide, ranging from passive desires to be dead to active, specific planning] (no intent/plan). The admitting note indicated Patient 4 had a history of suicide attempt by driving into an oncoming car in 2015. The admitting note indicated Patient 4 had a CSSRS (Columbia-Suicide Severity Rating Scale, a tool used to assess suicide risk by asking simple questions about suicidal thoughts and behaviors, with 0 points indicating no risk, 1-2 points indicating low risk, 3 or more points indicating moderate to high risk) score of 0 in the outpatient setting and the physician ’ s Suicide Risk and Assessment, dated 1/16/2026, indicated: Baseline chronic (a long-term period) risk: Moderately elevated baseline risk. Acute (a short-term period) risk: Not clearly elevated above their baseline. “At present, the patient does not meet criteria for involuntary [against his will] psychiatric hold; his passive [without active response or resistance] SI is fleeting [lasting a short period to time], ego-dystonic [thoughts, impulses, or behaviors that are inconsistent with an individual ’ s values or personalities, causing distress, guilt, or anxiety], and accompanied by clear protective factors; he denies HI [homicidal ideation, thoughts, planning, or intent to harm or kill another person].” During a review of Patient 4 ’ s physician ’ s (MD) 1 order, dated 1/16/2026, the order indicated “Routine observation (every 15 minute checks).” During a record review of Patient 30 ’ s Inpatient Admission Note, dated 3/12/2026, the note indicated Patient 30 was admitted on 3/12/2026 for recurrence of suicidal ideation and worsening depression (a serious, common medical mood disorder characterized by persistent sadness, emptiness, or loss of interest in activities) symptoms. During an interview on 4/13/2026 at 2:20 p.m. with Nurse Manager (NM) 2, NM 2 stated there was no need for staff to be monitored [for assessing proper use of the devices] while using and documenting the every 15 minute observations on the iPad and its accompanying devices (a wrist band, called a beacon, worn by each patient) since any the iPad works well and will indicate if observations are missed. During an observation on 4/14/2026 at 10:50 a.m. in the 4 North unit of the facility, the surveyor observed Clinical Care Partner (CCP) 2 performing the 15 minute observations for Patient 1 and Patient 30, without fully assessing the patients ’ behaviors. CCP 2 was observed by surveyor looking into each room ’ s closed door window (each patient room ’ s door has a window for viewing inside) for approximately one second. Surveyor immediately viewed Patient 1, Patient 8, Patient 9, Patient 30, and Patient 35 through their room ’ s door window as CCP 2 had. The surveyor observed: Patient 1 lying in his bed, his back toward the surveyor and the closed door, face and chest not visible; Patient 30 lying in his bed, his back toward the surveyor and the closed door, face and chest not visible; During an interview on 4/14/2026 at 10:57 a.m. with CCP 2, CCP 2 stated that for observations, if the door was closed, he would watch from the door ’ s window, and if the patient was lying down, he would make sure the patient was still breathing. CCP 2 stated if the patient was in their room not facing the door, he would enter the room to ask the patient how they are doing. CCP 2 stated during the every 15 minute observations, he would observe a patient ’ s chest for breathing for a few seconds until he could see the patient ’ s chest rise and fall. CCP 2 stated if the patient was found to be in the restroom, he would talk to them and wait for a reply. CCP 2 stated if the patient in the bathroom was a male, as CCP 2 is, CCP 2 would look at the patient in the bathroom. CCP 2 stated if the patient in the bathroom was a female, CCP 2 would call a female staff member to check on patient. CCP 2 stated for bathroom observations, he only had to see the patient ’ s legs and not the head or face. During a concurrent observation and interview on 4/14/2026 at 4:21 p.m. with Director of Quality Management and Rehabilitation (DQM) and the Chief Medical Officer (CMO), the hallway surveillance footage outside of Patient 4 ’ s room was viewed. At 11:16 a.m., 11:30 a.m., and 11:43 a.m., Clinical Care Partner (CCP) 3 was observed with an electronic device (an iPad) documenting Patient 4 ’ s location and behavior without visually observing Patient 4 ’ s location and behavior. The DQM and CMO verbally acknowledged with a “Yes” that the observations were not according to the facility ’ s policy. The DQM and CMO verbally acknowledged with a “Yes” that Patient 4 was found by a Unit Secretary (US) at 11:45 a.m. in a suicide attempt. The DQM and CMO acknowledged the last visual contact CCP 3 had on Patient 4 was at 11:11 a.m. The DQM stated the expectation was for the assigned observer to look the patient ’ s room, see if the patient was safe, not necessarily have an interaction with a patient, then document the location and behavior. The CMO stated, “You can look in, but you actually have to look in to see what is going on.” During an interview on 4/16/2026 at 10:19 a.m. with CCP 3, CCP 3 stated for the every 15 minute observations she will check the patient, where the patient is, see if the patient is in their room, or see if the patient is in the bathroom. CCP 3 stated for the observations she has to enter the location where the patient is. CCP 3 stated for Patient 4 ’ s 1/17/2026 every 15 minute observations, she did not enter Patient 4 ’ s room but did look inside the room by looking through the door ’ s window. CCP 3 stated it was important to see the patient because “we need to see if he is alive, to see if he is OK.” CCP 3 stated for Patient 4 ’ s every 15 minute observations on 1/17/2026, “I was clicking on the iPad, for some reason I didn ’ t change the location or behavior, I was just clicking.” CCP 3 stated the iPad ’ s default setting was whatever previous location and behavior entry was last entered on the iPad. During an interview on 4/16/2026 at 10:47 a.m. with Assistant Nurse Manager (ANM) 4, ANM 4 stated an observation to see if a patient was asleep would take 10 to 15 seconds. ANM 4 stated if a patient was in the bathroom, a staff member assigned to observations just has to talk to the patient, not see a patient unless the patient is a danger to self. ANM 4 stated there was no expectation for the staff member to speak to a patient during the every 15 minute observation. ANM 4 was asked if he monitors staff assigned to perform the 15 minute observations. ANM 4 stated he does not monitor staff but rather he looks at the electronic record to see if anyone is “in the red,” further stating the “red” indicates on the computer the 15 minute rounds on a patient have not been completed. ANM 4 was informed by surveyor that on 4/14/2026 CCP 2 was observed performing the 15 minute observations for Patient 1 and Patient 30, and spending what was probably one second viewing each patient through the respective door ’ s window. ANM 4 was shown the facility ’ s policy regarding “Nursing Observation of Patients,” revised 5/25/2022. ANM 4 stated, “Is this a new policy?” and “Wow. We are not matching the policy.” During a review of the facility ’ s policy and procedure (P&P) titled, “Nursing Observation of Patients,” dated 5/25/2022, the P&P indicated the following: 1. Patients will be assessed with the level of observation order by the physician and the RN will initiate and/or increase the level of observation, based on the RN ’ s professional judgement. 2. Routine observation – all patients will be visually observed every 15 minutes. 4. When rounding and the patient is awake, the staff member should have a verbal interaction or check-in with the patient, i.e., “I am rounding, is there anything you need?” 5. When the patient is asleep, they must be assessed for breathing, which may include entering the patient ’ s room to see the rise and fall of their chest or hear their breathing pattern. 6. When the patient is using the restroom, the staff member (preferably of the same identified gender) needs to visually observe the patient ’ s face/head.”

“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: 45774 Based on interview and record review, the facility failed to ensure two of 35 sampled patients (Patient 25 and Patient 27), were administered the correct pain medication for the type of pain patient experienced. This deficient practice had the the potential to result in inadequate pain control, untreated or worsening pain, and delayed symptom relief. Findings: A. During a review of Patient 25 ’ s “History and Physical” (H&P – a foundational medical document and process, combining a patient ’ s history with a hands-on assessment to form a diagnosis and plan), dated 3/13/2026, the H&P indicated Patient 25 was admitted to the facility on a 5150 hold (a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves]) for suicidal ideation (wanting to hurt themselves). During a concurrent interview and record review on 4/14/2026 at 3:30 p.m., Patient 25 ’ s nursing assessment, dated 3/30/2026, was reviewed. The assessment indicated Patient 25 complained of moderate pain (pain scale of five out of 10 possible score) at 4:41 p.m. ANM 3 confirmed that Patient 25 complained of moderate pain at 4:41 p.m. In the same concurrent interview and record review, Patient 25 ’ s medication administration record (MAR – a legal, essential document to track, document, and verify the administration of medications to patients, including dosage, time, and route), dated 3/30/2026, was reviewed. The MAR indicated Patient 25 was given Tylenol (a type of pain medication) 650 milligrams (mg, a unit of measurement for medication dosage) by mouth at 4:41 p.m. ANM 3 confirmed Patient 25 was given Tylenol 650 mg PO at 4:41 p.m. In the same concurrent interview and record review, Patient 25 ’ s physician order for pain medication, dated 3/12/2026, was reviewed. The order indicated Patient 25 had an order for Tylenol 650 mg PO for mild pain (numeric pain score of one to three out of 10 total). ANM 3 confirmed Patient 25 had an order for Tylenol 650 mg PO for mild pain. ANM 3 stated Patient 25 did not have a physician order for moderate pain and was given pain medication for mild pain. ANM 3 stated that the physician was not notified that Patient 25 complained of moderate pain on 3/30/2026 at 4:41 PM. ANM 3 stated Patient 25 did not get the right medication for the pain that patient experienced. During a review of the facility ’ s policy and procedure (P&P) titled, “Assessment/Re-assessment,” dated 11/30/2020, the P&P indicated the following: Assessment of a patient ’ s clinical needs was an on-going process, performed by health care professionals, about each patient ’ s physical, psychological, spiritual, cultural, and social needs, throughout the patient ’ s course of treatment and hospitalization. After admission, the physician will assess and document the patient ’ s physical, psychological and social status, history, perform a suicide risk assessment, medication reconciliation, and physical exam, within 24 hours. Based on the initial assessment, the attending physician will establish an initial treatment plan and communicate this in the patient ’ s medical record. The RN completes and documents nursing assessments, within 24 hours of admission. Reassessment of the patient ’ s physical (including pain), psychological, suicidal risk, spiritual, cultural, and social needs is relative to the patient ’ s diagnosis, the care setting, the patient ’ s desire for care, and the urgency of the patient ’ s condition and/or response to any previous care. When pain is present, RN will document pain score, at least once per shift. Assessment data are collected about each patient ’ s pain and need for pain management. During a review of the facility ’ s P&P titled “Pain Assessment and Management,” dated 8/31/2023, the P&P indicated the following: Patients are screened for pain, as part of the patient ’ s initial evaluation, and on an on-going basis, including pain history, location/intensity/quality/duration, alleviating/aggravating factors, previous treatments, patient ’ s pain goals, examination/observation of the site of pain, and risk factors. Patients receive prompt, effective pharmacologic, non-pharmacologic, and/or procedural management for their pain. Pain is reassessed with new reports of pain and following pharmacologic/non-pharmacologic interventions and are documented in the medical record. During a review of the facility ’ s P&P titled “Medication Administration,” dated 3/2026, the P&P indicated the following: Before the medication is administered, an order must be written by the patient ’ s provider. The medication order requirements included name of the medication, dosage, frequency, route of administration, date and time of the order, and indications for use. Requirements of medication administration include identifying the right patient, right drug, right route, and right time. Non-scheduled medications that should be administered at the specified time due per indication, as prescribed, including pro re nata (PRN – as needed) medications (for pain). All patients receiving medications are monitored for medication effects, side effects, and adverse reactions. All medications (including drug name, dose, route, and times) are documented in the medical records on the medication administration record (MAR), following administration. B. During a review of Patient 27 ’ s H&P, dated 4/4/2026, the H&P indicated Patient 27 was admitted to the facility for suicidal ideation with a history of post-traumatic stress disorder (PTSD – a mental health condition triggered by experiencing a terrifying, traumatic event) and bipolar disorder (a chronic mental health condition characterized by extreme mood swings, alternating between intense emotional highs and deep lows/depression). During a concurrent interview and record review on 4/15/2026 at 11:40 a.m. with ANM 3, Patient 27 ’ s nursing assessment, dated 4/5/2026, was reviewed. The assessment indicated Patient 27 complained of severe pain with a pain score of 9 out of 10 at 6:22 PM. ANM 3 confirmed that the assessment indicated Patient 27 ’ s pain. In the same concurrent interview and record review, Patient 27 ’ s MAR, dated 4/5/2026, was reviewed. The MAR indicated Patient 27 was administered Tylenol 325 mg PO on 4/5/2026 at 6:19 PM. ANM 3 confirmed that the MAR indicated Patient 27 was given Tylenol. In the same concurrent interview and record review, Patient 27 ’ s physician order for pain medication, dated 4/3/2026, was reviewed. The physician order indicated to give patient Tylenol 325 mg by mouth, for mild pain (numeric pain score 1 to 3, out of 10 total possible score) to moderate pain (numeric pain score 4 to 6, out of 10 total possible). ANM 3 stated physician was not notified that Patient 27 complained of severe pain (numeric pain score 9 out of 10), on 4/5/2026. ANM 3 stated patient did not get the right medication for the pain that patient experienced. During a review of the facility ’ s policy and procedure (P&P) titled, “Assessment/Re-assessment,” dated 11/30/2020, the P&P indicated the following: Assessment of a patient ’ s clinical needs was an on-going process, performed by health care professionals, about each patient ’ s physical, psychological, spiritual, cultural, and social needs, throughout the patient ’ s course of treatment and hospitalization. After admission, the physician will assess and document the patient ’ s physical, psychological and social status, history, perform a suicide risk assessment, medication reconciliation, and physical exam, within 24 hours. Based on the initial assessment, the attending physician will establish an initial treatment plan and communicate this in the patient ’ s medical record. The RN completes and documents nursing assessments, within 24 hours of admission. Reassessment of the patient ’ s physical (including pain), psychological, suicidal risk, spiritual, cultural, and social needs is relative to the patient ’ s diagnosis, the care setting, the patient ’ s desire for care, and the urgency of the patient ’ s condition and/or response to any previous care. When pain is present, RN will document pain score, at least once per shift. Assessment data are collected about each patient ’ s pain and need for pain management. During a review of the facility ’ s P&P titled “Pain Assessment and Management,” dated 8/31/2023, the P&P indicated the following: Patients are screened for pain, as part of the patient ’ s initial evaluation, and on an on-going basis, including pain history, location/intensity/quality/duration, alleviating/aggravating factors, previous treatments, patient ’ s pain goals, examination/observation of the site of pain, and risk factors. Patients receive prompt, effective pharmacologic, non-pharmacologic, and/or procedural management for their pain. Pain is reassessed with new reports of pain and following pharmacologic/non-pharmacologic interventions and are documented in the medical record. During a review of the facility ’ s P&P titled “Medication Administration,” dated 3/2026, the P&P indicated the following: Before the medication is administered, an order must be written by the patient ’ s provider. The medication order requirements included name of the medication, dosage, frequency, route of administration, date and time of the order, and indications for use. Requirements of medication administration include identifying the right patient, right drug, right route, and right time. Non-scheduled medications that should be administered at the specified time due per indication, as prescribed, including pro re nata (PRN – as needed) medications (for pain). All patients receiving medications are monitored for medication effects, side effects, and adverse reactions. All medications (including drug name, dose, route, and times) are documented in the medical records on the medication administration record (MAR), following administration.”

“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: 38310 Based on interview and record review, the facility failed to ensure: two of five sampled staff members had documentation of physical clearance to perform duties and were free from communicable diseases, prior to working with patients. (Estella) an effective system for preventing and controlling transmission of infections among personnel and patients, by not verifying two (2) of four medical staffs (MD1 and MD4) Tuberculosis (TB, is a serious, contagious infection caused by Mycobacterium tuberculosis bacteria, typically attacking the lungs) status, and three (3) of four medical staffs (MD1, MD2, and MD3) hepatitis B immune (Hepatitis B [hep B] is a potentially life-threatening infection caused by the hepatitis B virus, HBV, that can cause both acute and chronic liver disease and places people at high risk of death from cirrhosis and liver cancer that the virus can be transmitted through exposure of blood or body fluid from a infected individual) status. This deficient practice had the potential risk of acquiring or transmitting of communicable diseases from employed staff members and/or providers to their patients that could lead to serious infection and possible mortality. Findings: A. 1. During a concurrent interview and record review on 4/15/2026 at 3:56 p.m. with the Occupational Health Manager (OHM), Registered Nurse (RN) 2 ’ s employee health records were reviewed. OHM stated the facility had no documentation of the following: Health clearance to determine suitability for duties, prior to beginning employment. Tuberculosis (TB – a contagious infection caused by Mycobacterium tuberculosis bacteria, primarily attacking the lungs, which is transmitted through air droplets) screening (done annually with questionnaire to identify signs/symptoms and skin/blood test to check for disease) was not done annually, since 2023. Tetanus/Diphtheria/Acellular Pertussis (Tdap – a combination booster vaccine that protects against three serious bacterial infections including tetanus/lockjaw, diphtheria, and acellular pertussis/whooping cough) had no records of immunity and no vaccination records. Hepatitis B (HBV - a potentially serious liver infection caused by the hepatitis B virus) had no records of immunity or vaccination series. Influenza had no questionnaire done for screening (done annually) and/or no vaccination records. 2. During a concurrent interview and record review on 4/15/2026 at 4:25 p.m. with the OHM, Clinical Care Partner (CCP) 3 ’ s health records were reviewed. OHM stated the facility had no documentation for the following: Health clearance to determine suitability for duties, prior to beginning employment. Tdap - no records of immunity or vaccination records. HPV – no records of immunity or vaccination records. Influenza – no documentation of annual questionnaire done, since 2024 – done annually. Measles/Mumps/Rubella (MMR – communicable diseases causing fever, rashes, and/or swollen glands) – no records of immunity or vaccination records. Chickenpox – no records of immunity or vaccination records. B. During a concurrent interview and record review on 4/16/26 at 10:45 a.m. with Manager of Medical Staff (MMS), the credentialing (verifies a physician ’ s qualifications, education, training, licenses, and background, to ensure patient safety and enable insurance billing) of four providers (MD1, MD2, MD3, MD4) were reviewed. The credentialing indicated that three (3) providers (MD1, MD2 and MD3) had no record of Hepatitis immune status on files. Concurrently, there is no current TB status was provided for 2 providers (MD1 and MD4) during the credentialing record review. MMS stated that the reappointment (a periodic typically every two re-evaluations of a practitioner ’ s credentials, clinical competence, and professional standing to maintain hospital privileges) process included only reviewing providers ’ TB status but not Hepatitis B immune. During an interview on 4/16/26 at 1130 a.m., with Clinical Regulatory Affairs Specialist (CRAS), stated that she verified with director of occupational health, there is no separate policy of for exposure control plan for bloodborne pathogens and TB testing for providers, the policies applied to all staffs included the providers that providers required to have annual TB screening or testing and Hep B immune status on file. During a review of the facility ’ s policy and procedure (P&P) titled, “Exposure Control Plan for Bloodborne Pathogens”, HS IC006, dated 1/2026, indicated that The UCLA Health System has implemented an Exposure Control Plan for Bloodborne Pathogens to minimize the risk of transmission to employees. This plan is consistent with the requirements of CAL/OSHA Bloodborne Pathogens Standard Title 8, Code of California Regulations, Section 5193 .... This plan applies to all job classifications across the UCLA Health System where an occupational exposure might/could occur ... The Hepatitis B vaccination program is administered by Occupational Health (OH) for all employees. The vaccine series is offered at time of employment to those who are unvaccinated or have low titer levels and is also reviewed after exposure event. Employees refusing vaccination must sign a declination form ... Occupational health records, as required by this section, will be maintained for at least the duration of employment plus 30 years ...Exposure determination categories I included employees who routinely have contact with blood or body fluids and/or used sharps ....physicians (attendings, fellows, residents, interns) .... During a review of the facility ’ s policy and procedure (P&P) titled, Quantiferon Gold in Tube Testing for Newhires and Existing Employees, Staff and Volunteers (Tuberculin TB Testing), HS 7406, dated 2/2025, indicated that UCLA Health System, David Geffen School of Medicine and UCLA School of Dentistry. UCLA Health System includes Ronald Reagan UCLA Medical Center, Resnick Neuropsychiatric Hospital, UCLA Santa Monica Medical Center, and UCLA West Valley Medical Center...To ensure a safe and healthy environment for employees, faculty, medical and allied health staff, volunteers, patients and visitors at the covered UCLA facilities ... All prospective employees, faculty, and volunteers at these organizations, including applicants to the Medical and Allied Health Staff, must provide evidence that they are free of active TB prior to starting their first day of employment via a three step screen and then the appropriate annual education or screening thereafter .... All clinical employees must undergo annual TB risk assessment and annual TB education .... Annual symptom screening will be determined by the employee’s risk assessment ... Any employee who comes on site to a clinical setting (i.e. hospitals, clinics, labs, etc) for any reason must comply with this policy by completing the annual TB risk assessment and TB education module.”

“Document Therapeutic Efforts CFR(s): The treatment received by the patient must be documented in such a way to assure that all active therapeutic efforts are included. This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to ensure that entries in the “Behavioral Health – Patient Observation Sheet” monitoring form (a documentation form used for assigned observation staff to document the location and the behavior of the patients who have an order for every 15 minute observations) were properly documented for one out of 35 sampled patients (Patient 4) in accordance with the facility ’ s “Documentation of Nursing Care: Inpatient Services” policy and procedure. The deficient practice had the potential to cause miscommunication among healthcare providers and place patients at risk for missed interventions, delays in treatment, or incorrect treatments. Findings: During a review of Patient 4 ’ s “Inpatient Admission Note,” dated 1/16/2026, the admitting note indicated Patient 4 was admitted to the facility voluntarily on 1/16/2026 with an admission diagnosis of bipolar 1 disorder [a serious mental health condition characterized by at least one manic (a state of abnormally elevated energy and frantic activity) episode that lasts at least seven days and is severe enough to require hospitalization] with psychotic features [the patient experiences a loss of contact from reality, such as hallucinations (sensing things not there) or delusions (false beliefs)], worsening anxiety (feelings of tension, worried thoughts, with physical changes such as an increased heart rate or sweating) with significant financial stressors, strong support from multiple family members, and a recent discharge from the facility one week prior to readmission on 1/16/2026. The 1/16/2026 admitting note indicated Patient 4 had made vague statements such as “no way out ...unsolvable ...” but denied any active suicidal ideation [SI, thoughts or ruminations about dying by suicide, ranging from passive desires to be dead to active, specific planning] (no intent/plan). The admitting note indicated Patient 4 had a history of suicide attempt by driving into an oncoming car in 2015. The admitting note indicated Patient 4 had a CSSRS (Columbia-Suicide Severity Rating Scale, a tool used to assess suicide risk by asking simple questions about suicidal thoughts and behaviors, with 0 points indicating no risk, 1-2 points indicating low risk, 3 or more points indicating moderate to high risk) score of 0 in the outpatient setting and the physician ’ s Suicide Risk and Assessment, dated 1/16/2026, indicated: Baseline chronic (a long-term period) risk: Moderately elevated baseline risk. Acute (a short-term period) risk: Not clearly elevated above their baseline. “At present, the patient does not meet criteria for involuntary [against his will] psychiatric hold; his passive [without active response or resistance] SI is fleeting [lasting a short period to time], ego-dystonic [thoughts, impulses, or behaviors that are inconsistent with an individual ’ s values or personalities, causing distress, guilt, or anxiety], and accompanied by clear protective factors; he denies HI [homicidal ideation, thoughts, planning, or intent to harm or kill another person].” During a review of Patient 4 ’ s physician ’ s (MD) 1 order, dated 1/16/2026, the order indicated “Routine observation (every 15 minute checks).” During a review of concurrent interview and record review on 4/15/2025 at 5:00 p.m. with the Director of Quality Management and Rehabilitative Services (DQM), Patient 4 ’ s “Behavioral Health – Patient Observation Sheet,” dated 1/17/2026, was reviewed. The observation sheet indicated Patient 4 ’ s location and behavior were was Day Room [a room used for meals, group therapy (a small group of patients will meet with a mental health therapist), occupational therapy (therapy to address physical, emotional, and social needs to improve quality of life), and other activities] and Patient 4 ’ s behavior was GR (Group Therapy session), respectively, for the following times: 10:57 a.m. 11:10 a.m. 11:12 a.m. 11:25 a.m. 11:38 a.m. 11:53 a.m. 12:04 p.m. 12:06 p.m. 12:08 p.m. Durning a concurrent observation and interview on 4/14/2026 at 4:21 p.m. with the Director (DQM) of Quality Management and Chief Medical Officer (CMO), the facility ’ s security footage outside of Patient 4 ’ s room, date-stamped 1/17/2026 from 10:56 a.m. to 11:46 p.m., was reviewed. The following was observed in the footage: 1. 10:56 a.m. Clinical Care Partner (CCP) 3 with iPad (device used to document patient location and activity) sitting at desk in chair with monitor, in hallway outside of Patient 4 ’ s room. 2. 10:58 a.m. Patient 4 entered his room. Patient 4 closes his door. 3. 11:02 a.m. Patient 4 left his room, looked into the day room through the day room ’ s window, walked past his (Patient 4) room door, CCP 3, with iPad in hand, looked at Patient 4. 4. 11:03 a.m. Patient 4 walked back to his room. 5. 11:04 a.m. CCP 3 sat back in chair outside Patient 4 ’ s room. 6. 11:10 a.m. Patient 4 left his room, CCP 3 glanced at Patient 4 but did not reach for iPad. 7. 11:11 a.m. Patient 4 walked back to his room, CCP 3 and another Clinical Care Partner spoke but iPad was not used. 8. 11:15 a.m. CCP 3 went down hallway with iPad and out of view camera view. 9. 11:16 a.m. CCP 3 walked past rooms, including Patient 4 ’ s room, with iPad, appearing to document, and was not observed to have looked in rooms. 10. 11:17 a.m. CCP 3 sat down in chair in hallway outside of Patient 4 ’ s room. 11. 11:18 a.m. CCP 4 and CCP 3 spoke with each other. Patient 4 ’ s door moving but not opening fully. 12. 11:19 a.m. CCP 4 looked briefly into Patient 4 ’ s door window. CCP 4 then walked away out of sight. 13. 11:30 a.m. CCP 3 took iPad. CCP 3 walked past Patient 4 ’ s room (and other room visible in the video), stood approximately one foot away from door. CCP 3 did not look into rooms or door windows. CCP 3 appeared to document on iPad Patient 4 ’ s status and location. 14. 11:34 a.m.: Patient 4 ’ s door slightly opened from the inside, Patient 4 ’ s head was only partially visible and was not visible for very long. Patient 4 did not exit his room. Patient 4 closed his door, remaining inside his room. 15. 11:35 a.m.: CCP 3 made a very subtle but not full glance to patient ’ s door. 16. 11:43 a.m. CCP 3 takes the iPad, walks down hallway to made rounds, not looking into patient rooms and keeping approximately one foot away from each door CCP 3 observed.. 17. 11:44 - 11:45 a.m.: Unit Secretary (US) approached and entered Patient 4 ’ s room, immediately ran out of room, alerted staff to a situation. Several facility staff, being alerted, approached to assess and begin a code blue. 18. 11:46 a.m. CCP 3 returned to area outside of Patient 4 ’ s room. During a concurrent interview and record review on 4/14/2026 at 5:05 p.m. with DQM, the DQM verbally acknowledged that the video/security footage dated 1/17/2026 outside of Patient 4 ’ s room indicated Patient 4 was in the hallway outside of his room walking, entering his room and exiting his room during the time period of 10:58 a.m. to 11:45 a.m., the time when Patient 4 was found in his (Patient 4) room in a suicide attempt. DQM verified Patient 4 ’ s observation sheet documentation entries made by CCP 3 were not correct since Patient 4 could be observed on the video walking in hallway outside of his room, entering his room, exiting his room, and returning to his room. DQM stated Patient 4 ’ s location was not in the Day Room after 10:58 a.m. nor was Patient 4 in group therapy as indicated on Patient 4 ’ s 1/17/2026 ’ s observation sheet. During a record review Patient 1 ’ s Cardiopulmonary Arrest Record/Order,” dated 1/17/2026, the record indicated Patient 4 left the unit at 12:10 p.m., with the destination General Acute Care Hospital (GACH) 1 ’ s ICU (intensive care unit, a specialized hospital department that provides high-level care for critically ill patients), and taken off life support (the use of specialized equipment to maintain a person ’ s essential functions, such as breathing) two weeks later resulting in Patient 4 ’ s death. During an interview on 4/16/2026 at 10:19 a.m. with CCP 3, CCP 3 stated for the every 15 minute observations, “I was clicking on the iPad, for some reason I didn ’ t change the location or behavior, I was just clicking.” During a review of the facility ’ s policy and procedure (P&P), titled, “Documentation of Nursing Care: Inpatient Services,” revised 11/15/2018, the P&P indicated, “In the event a documentation error is made, Electronic Health Record entries are to be modified to correct the identified error.””