Del Amo Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient’s Rights was met, as evidenced by: 1. The facility failed to ensure its staff followed the facility’s process to address and respond to a grievance (formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care that requires investigation) filed by one of 32 sampled patients (Patient 13). The grievance (Patient 13 reported receiving incorrect medication and being treated rudely by facility staff) was filed with the facility’s nurse manager and was not properly addressed in a timely manner (within 7 days), in accordance with the facility’s policy regarding complaint and grievance procedures. There was no escalation of the incident to Risk Management, no follow-up, and no patient notification regarding the outcome of the facility’s investigation into Patient 13’s grievance. This deficient practice resulted in an incomplete investigation and lack of response to Patient 13’s complaint thus violating the patient’s right regarding the right to voice concerns about patient care and potentially leading to Patient 13’s dissatisfaction with the quality of care received at the facility. (Refer to A-0118) 2. The facility failed to follow its grievance process for one (1) of thirty two (32) sampled patients (Patient 3), when staff did not identify, document, or process a parent’s (Patient 3’s parent) disagreement with the discharge of a minor patient (Patient 3) as a grievance, and did not forward the complaint for investigation or written response, as required by the facility’s policy titled “Patient Complaint/Grievance Process.” This deficient practice had the potential for Patient 3’s parent’s safety concerns to go uninvestigated; the potential for psychosocial distress to both Patient 3 and Patient 3’s parents due to feeling dismissed, unsafe, or unsupported during the discharge process; and the potential for delays in addressing unresolved care issues that affect patient safety. The inability to identify the nurse who wrote the note (regarding Patient 3’s parent’s disagreement with Patient 3’s discharge) could make it harder for the hospital to fully review the complaint, make it difficult to hold staff responsible for their actions, and reduce the patient’s or family’s confidence in the hospital’s complaint process. (Refer to A-0118) 3. The facility failed to ensure that one of 32 sampled patients (Patient 25) received a Probable Cause Hearing (PCH, legal hearing to determine if there was “good cause [reason]” to remain in a hospital for a specific amount of time), in accordance with the facility’s policy regarding “Inappropriate Use of Involuntary Commitment,” when Patient 25 was placed on a 5250 (14 day hold [hold, remain in a hospital for treatment without their consent]) on 12/21/2025 and 5270 (30 day hold) on 1/4/2026. This deficient practice prevented Patient 25 from exercising the right to have a hearing, participate in the hearing, and/or contest (challenge) their hold and legal status as a patient, which may result in erosion of therapeutic trust in healthcare systems, reduced treatment adherence or avoidance of care leading to worsening of mental health issues. (Refer to A-0129) 4. The facility failed to ensure that Patient 20’s custody order (a legally binding court document that identifies which parent has legal custody [the authority to make decisions regarding the child’s health care]) was honored by facility staff. The facility contacted both parents regarding Patient 20’s health-care decisions and involved Parent 2 (the non-custodial parent) in the discharge process, even though only Parent 1 was awarded legal custody to make health-care decisions for Patient 20. This deficient practice violated Patient 20’s right to have medical decisions made only by the legally authorized representative and also violated Patient 20’s right to privacy and confidentiality, as medical information was shared with a parent who was legally prohibited from participating in health-care decisions. In addition, this deficient practice had the potential to cause significant psychological distress to Patient 20, including anxiety (a feeling of worry, nervousness, or unease), fear (an unpleasant emotion caused by the belief that someone or something is dangerous), and emotional instability (difficulty regulating emotions or maintaining emotional control). (Refer to A-0129) 5. The facility failed to ensure its staff offered one of 32 sampled patients (Patient 12) and the patient’s (Patient 12) legal guardian the opportunity to file a police report after Patient 12 was hit on the back of head five (5) times, on the right temple (right side of the head between forehead and ear), chin, and nose by Patient 26, on 9/10/2025, causing Patient 12 to suffer from a non-displaced fracture (a stable broken bone) of nasal (nose) bone. This deficient practice resulted in Patient 12 and Patient 12’s legal guardian not being able to exercise the right to participate in decisions regarding Patient 12’s care including the right to have an allegation of physical assault reported to law enforcement allowing an immediate investigation by authorities, which is vital for preventing further harm or abuse. (Refer to A-0129) 6. The facility failed to ensure staff provided translation service (provide qualified, real-time language assistance to patients with limited English proficiency (LEP) or hearing impairments. These services ensure accurate communication of medical information) when obtaining release of information form titled, “Authorization for Release of Protected Health Information (ROI form, the release of information form, written consent [authorization] from patient to whom and what type of health information to be disclosed or released to)” form, for one of 32 sampled patients (Patient 13) when Patient 13, whose preferred language was Spanish, was not provided with Spanish translation or the ROI form written in Spanish, in accordance with the facility’s nondiscrimination policy. This deficient practice had the potential to result in Patient 13 not fully understanding the content of the ROI form which may lead to the release of unnecessary health information to people. (Refer to A-0129) 7. The facility failed to ensure the facility’s psychiatrist (physician specializes in mental health) discussed with two of 32 sampled patients (Patient 14 and Patient 15) about the 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) including the rights of having court hearing (an automatic, informal legal proceeding held within 4 days of a 5150 hold [an involuntary psychiatric detention under California law that allows a qualified professional to hold an individual for up to 72 hours for evaluation when the person is deemed a danger to self, danger to others, or gravely disabled-requires assistance with performing activities of daily living such as hygiene or grooming] to determine if “probable cause” exists to detain a patient for up to 14 additional days for intensive mental health treatment due to danger to self, others, or grave disability), when Patients 14 and 15 were placed on 5250-hold, in accordance with the facility’s policy of involuntary commitment (a legal process where an individual is forced into a psychiatric facility or treatment program against their will, typically used as a last resort when mental health issues cause an immediate danger to themselves or others. It requires specific legal criteria, such as a court order or emergency medical evaluation, to manage risk and provide care). This deficient practice violated the patient rights of Patient 14 and Patient 15 by not knowing and exercising the rights of having different court hearings including certification review hearing (also known as probable cause hearing, a legal proceeding with a specific purpose related to involuntary psychiatric holds to determine if there is sufficient legal justification [probable cause] to continue holding an individual involuntarily for intensive treatment due to a mental disorder) and/or Writ of Habeas Corpus (a legal procedure invoking the jurisdiction of a court to review whether the detention or imprisonment of an individual was lawful), during the 14-day involuntary hold period, while at the facility. This deficient practice also resulted in Patient 15 not knowing what court hearing Patient 15 would be having and when to expect the court hearing to be held. This deficient practice also had the potential to cause psychological distress for Patients 14 and 15 due to lack of understanding of the legal basis and timeline for the continued involuntary hold. (Refer to A-0129) 8. The facility failed to ensure its physician evaluated one of 32 sampled patient’s (Patient 16) need for a 5250-hold (14-day hold, allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) before the original 5150-hold (72-hour 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) expired, in accordance with facility’s policy of involuntary commitment. . This deficient practice resulted in detaining Patient 16 at a psychiatric hospital (inpatient hospital that provides treatment and therapy for people who have mental, emotional and behavioral disorders) without a valid involuntary hold and a valid legal justification which may lead to psychological distress for Patient 16. (Refer to A-0129) 9. The facility failed to ensure its psychiatrist provided information and obtained informed consents (a process by which a patient is informed of any antipsychotic medication that have been prescribed to him or her and the patient’s consent is obtained) prior to ordering psychotropic medications (chemical substances that affect brain function, altering mood, perception, consciousness, and behavior to treat mental illnesses or disorders) for one of 32 sampled patients (Patient 14), in accordance with the facility’s policy regarding medication consent, when Patient 14 received lithium (mood-stabilizing medication to treat and prevent acute [new onset] manic episode and maintenance of bipolar disorder), olanzapine (antipsychotic medication to treat schizophrenia, and bipolar disorder), hydroxyzine (medication to treat anxiety), trazodone (antidepressant medication to treat insomnia [difficulty falling asleep] and depression) and lorazepam (sedative-hypnotic medication to manage anxiety), without an informed consent from 10/6/2025 to 10/23/2025. This deficient practice had the potential to result in Patient 14 not knowing the medications’ purpose, and side effects when receiving the psychotropic medications during hospitalization. (Refer to A-0131) 10. The facility failed to ensure one of 32 sampled patients (Patient 23) had an Informed Consent (a process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) form for Medication, properly filled out either with a patient’s signature to indicate agreement to a medication prescribed or notation of patient refusal, in accordance with the facility’s policy and procedure (P&P) titled “Informed Consent for Psychotropic Medications (chemical substances that affect brain function, altering mood, perception, consciousness, and behavior to treat mental illnesses or disorders),” when Patient 23’s “Medication Consent forms for: Anti-Manic (high energy)/Mood Stabilizers (medications designed to reduce extreme emotional highs [mania] and lows [depression])” and “Medication Consent for: Sedatives (to make someone sleepy), Hypnotics (make someone focused, sleepy and relaxed), and Anti-Anxiety (relaxation) Agents,” did not indicate Patient 23’s agreement or refusal to take the medications prescribed, and did not indicate the dosage range of psychotropic medications being prescribed. This deficient practice had the potential for Patient 23 not being able to exercise the right to be fully informed about their medication, the dosage, benefits and risks of taking the medication, which may lead to poor medication compliance, mistrust of providers, and unmanaged side effects. (Refer to A-0131) 11. The facility failed to ensure a complete informed consent (a process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) process for one of 32 sampled patients (Patient 27), when Patient 27’s medication consent form for Prazosin (medication used to treat Post Traumatic Stress Disorder [PTSD, mental health condition caused by extremely stressful or terrifying event] related nightmares) did not indicate the dosage and the dosage range (recommended span between the lowest effective dose and highest safe dose of a medication), in accordance with the facility’s policy and procedure (P&P) titled, “Informed Consent for Psychotropic Medications (chemical substances that affect brain function, altering mood, perception, consciousness, and behavior to treat mental illnesses or disorders), MM-20,” This deficient practice had the potential to result in Patient 27 and/or the patient’s representative not being adequately informed of the proposed medication treatment, thereby impairing their ability to make an informed decision regarding what would be in the patient’s best interest. (Refer to A-0131) 12. The facility failed to ensure a safe care setting for three (3) of thirty two (32) sampled patients (Patient 1, Patient 25, and Patient 32) by not implementing the documented intervention of bathroom supervision (continuous staff presence while a patient uses the bathroom) for Patient 1, by not differentiating monitoring or intervention levels for high, moderate, or low suicide-risk patients (levels describing a patient’s likelihood of attempting self-harm) for Patients 1, 25 and 32 (who had access to private bathrooms in their rooms without bathroom supervision, which require being on one-to-one observation), and when the Registered Nurse (RN, a licensed nurse responsible for clinical assessment and interventions) did not notify the physician or obtain the required physician order for bathroom supervision after documenting the intervention regarding bathroom supervision for Patient 1, in accordance with the facility’s policy “Assessment for Suicide Risk Potential II,” which directed that nurse-initiated precautions must be communicated to, and ordered by, a physician before implementation (for Patient 1) and in accordance with the facility’s policy regarding the patients’ right to be free from harm for Patients 1, 25 and 32. This deficient practice resulted in Patient 1 sustaining a life-threatening ligature event (an item wrapped tightly around the neck that restricts breathing) in the bathroom, where the patient (Patient 1) was found unresponsive (not reacting or responding), cyanotic (bluish skin color from lack of oxygen), and bleeding, requiring emergency intervention (immediate life-saving medical response). This deficient practice also placed Patients 25 and 32, and all other patients at the facility, who were at high risk for suicide and who had access to private bathrooms, without bathroom supervision, at risk for similar serious harm. (Refer to A-0144) 13. The facility failed to ensure one of 32 sampled patients (Patient 25) was free from harm, in accordance with the facility’s policy regarding patient supervision, when Patient 25 sustained a fall and femur (thighbone) fracture (broken bone), while playing basketball with his peers and were unsupervised by facility staff. This deficient practice resulted in femur fracture for Patient 25 and also had the potential to cause severe harm and/or death to other patients due to the lack of staff supervision. (Refer to A-0144) 14. The facility failed to ensure that one (1) of 32 sampled patients (Patient 2) was free from abuse (intentional or unintentional physical or emotional harm), in accordance with the facility’s “Patient Precautions” policy (policy for identifying, evaluating, and mitigating risks such as assault, suicide [the act of intentionally causing one’s own death], and elopement [when a patient left a healthcare facility or supervised setting without authorization or permission]), when the facility did not perform a risk assessment (a clinical evaluation of danger to self or others), did not increase monitoring (raising the frequency of staff checks such as from every 15 minutes to every 5 minutes or direct line-of-sight observation [a high-level safety protocol where a dedicated staff member keeps a patient within their direct, unobstructed view at all times to prevent harm), and did not separate the patients (by placing them in different rooms or units), after Patient 2 was assaulted (physical attack) by Patient 5 (Patient 2 was struck with a closed fist in the jaw [first incident] and struck with Patient 5’s fist on the left side of the head [second incident]). These failures occurred despite nursing notes indicating that the physician was notified regarding the incidents of assault. This deficient practice resulted in Patient 2 having been physically assaulted twice within 24 hours by the same patient (Patient 5). Patient 2 experienced repeated exposure to physical aggression (hitting or striking) and emotional distress (fear, anxiety, or psychological harm), increased vulnerability, and contributed to an unsafe treatment environment for other patients and staff. (Refer to A-0145) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare 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: 36206 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.a. The facility failed to assess the blood sugar levels, as ordered by the physician, for one of 32 sampled patients (Patient 6), in accordance with the physician’s order and the facility’s policy regarding blood glucose (blood sugar) monitoring. This deficient practice left Patient 6’s blood sugar levels unmonitored and had the potential to result in adverse effects (negative or undesirable effect) if high or low sugar levels remained undetected and/or untreated. (Refer to A-0395) 1.b. The facility failed to assess the vital signs (VS- temperature, blood pressure, pulse [heartbeat], respiratory rate [number of breaths per minute]) for one of 32 sampled patients (Patient 6), in accordance with the physician’s order and the facility’s policy regarding vital signs assessment. This deficient practice had the potential for changes in Patient 6’s condition to be unidentified by staff, which may delay the implementation of necessary interventions to treat negative changes in Patient 6’s condition such as sudden drop in blood pressure leading to patient harm and/or death. (Refer to A-0395) 2. The facility failed to ensure one of 32 sampled patient’s (Patient 11) neuro-checks (neurological [pertaining to brain] assessments done at regular intervals to check the patient’s alertness, thinking, and how well the brain is working), were completed every 4 hours, as ordered by the physician, after Patient 11 attempted to strangulate (to compress or constrict a body part [like the throat] to stop airflow or blood circulation) herself. This deficient practice had the potential to result in Patient 11 developing neurological complications (decline in brain function) that are not promptly assessed or treated. (Refer to A-0395) 3. The facility failed to ensure its nursing staff assessed one of 32 sampled patient’s (Patient 13) compliance (to follow) with a prescribed psychotropic medication (chemical substances that affect brain function, altering mood, perception, consciousness, and behavior to treat mental illnesses or disorders) regime (prescribed medication plan) and did not notify the psychiatrist (physician specializes in mental health), when Patient 13 refused to take the prescribed psychotropic medication duloxetine (medication to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest in life], anxiety [a group of mental disorders characterized by significant feelings of fear] and various pain conditions), as ordered by the psychiatrist during Patient 13’s hospitalization. Patient 13 was discharged with duloxetine prescription on 10/16/2025. This deficient practice resulted in the physician not being able to evaluate Patient 13’s compliance with the treatment plan or considering alternative psychotropic medications for Patient 13 to manage Patient 13’s mental illness before discharge, which had the potential for Patient 13’s continued noncompliance with medication regimen after discharge from the facility, worsening of Patient 13’s mental illness and possible rehospitalization. (Refer to A-0395) 4. The facility failed to ensure the nursing staff developed and kept current a nursing care plan (a structured, written document that outlines a personalized, holistic approach to a patient’s care) that reflected the patient’s nursing care needs for one (1) of 32 sampled patients (Patient 1). On 1/28/2026 at 4:15 p.m., Patient 1 was assessed using the Columbia Suicide Severity Rating Scale (C-SSRS, a standardized suicide [the act of causing one’s own death]-risk screening tool) and received a score of 24, the highest-risk category. The Nursing Admission Assessment indicated the intervention “Bathroom Supervision (continuous staff presence while a patient uses the bathroom to prevent self-harm).” The intervention regarding bathroom supervision was required based on the assessment findings (on the C-SSRS), but it (the bathroom supervision intervention) was not included in the interdisciplinary Treatment Plan (a collaborative, patient-centered roadmap created by a team of experts-including psychiatrists, nurses, social workers, and therapists-to address a patient’s comprehensive mental, physical, and social needs), and there was no documentation explaining why the intervention regarding bathroom supervision was omitted. As a result, the nursing care plan did not include an intervention identified as necessary during Patient 1’s admission. This deficient practice resulted in the nursing care plan not having included the suicide-risk intervention, regarding bathroom supervision, which was identified by nursing staff for Patient 1. Without the intervention (on bathroom supervision) documented in the plan of care, nursing staff lacked a plan-based direction for providing the required supervision during bathroom use, creating the potential for unmonitored bathroom access and exposure to ligature (any fixture or objects in an environment that could be used to anchor a cord, rope, or clothing for strangulation or hanging)-related harm for Patient 1 and for other patients whose assessed interventions are not incorporated into their plans of care. (Refer to A-0396) 5. The facility failed to ensure its staff conducted standard rounding (Q15-min rounding, refer to patient safety rounds [scheduled checks performed by staff at regular intervals, such as every 15 minutes, to monitor patient location, behavior, and overall safety, ensuring that precautions are in place to prevent harm to the patient or others]) every fifteen (15) minutes and identified any contraband (prohibited, banned) items, including linens, in accordance with the facility’s policy regarding patient rounds and contraband checks for its psychiatric (mental illness) patients. Staff did not conduct Q15 min rounding on one of 32 sampled patients (Patient 11) for 38 minutes on 2/16/2026 from 6:24 p.m. to 7:02 p.m. Patient 11 was then found with a ripped flat sheet tied around her (Patient 11’s) neck. This deficient practice had the potential to result in Patient 11 suffering from severe injuries and/or death. (Refer to A-0398) 6. The facility failed to ensure its staff separated one of 32 sampled patients (Patient 12, the victim) from another patient (Patient 26, the perpetrator), in accordance with the facility’s policy regarding patient precautions, when Patient 12 and Patient 26 were still assigned to the same room after Patient 12 was physically assaulted (physical attack) by Patient 26 on 9/10/2025. Patient 12 was hit on the back of head five (5) times as per patient (Patient 12), on the right temple (right side of the head between forehead and ear), chin, and nose. This deficient practice resulted in Patient 12 experiencing anxiety (a feeling of fear, unease, and restlessness) when seeing Patient 26, thus putting Patient 12 at risk of additional emotional distress. (Refer to A-0398) 7. The facility failed to ensure nursing staff performed a suicide risk assessment (a daily check that evaluates whether a patient has thoughts or behaviors showing they may try to harm themself) on 2/17/2026, for one of 32 sampled patients (Patient 11), as required by the facility’s policy for SI screening (SI means suicidal ideation, which refers to thoughts of wanting to harm or kill oneself). This deficient practice had the potential to result in Patient 11 experiencing another self-harm attempt that could have gone unnoticed, especially because Patient 11 had attempted suicide (act of causing one’s own death) in the facility on 2/16/2026 around 7 p.m. (Refer to A-0398) 8. The facility failed to administer venlafaxine (a medication used to treat depression [a common, serious mood disorder characterized by persistent sadness, loss of interest in activities, and low energy, lasting for at least two weeks]), as ordered by the physician, for one of 32 sampled patients (Patient 6), in accordance with the physician’s orders and the facility’s policy and procedure regarding medication administration. This deficient practice resulted in Patient 6 not receiving medication on the day it was ordered and resulted in a delay in providing treatment for Patient 6’s depression. (Refer to A-0405) 9. The facility failed to ensure one of 32 sampled patient’s (Patient 27) medication Prazosin (medication used to treat Post Traumatic Stress Disorder [PTSD, mental health condition caused by extremely stressful or terrifying event] related nightmares), was administered in a timely manner, in accordance with the physician’s order and the facility’s policy regarding medication administration. This deficient practice had the potential for Patient 27 to experience a return of severe nightmares due to delayed treatment. (Refer to A-0405) 10. The facility failed to ensure nursing staff notified the physician (medical practitioner responsible for patient care) of a change in condition related to medication administration for one (1) of thirty two (32) sampled patients (Patient 2). After an increased dosage of Risperidone (an antipsychotic medication used to treat mood or thought disorders), Patient 2 reported worsening symptoms, including restlessness (an inability to sit still), inability to sleep (insomnia), and overall deterioration. Nursing staff documented the concern but did not notify the physician and did not document any provider notification, in accordance with the facility’s “Chain of Command” policy (a policy requiring staff to contact the responsible physician when a patient has a medical need or change in condition). This deficient practice had the potential for Patient 2’s symptoms to worsen without timely clinical intervention; delay in adjusting or discontinuing the medication; and unnecessary discomfort or distress. The failure to notify the physician also had the potential to compromise safe medication management and continuity of care (ensuring treatment plans remain consistent and communicated). (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. 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 (CoP) for Medical Record Services was met, as evidenced by: 1. The facility failed to ensure medical records included a completed discharge summary (a critical clinical document prepared by healthcare professionals upon a patient’s release, outlining the entire hospital stay. It summarizes the reason for admission, diagnostic results, treatments, medication changes, and follow-up plans, serving as a vital handover tool to ensure safe, continuous care) within thirty (30) days after discharge, for one of 32 sampled patients (Patient 7), in accordance with the facility’s policies and procedures regarding format and content of the medical record. This deficient practice had the potential to compromise the patient’s next level of care, without knowing the summary of the course of the patient’s hospitalization. (Refer to A-0438) 2. The facility failed to ensure its staff documented accurately, on the standard every fifteen (Q15) minute rounding form (records used by staff to document patient checks every 15 minutes to ensure continuous safety monitoring), for one of 32 sampled patients (Patient 11), in accordance with the facility’s rounding policy, when a Mental Health Technician (MHT 8) documented that patient rounding on 2/16/2026 at 6:30 p.m. and at 6:45 p.m., were completed without actually performing the rounding. This deficient practice resulted in Patient 11’s rounding record being inaccurate and failing to represent Patient 11’s actual activity and behavior during that time. This deficient practice also increased Patient 11’s safety risk for undetected condition change, due to lack of patient rounding. (Refer to A-0438) 3. The facility failed to ensure medical record entries were legible (readable handwriting or text), complete (containing all required information), and authenticated (signed by the person who wrote the entry), in accordance with the facility’s “Documentation Standards” policy, for one (1) of 32 sampled patients (Patient 3). Medical record entries written by the social worker (SW) and psychiatrist (MD-medical doctor) were not legible, contained multiple un?initialed cross?outs (corrections without staff initials indicating who made the change), and lacked clear authorship (inability to determine who wrote the note). This deficient practice had the potential to result in misinterpretation of clinical information (incorrect understanding of the patient’s condition or care), interfere with continuity of care (coordination of care between healthcare providers), and compromise safe discharge planning (ensuring a patient is medically and psychiatrically stable for discharge) for Patient 3. (Refer to A-0450) 4. The facility failed to ensure the medical record contained the results of consultative evaluations by Internal Medicine physicians for two of 32 sampled patients (Patient 11 and Patient 18) following a significant medical event when: 4.a. The Internal Medicine physician (a physician responsible for evaluating and treating medical health issues in a psychiatric hospital) did not document the consultative evaluation for the assessment of Patient 18’s skin injury, which was sustained after a fall in the shower on 11/27/2024, in accordance with the facility’s Medical Bylaws (are the legally mandated, governing documents that outline the structure, responsibilities, and rules for physicians and providers within a hospital or healthcare organization. They establish the framework for self-governance, credentialing, peer review, and due process, ensuring quality patient care while defining the relationship between the medical staff and the hospital’s governing board) pertaining to timely completion of required medical records. This deficient practice regarding lack of documentation had the potential for the clinicians not to be able to track the progress of Patient 18’s skin injury leading to possible missed infection, improper treatment plan, and poor continuity of care. (Refer to A-0464) 4.b. The Internal Medicine physician did not complete a progress note, in accordance with the facility’s Medical Bylaws, for Patient 11, who was found with a ripped bed sheet tied around her (Patient 11) neck in an attempt to strangle herself on 2/16/2026. This deficient practice compromised Patient 11’s health and safety because no medical evaluation was completed to rule out hidden neck injuries, breathing difficulties, or other medical complications that can occur after a strangulation attempt. (Refer to A-0464) 5. The facility failed to ensure that a physician’s discharge progress note was completed and a discharge summary (a document that explains what happened during the hospital stay, the treatment provided, the patient’s condition at discharge, and what follow-up care is needed) was filed, for one of 32 sampled patient’s (Patient 17) medical record, in accordance with the facility’s policy regarding the format and content of a patient’s medical record. This deficient practice had the potential to compromise Patient 17’s well-being and continuity of care because future healthcare providers would not have important information about the patient’s treatment, diagnosis, and follow-up needs. In addition, this deficient practice (not completing and filing the discharge summary) could also lead to delays or mistakes in follow-up care for Patient 17 and make communication between care teams more difficult. (Refer to A-0468) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“Special Medical Record Requirements CFR(s): Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals The medical records maintained by a psychiatric hospital must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution. This Condition is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Special Medical Record Requirements was met, as evidenced by: 1. The facility failed to ensure its multi-disciplinary team (a group of professionals including physicians, nurses, social workers and therapists who collaborate to provide comprehensive and coordinated patient care) addressed all active problems identified on the master treatment plan (a comprehensive, individualized, and written document outlining a patient’s diagnosis, treatment goals, and therapeutic interventions), on a weekly basis, for one of 32 sampled patients (Patient 11), in accordance with the facility’s policy regarding active and individualized treatment plan, when the multi-disciplinary team did not discuss Patient 11’s progress and continued need for linen restriction during three (3) treatment plan review meetings: 2/4/2026, 2/11/2026, and 2/18/2026. This deficient practice could have resulted in insufficient monitoring of compliance with linen restrictions, potentially leading to unmet patient care needs or overlooked discussions about further requirement. As a consequence, Patient 11 was able to access prohibited linens (flat sheet) and engage in self-harming behavior. On 2/16/2026, Patient 11 was found with a torn flat sheet tied around her (Patient 11’s) neck. (Refer to A-1640) 2. The facility failed to ensure that one of 32 sampled patient’s (Patient 11) progress note was recorded when: 2.a. The Internal Medicine physician (the medical doctor who checks the patient’s physical health) did not complete a progress note after Patient 11 was found with a ripped bedsheet tied around her neck in an attempt to strangle herself on 2/16/2026. This deficient practice resulted in Patient 11’s health being compromised because there was no medical check or evaluation to make sure the patient did not have hidden neck injuries, breathing problems, or other medical issues that can happen after a strangulation attempt. (Refer to A-1655) 2.b. The psychiatrist (a medical doctor specializing in diagnosing and treating mental health conditions) did not complete a daily progress note (a written update about the patient’s treatment, response, and any changes in their condition) for Patient 11, in accordance with the facility’s medical record requirements. This deficient practice had the potential to compromise Patient 11’s continuity of care because missing progress notes can create gaps in communication, delay treatment decisions, and prevent timely adjustments to the patient’s care and treatment goals. (Refer to A-1655) 3. The facility failed to ensure that the master treatment plan (a document that lists the patient’s goals, risks, symptoms, and the interventions staff will use to treat and keep the patient safe) was updated timely, in accordance with the facility’s policy regarding treatment plan revisions, for one of 32 sampled patients (Patient 11), after Patient 11 attempted to strangulate herself (an attempted suicide while hospitalized, meaning the patient tried to harm themself in a way that could have resulted in death) on 2/16/2026. This deficient practice had the potential to place Patient 11 at continued risk of self-harm because the treatment plan did not reflect the new and urgent safety needs. In addition, Patient 11’s safety, well-being, and continuity of care could have been compromised due to delayed interventions, inconsistent staff actions, and lack of coordinated treatment planning. (Refer to A-1661) 4. The facility failed to ensure that a completed discharge summary (a document that explains what happened during the hospital stay, the treatment provided, the patient’s condition at discharge, and what follow-up care is needed), was filed in the medical record, for one of 32 sampled patients (Patient 17), in accordance with the facility’s policy regarding format and content of medical records. This deficient practice had the potential to compromise Patient 17’s well-being and continuity of care because future healthcare providers would not have important information about the patient’s treatment, diagnosis, and follow-up needs. In addition, this deficient practice (not completing and filing the discharge summary) could also lead to delays or mistakes in follow-up care for Patient 17 and make communication between care teams more difficult. (Refer to A-1670) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to: 1. Ensure its staff followed the facility’s process to address and respond to a grievance (formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care that requires investigation) filed by one of 32 sampled patients (Patient 13). The grievance (Patient 13 reported receiving incorrect medication and being treated rudely by facility staff) was filed with the facility’s nurse manager and was not properly addressed in a timely manner (within 7 days), in accordance with the facility’s policy regarding complaint and grievance procedures. There was no escalation of the incident to Risk Management, no follow-up, and no patient notification regarding the outcome of the facility’s investigation into Patient 13’s grievance. This deficient practice resulted in an incomplete investigation and lack of response to Patient 13’s complaint (Patient 13 reported receiving incorrect medication and being treated rudely by facility staff) thus violating the patient’s right regarding the right to voice concerns about patient care and potentially leading to Patient 13’s dissatisfaction with the quality of care received at the facility. 2. Follow its grievance process for one (1) of thirty two (32) sampled patients (Patient 3), when staff did not identify, document, or process a parent’s (Patient 3’s parent) disagreement with the discharge of a minor patient (Patient 3) as a grievance, and did not forward the complaint for investigation or written response, as required by the facility’s policy titled “Patient Complaint/Grievance Process.” This deficient practice had the potential for Patient 3’s parent’s safety concerns to go uninvestigated; the potential for psychosocial distress to both Patient 3 and Patient 3’s parent due to feeling dismissed, unsafe, or unsupported during the discharge process; and the potential for delays in addressing unresolved care issues that affect patient safety. The inability to identify the nurse who wrote the note (regarding Patient 3’s parent’s disagreement with Patient 3’s discharge) could make it harder for the hospital to fully review the complaint, make it difficult to hold staff responsible for their actions, and reduce the patient’s or family’s confidence in the hospital’s complaint process. Findings: 1. During a review of Patient 13’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 10/11/2025, the “psych eval” indicated, Patient 13 was admitted to the facility on 10/10/2025 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 and treatment) for danger to self for overdosing (when a person consumes a toxic amount of a substance such as prescription medications or alcohol) on medications after having an argument with family members. During a review of Patient 13’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 10/11/2025, the psych eval record also indicated Patient 13 was admitted with a diagnosis 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), with psychotic features (delusions [holding fixed, false beliefs or having an unrealistic, irrational view of reality that persists despite evidence to the contrary] and hallucination [seeing, hearing, smelling, tasting, or feeling things-that seem real but are created by the mind, often due to brain chemistry changes, mental illness, neurological conditions, or drug use]), severe recurrent (occurring often or repeatedly), without psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality). During a concurrent interview and record review on 2/19/2026 at 2:39 p.m. with the Nurse Manager (NM 1), Patient 13’s Progress Record (nurse note), dated 10/16/2025, was reviewed. The “Progress Record” indicated, Patient 13 allegedly was given another patient’s medications on 10/12/2025, in the evening, at the facility’s dining room. The “Progress Record” also indicated, Patient 13 alleged nursing staff (unknown name) stated to Patient 13 “if you (Patient 13) do not take your (Patient 13) medications, you (Patient 13) are going to be put on a list and the doctor is going to keep you (Patient 13) here longer.” The Progress Record further indicated, “I (NM 1) provided patient (Patient 13) assurance that I (NM 1) am investigating this matter.” The “Progress Record” also indicated NM 1 completed the note entry on 10/16/2025, at 1:34 p.m. NM 1 stated Patient 13 informed her (NM 1) that Patient 13 was given wrong medications and staff was rude to Patient 13 on 10/13/2025. NM 1 further stated she (NM 1) started the investigation and brought it up to Risk Management department to perform a security footage review to verify Patient 13’s complaint. NM 1 further stated she (NM 1) had not heard back from Risk Management. NM 1 also stated she (NM 1) had not followed-up with Patient 13 (to provide an update on the investigation of Patient 13’s allegations). During an interview on 2/24/2026 at 2:57 p.m. with the Director of Clinical Services (DIR 2), DIR 2 stated she (DIR 2) covered as patient advocate and processed grievance (formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care that requires investigation) received for October 2025. DIR 2 stated she (DIR 2) did not receive any complaint or grievance for Patient 13. DIR 2 further stated any unresolved complaint should have been escalated to Risk Management and to patient advocate for follow up as a grievance. During an interview on 2/24/2026 at 4:35 p.m. with the Director of Risk Management (DIR 1), DIR 1 stated there was no incident report/grievance report filed regarding Patient 13’s complaint of receiving wrong medications and nursing staff behavior on 10/12/2025. DIR 1 also stated she (DIR 1) did not remember performing any security footage review for Patient 13’s complaint. DIR 1 further stated nursing staff should have completed an incident report so that Risk Management could refer to the appropriate department to follow up. During an interview on 2/25/2026 at 11:09 a.m. with the Chief Nursing Officer (CNO), CNO stated NM 1 should have completed an incident report and performed an investigation regarding Patient 13’s complaint. CNO further stated NM 1 should have informed Patient 13 about investigation findings after NM 1 concluded the investigation into the incident involving Patient 13. CNO further stated the complaint (by Patient 13) was unsubstantiated (not supported or proven by evidence), however there was no documentation to support the complaint being investigated and followed up. CNO also stated NM 1 did not escalate the complaint to patient advocate to be processed as a grievance. During a review of the facility’s policy and procedure (P&P) titled, “Patient Complaint/ Grievance Process,” dated 7/2025, the P&P indicated, “All patients shall be informed of the grievance process and the availability of the Patient Advocate upon admission. It is the responsibility of each staff member to respond in a timely manner to any concern or complaint voiced by patient, their families, and/or patient representatives no matter how trivial the complaint may appear to be ... Responsible Persons: 1. All [facility] employees are responsible for responding to patient concerns in a timely manner and for initiating steps to promptly resolve the concern if possible. The person filing the grievance will be notified of the investigation within 7 days. 2. Department Managers or Directors or House Supervisors are responsible for: a. Supporting their employees in their efforts to respond to concerns on the spot, when possible, leaders are encouraged to include staff identified in the complaint, in the investigation and/or resolution process; b. assuring that documentation related to patient complaints and grievances is completed in a timely and thorough manner. Definition ... Grievance: formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care (when the complaint is not resolved at the time of the complaint by staff present) ...” During a review of the facility’s policy and procedure (P&P) titled, “Incident Reporting Process,” dated 6/2025, the P&P indicated, “The purpose of an incident reporting process is to: A. Support timely reporting of serious injuries, suspected violations of laws or Federal/ State regulations, or other mandatory reporting situations... B. Provide a database for trending analysis of reported incidents to improve patient safety ... Incidents expected to be reported via the Incident Reporting Process constitute any of the following incidents types but may not be limited to this list ...patient care/ treatment ... complaint ...” During a review of the facility’s patient handbook titled, “Rights for Individuals in Mental Health Facilities,” dated 5/2014, the patient handbook indicated, “You cannot be threatened or asked to give up any of your rights as a condition for admission or receiving treatment ... What to Do if You Have a Complaint ... You have the right to complain about your living conditions, any physical or verbal abuse, any threats or acts of cruelty, or your treatment in the facility without being punished for voicing such complaints. The patients’ right advocate is responsible for investigating and trying to resolve complaints concerning your rights. If the advocate is unable to help you with your concern, your complaint may be referred, with your permission, to another agency that can assist you. If you are dissatisfied with the advocate’s response to your complaint, you can request that the complaint be referred to the facility director or to the mental health director.” 2. During a review of Patient 3’s “Initial Psychiatric Evaluation (a clinical assessment completed at the start of mental health treatment)” note, dated 12/6/2025, the note indicated, Patient 3 was a 14-years-old, who was admitted to the facility on a 5585 hold (an involuntary 72?hour psychiatric hold for minors (any person under 18 years of age who is not emancipated [released from parental care and responsibility]) due to danger to self, danger to others, or grave disability (inability to care for oneself). During a concurrent interview and record review on 1/17/2026 at 3:15 p.m. with the Nurse Manager (NM 2), Patient 3’s Progress Notes, dated 12/14/2025 - 12/15/2025, were reviewed. The notes indicated the following: -12/14/2025: Patient 3 refused medication. -12/15/2025 at 11:30 a.m.: “Spoke to the parents of (Patient 3). They are concerned about his (Patient 3’s) discharge and concerned with his noncompliance with medication since Saturday (12/13/2025).” -12/15/2025 at 12:59 p.m.: “PT (Patient 3) mother refused to sign all documentation and stated she does not feel that it is a safe discharge. RN informed mother that pt (Patient 3) has been assessed by attending psychiatrist and does not meet criteria to prolong stay ...” -NM 2 confirmed that these entries in Patient 3’s Progress Notes represented a parent’s expressed disagreement with the discharge and a safety concern, both of which met the facility’s definition of a grievance (a complaint that is not resolved immediately by staff) because the concern was unresolved at the bedside. NM 2 verified that the record contained no documentation indicating the concern was entered or processed as a grievance. During the same concurrent interview and record review on 1/17/2026 at 3:15 p.m. with the Nurse Manager (NM 2), the review of the same entries in Patient 3’s Progress Notes (11:30 a.m. and 12:59 p.m., 12/15/2025) showed handwritten RN names and signatures that were illegible (not readable), preventing identification of the documenting nurse. NM 2, manager of the youth unit, could not determine which RN authored the notes. During interviews on 2/17/2026 at 2:15 p.m. and 2/18/2026 at 12:30 p.m., with the Director of Risk Management (DIR 1, the individual responsible for overseeing incident reporting and patient safety processes), the surveyor requested the identification of the RN who authored the notes (dated 12/15/2025 at 11:30 a.m. and 12:59 p.m.) and availability for interview. The facility was unable to identify the RN and did not provide documentation showing the concern of patient 3’s parent had been forwarded to Patient Relations (the department responsible for managing patient complaints) or processed as a grievance. During an interview on 2/20/2026 at 11:38 a.m. with the Director of Clinical Services/Patient Advocate (DIR 2, the staff member responsible for receiving and processing patient grievances), DIR 2 stated that they processed grievances during 2025 and did not receive any complaint or grievance for Patient 3. DIR 2 described the grievance process, stating that unresolved complaints must be escalated to Risk Management and the Patient Advocate, and that staff must offer a grievance form to the complainant and document the offer in the progress notes. Dir 2 confirmed that no such documentation existed for Patient 3. During a review of the facility’s policy and procedure (P&P) titled, “Patient Complaint/ Grievance Process,” dated 7/2025, the P&P indicated: “All patients shall be informed of the grievance process and the availability of the Patient Advocate (facility staff who assist patients in resolving concerns) upon admission. It is the responsibility of each staff member to respond in a timely manner to any concern or complaint voiced by patients, their families, and/or patient representatives no matter how trivial the complaint may appear to be ... Responsible Persons: 1. All facility employees are responsible for responding to patient concerns in a timely manner and for initiating steps to promptly resolve the concern if possible. 2. Department Managers or Directors or House Supervisors (lead nursing staff overseeing operations during each shift) are responsible for: a. Supporting their employees in their efforts to respond to concerns on the spot ... b. Assuring that documentation related to patient complaints and grievances is completed in timely and thorough manner. Definition ... Grievance: formal or informal written or verbal complaint made the hospital by a patient or the patient’s representative regarding the patient’s care when the complaint is not resolved at the time of the complaint by staff present ...” During a review of the facility’s patient handbook titled, “Rights for Individuals in Mental Health Facilities,” dated 5/2014, the patient handbook indicated, “You cannot be threatened or asked to give up any of your rights as a condition for admission or receiving treatment ... What to Do if You Have a Complaint ... You have the right to complain about your living conditions, any physical or verbal abuse, any threats or acts of cruelty, or your treatment in the facility without being punished for voicing such complaints. The patients’ right advocate is responsible for investigating and trying to resolve complaints concerning your rights. If the advocate is unable to help you with your concern, your complaint may be referred, with your permission, to another agency that can assist you. If you are dissatisfied with the advocate’s response to your complaint, you can request that the complaint be referred to the facility director or to the mental health director.””

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 50516 Based on observation, interview and record review, the facility failed to: 1. Ensure that one of 32 sampled patients (Patient 25) received a Probable Cause Hearing (PCH, legal hearing to determine if there was “good cause [reason]” to remain in a hospital for a specific amount of time), in accordance with the facility’s policy regarding “Inappropriate Use of Involuntary Commitment,” when Patient 25 was placed on a 5250 (14 day hold [hold, remain in a hospital for treatment without their consent]) on 12/21/2025 and 5270 (30 day hold) on 1/4/2026. This deficient practice prevented Patient 25 from exercising the right to have a hearing, participate in the hearing, and/or contest (challenge) their hold and legal status as a patient, which may result in erosion of therapeutic trust in healthcare systems, reduced treatment adherence or avoidance of care leading to worsening of mental health issues. 2. Ensure that Patient 20’s custody order (a legally binding court document that identifies which parent has legal custody [the authority to make decisions regarding the child’s health care]) was honored by facility staff. The facility contacted both parents regarding Patient 20’s health-care decisions and involved Parent 2 (the non?custodial parent) in the discharge process, even though only Parent 1 was awarded legal custody to make health-care decisions for Patient 20. This deficient practice violated Patient 20’s right to have medical decisions made only by the legally authorized representative and also violated Patient 20’s right to privacy and confidentiality, as medical information was shared with a parent who was legally prohibited from participating in health-care decisions. In addition, this deficient practice had the potential to cause significant psychological distress to Patient 20, including anxiety (a feeling of worry, nervousness, or unease), fear (an unpleasant emotion caused by the belief that someone or something is dangerous), and emotional instability (difficulty regulating emotions or maintaining emotional control). 3. Ensure its staff offered one of 32 sampled patients (Patient 12) and the patient’s (Patient 12) legal guardian the opportunity to file a police report after Patient 12 was hit on the back of head five (5) times, on the right temple (right side of the head between forehead and ear), chin, and nose by Patient 26, on 9/10/2025, causing Patient 12 to suffer from a non-displaced fracture (a stable broken bone) of nasal (nose) bone. This deficient practice resulted in Patient 12 and Patient 12’s legal guardian not being able to exercise the right to participate in decisions regarding Patient 12’s care including the right to have an allegation of physical assault reported to law enforcement allowing an immediate investigation by authorities, which is vital for preventing further harm or abuse. 4. Ensure staff provided translation service (provide qualified, real-time language assistance to patients with limited English proficiency (LEP) or hearing impairments. These services ensure accurate communication of medical information) when obtaining release of information form titled, “Authorization for Release of Protected Health Information (ROI form, the release of information form, written consent [authorization] from patient to whom and what type of health information to be disclosed or released to)” form, for one of 32 sampled patients (Patient 13) when Patient 13, whose preferred language was Spanish, was not provided with Spanish translation or the ROI form written in Spanish, in accordance with the facility’s nondiscrimination policy. This deficient practice had the potential to result in Patient 13 not fully understanding the content of the ROI form which may lead to the release of unnecessary health information to people. 5. Ensure the facility’s psychiatrist (physician specializes in mental health) discussed with two of 32 sampled patients (Patient 14 and Patient 15) about the 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) including the rights of having court hearing (an automatic, informal legal proceeding held within 4 days of a 5150 hold [an involuntary psychiatric detention under California law that allows a qualified professional to hold an individual for up to 72 hours for evaluation when the person is deemed a danger to self, danger to others, or gravely disabled-requires assistance with performing activities of daily living such as hygiene or grooming] to determine if “probable cause” exists to detain a patient for up to 14 additional days for intensive mental health treatment due to danger to self, others, or grave disability), when Patients 14 and 15 were placed on 5250-hold, in accordance with the facility’s policy of involuntary commitment (a legal process where an individual is forced into a psychiatric facility or treatment program against their will, typically used as a last resort when mental health issues cause an immediate danger to themselves or others. It requires specific legal criteria, such as a court order or emergency medical evaluation, to manage risk and provide care). This deficient practice violated the patient rights of Patient 14 and Patient 15 by not knowing and exercising the rights of having different court hearings including certification review hearing (also known as probable cause hearing, a legal proceeding with a specific purpose related to involuntary psychiatric holds to determine if there is sufficient legal justification [probable cause] to continue holding an individual involuntarily for intensive treatment due to a mental disorder) and/or Writ of Habeas Corpus (a legal procedure invoking the jurisdiction of a court to review whether the detention or imprisonment of an individual was lawful), during the 14-day involuntary hold period, while at the facility. This deficient practice also resulted in Patient 15 not knowing what court hearing Patient 15 would be having and when to expect the court hearing to be held. This deficient practice also had the potential to cause psychological distress for Patients 14 and 15 due to lack of understanding of the legal basis and timeline for the continued involuntary hold. 6. Ensure its physician evaluated one of 32 sampled patient’s (Patient 16) need for a 5250-hold (14-day hold, allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) before the original 5150-hold (72-hour 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) expired, in accordance with facility’s policy of involuntary commitment. . This deficient practice resulted in detaining Patient 16 at a psychiatric hospital (inpatient hospital that provides treatment and therapy for people who have mental, emotional and behavioral disorders) without a valid involuntary hold and a valid legal justification which may lead to psychological distress for Patient 16. Findings: 1. During a record review of Patient 25’s “Initial Psychiatric Evaluation (a clinical assessment completed at the start of mental health treatment),” dated 12/19/2025, the record indicated Patient 25 was admitted to the facility on a 5150 (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 suicidal ideation (plan to self-harm). The Initial Psychiatric Evaluation also indicated Patient 25 had psychiatric history of past hospitalizations and suicide (the act of intentionally causing one’s own death) attempts. During a record review of Patient 25’s “Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 days intensive mental health treatment) or 5270.15 (additional 30 days intensive mental health treatment) of the Welfare and Institutions Code (a set of state statutes governing public social services, welfare programs, juvenile justice, and mental health services),” dated 12/21/2025, the record indicated Patient 25 was placed on a 14 day hold for being a danger to himself and gravely disabled (requires assistance with performing activities of daily living). During a record review of Patient 25’s “Notice of Certification for Intensive Treatment Pursuant to Section 5250 or 5270.15 of the Welfare and Institutions Code,” dated 1/4/2026, the record indicated Patient 25 was placed on a 30 day hold for being gravely disabled. During an interview on 2/20/2026 at 11:35 a.m. with the Director of Social Services (DIR) 2, DIR 2 stated a Probable Cause Hearing (PCH, legal hearing to determine if there was “good cause [reason]” to remain in a hospital for a specific amount of time) should be done within four business days per patient rights law. DIR 2 stated the process for a PCH included asking the patient if they would like to attend the hearing remotely or in person, and if they would like to contest (challenge) the hearing. The hearing officer would make a decision as to whether the hold would be upheld (remain in effect) and the patient would be informed as to how many days were left in the hold. If the patient wanted to contest, the patient could file a writ (formal written order) to request another hearing, where the physician and lawyer would be present. During a concurrent interview and record review on 2/20/2026 at 11:46 a.m. with DIR 2, Patient 25’s “5150,” dated 12/19/2025, “5250,” dated 12/21/2025, and “5270,” dated 1/4/2026, were reviewed. DIR 2 stated a patient should get a hearing for every new hold. DIR 2 could not locate documentation of a PCH in Patient 25’s medical records for the 5250 and 5270 hold orders. During an interview on 2/20/2026 at 1:34 p.m. with the Program specialist (PS), PS stated if a hold was extended past 5150 (72 hours detainment), by law, patients needed to have a scheduled hearing. PS stated Patient 25 did not have a hearing because Patient 25 was scheduled to be discharged. PS stated no one expressed to him (PS) that Patient 25’s discharge was cancelled. PS stated he (PS) would have been informed by either the physician, nurse, or social worker of discharges, and referred to a white board that indicated who was going to be discharged. PS stated if a patient was being discharged, he (PS) would inform the court, and the patient would not have a hearing. During a concurrent interview and record review on 2/20/2026 at 1:34 p.m. with the program specialist (PS), Patient 25’s 5270, dated 1/4/2,026 was reviewed. PS stated the 5270 was not filed and PS could not answer as to why Patient 25 did not have a hearing (PCH). PS stated this (the PCH) was important because the patient (Patient 25) had a right to the hearing and a right to challenge a hold at any level and disagree with the doctor’s assessment. During a concurrent interview and record review on 2/23/2026 at 10:19 a.m. with DIR 2, Patient 25’s “Certification Review Hearing Record,” undated, was reviewed. The “Certification Review Hearing Record” indicated the hearing was not held because of discharge (Patient 25 was discharged on 1/18/2026. The 5250 was signed 12/21/2025 and the 5270 was signed 0n 1/4/2026). DIR 2 stated the program specialist (PS) or whoever was covering for PS was accountable and should have also informed the social worker of a hearing. DIR 2 stated Patient 25’s legal status should have been voluntary since there was no hearing. DIR 2 confirmed Patient 25 did not have a voluntary status order. During a review of the facility’s policy and procedure (P&P) titled, “Appropriate Use of Involuntary Commitment,” dated 9/2025, the P&P indicated, “All patients placed on a first 5250 hold shall be provided a Certification Review Hearing ...Procedures for issuing a 30-day certification: 8. A Certification Review Hearing is required.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights Handbook, undated, the P&P indicated, “If you are held beyond 72 hours, you have the right to remain in the hospital for voluntary treatment. If you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four days of the end of your 72-hour hold ... You may be held for an additional 30 days if your doctor determines that you remain gravely disabled and you are unwilling to accept voluntary treatment. Another certification hearing will automatically be held. You have the right to have a patients’ rights advocate assist you at the hearing. You also have the right to request a writ of habeas corpus at any time during this period and to have a patients’ rights advocate or attorney assist you at the hearing.” 2. During a review of Patient 20’s Initial Psychiatric Evaluation (Psych Eval, a formal clinical assessment performed by a psychiatrist to evaluate a patient’s mental status, symptoms, diagnosis, and treatment needs), dated 8/25/2025, the Psych Eval indicated that Patient 20 was admitted due to suicidal ideation (thoughts of wanting to end one’s life, which may include a plan, intent, or expressed desire to cause self?harm), with a chief complaint: “I want to overdose (when a person consumes a toxic amount of a substance such as prescription medications or alcohol).” The Psych Eval further indicated that Patient 20 was admitted to the facility on 8/25/2025 after expressing a depressed mood and feelings of helplessness and hopelessness. During an interview and concurrent record review on 2/20/2026 at 2:15 p.m. with the Director of Social Services (Dir 2), Patient 20’s Social Worker (SW) notes, dated 8/28/2025, were reviewed. The note, documented at 10:45 a.m., indicated that the Social Worker spoke to both parents of Patient 20 regarding discharge planning (a centralized, interdisciplinary process that determines the necessary care a patient requires after leaving a hospital, ensuring a safe transition to home or another facility) for Patient 20, and the note further indicated that “Patient’s (Patient 20) parents will pick up (Patient 20) at 11:30 a.m.” Dir 2 verified that both parents were documented as being involved in Patient 20’s discharge planning (a process that ensures that the patient has a safe, coordinated, and appropriate transition from the hospital to the next level of care). During a concurrent interview and record review on 2/20/2026 at 2:53 p.m. with the Director of Social Services (Dir 2), Patient 20’s Registered Nurse (RN) discharge note, dated 8/28/2025, was reviewed. The note indicated that both the mother and the father of Patient 20 were provided with the discharge packet. Dir 2 verified the documentation. During an interview on 2/20/2026 at 2:53 p.m. with the Director of Social Services (Dir 2), Dir 2 reviewed Patient 20’s psychosocial assessment (a structured Social Services evaluation that gathers information about a patient’s mental health needs, family dynamics, living situation, supports, risks, and social factors that may affect treatment and discharge planning), dated 8/26/2025. Dir 2 stated that the Social Worker (SW) had spoken with Parent 1 (Patient 20’s father) and was informed that Parent 1 had full legal custody over Patient 20. Dir 2 also stated that, unless the facility received proof of legal custody, the facility would continue to recognize both parents and involve both in medical decision?making for Patient 20 due to Patient 20 being a minor (a person under the age of legal adulthood who cannot make independent medical decisions and requires a legally authorized representative). During a concurrent interview and record review on 2/20/2026 at 3:12 p.m. with the Director of Social Services (Dir 2), Patient 20’s Child Custody and Visitation Order, dated 6/24/2021, was reviewed. The order indicated that Parent 1 (Patient 20’s father) had full legal custody over Patient 20 (meaning Parent 1 had the exclusive legal authority to make decisions regarding Patient 20’s health care). The printed custody?order attachment in the medical record did not include any notation indicating who printed the document or when it was placed into Patient 20’s chart. Dir 2 stated that because the documentation did not include the date it was received, it was possible that the custody documents were not received until the patient (Patient 20) was physically discharged to the parents on 8/28/2025. Dir 2 also acknowledged that it was equally possible that the documents were printed and filed into Patient 20’s chart at any time between 8/25/2025 (the admission date) and 8/28/2025 (the discharge date). During a review of a complaint received by the health department (a state regulatory agency responsible for oversight of healthcare facilities, investigation of complaints, and enforcement of patient?rights and safety standards) on 9/19/2025, the complaint indicated that Patient 20’s discharge was delayed because the facility refused to discharge Patient 20 until both parents arrived on 8/28/2025. The complaint also indicated that the facility had been provided court-ordered custody documentation via email (an electronic method of sending written communication and attachments between parties) on 8/26/2025, and that a response confirming receipt of the documentation was emailed back to Parent 1. However, despite receiving the documentation, the custody order was not honored, and the parental conflict that occurred at the time of discharge caused severe emotional distress to Patient 20, who had recently been admitted for depression. During an interview on 2/20/2026 at 3:12 p.m. with the Director of Social Services (Dir 2), Dir 2 stated that whoever received the custody documents on the unit must review them to determine which parent had legal custody and which parent had physical custody, and that if both parents were trying to be involved, staff must request the custody agreement from both. Dir 2 added, “We cannot take the parents’ word for it; if there is a custody agreement, the facility is bound by it (meaning the facility is legally required to follow the terms of the court order when determining who is authorized to participate in medical decision-making).” Dir 2 further stated that, based on the documentation just reviewed, she (Dir 2) could not determine what occurred in Patient 20’s case. Dir 2 also stated that she (Dir 2) had reached out to the social worker who was involved in Patient 20’s case but was not able to obtain confirmation that an email from Parent 1 was received at any time while Patient 20 was in the facility from 8/25/2025 to 8/28/2025. During a review of the facility’s policy and procedure (P&P) titled, Patient Rights Handbook, undated, the P&P indicated that patients have the right to decision?making regarding their plan of care, including the right to receive information necessary to make informed decisions about treatment options. 3. During a review of Patient 12’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 9/10/2025, the “psych eval” indicated, Patient 12 was admitted to the facility on 9/9/2025 on 5585-hold (allows a minor [under 18 of age] 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 by taking six to seven Ativan (medication to manage severe anxiety) tablets. The psych eval also indicated that Patient 12 had an admitting diagnosis of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 26’s “Initial Psychiatric Evaluation (psych eval),” dated 9/10/2025, the “psych eval” indicated, Patient 26 was admitted to the facility on 9/9/2025 on 5585-hold for danger to self and danger to others with diagnoses including but not limited to depressed mood (feeling of sadness, tearfulness, or hopelessness) and disruptive mood dysregulation disorder (DMDD, a childhood condition characterized by severe, chronic irritability and frequent, intense temper outbursts [verbal or physical] that are disproportionate to the situation). During an interview on 2/19/2026 at 11:20 a.m. with Registered Nurse (RN 12), RN 12 stated that after a patient-to-patient altercation (patient-to-patient aggression) occurred, both patients (the victim and the perpetrator [aggressor]) would be separated by the nursing staff and assessed for any injuries. RN 12 also stated nursing staff would offer the victim the opportunity to file a police report. RN 12 further stated that it was within the patient’s right to file a police report. During an interview on 2/20/2026 at 11:32 a.m. with Nurse Manager (NM 2) of Youth Services (inpatient Behavioral Health Unit [inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders] servicing patients age 13 to 17), NM 2 stated that after patient-to-patient altercation, the involved patients would be separated and not allowed to be in the same room to prevent another altercation (verbal argument that can easily escalate into a physical fight) from happening. NM 2 further stated the victim might feel uneasy and scared when seeing the perpetrator. During a concurrent interview and record review on 2/20/2026 at 11:38 a.m. with NM 2, Patient 12’s “Progress Record (nurse note),” dated 9/10/2025, was reviewed. The “Progress Record” indicated, at 1745 (5:45 p.m.), while eating dinner at the cafeteria, patient (Patient 12) was attacked by another male patient (Patient 26) unprovoked (not caused by anything done or said). Patient (Patient 12) was hit on the back of head five (5) times as per patient (Patient 12), on right temple (right side of the head between forehead and ear), chin, and nose.” The “Progress Record” also indicated, Patient 12 was sent to another facility emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) for further care. The “Progress Record” also indicated, Patient 12’s legal guardian was informed of the incident. NM 2 stated Patient 12 was the victim and Patient 26 was the perpetrator. NM 2 further stated it was a physical assault. NM 2 said nursing staff should have offered Patient 12 and Patient 12’s legal guardian the opportunity to file police report for the physical assault. NM 2 stated it was Patient 12’s right to file a police report. NM 2 also stated there was no documentation that Patient 12 and Patient 12’s legal guardian was offered an opportunity to file a police report. During a review of Patient 12’s “Out of Hospital Consultation Report (consultation report completed by the outside facility ED physician),” dated 9/10/2025, the consultation report indicated, Patient 12 had nasal (nose) swelling and bruising, tenderness to nose, left elbow, and abrasion at right lower leg. The consultation report also indicated Patient 12 had a non-displaced fracture (a stable broken bone) of the nasal (nose) bone per X ray (an imaging procedure to create detailed image of the body’s internal structure such as bones, tissues and organs) report. During an interview on 2/20/2026 at 11:38 a.m. with Nurse Manager (NM 5), NM 5 stated it was a patient’s right to file a police report after being physically assaulted. NM 5 further stated nursing staff should offer patient the opportunity to file a police report and document in the patient’s medical record. NM 5 further stated if it was not documented, it did not happen. During an interview on 2/23/2026 at 9:50 a.m. with Director (DIR 1) of Risk Management, DIR 1 stated it was the facility’s practice to offer the victim an opportunity to file a police report after a physical altercation. During an interview on 2/24/2026 at 2:46 p.m. with the Director (DIR 2) of Clinical Services, DIR 2 stated the facility should act as patient’s advocate. DIR 2 stated nursing should provide police department phone number for the patient or patient’s legal guardian so they can file a police report after being physically assaulted. DIR 2 stated this was the patient’s rights as a member of society. DIR 2 stated patients had rights to press charges on someone hurting them. During a review of the facility’s patient handbook titled, “Rights for Individuals in Mental Health Facilities,” dated 5/2014, the patient handbook indicated, “You cannot be threatened or asked to give up any of your rights as a condition for admission or receiving treatment ...Rights That Cannot Be Denied ... Persons with mental illness have the same legal rights and responsibilities that are guaranteed to all other persons by the federal and state constitution and laws unless specifically limited by federal or state laws and regulations ... You have the right to dignity, privacy and human care ... You have the right to be free from abuse, neglect, or harm ... You also have the right to be free from potentially harmful situations or conditions.” 4. During a review of Patient 13’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 10/11/2025, the “psych eval” indicated, Patient 13 was admitted to the facility on 10/10/2025 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 and treatment) for danger to self for overdosing (when a person consumes a toxic amount of a substance such as prescription medications or alcohol) on medications after having an argument with family members. The Psych eval also indicated Patient 13 was admitted with diagnosis 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) with psychotic features (delusions [holding fixed, false beliefs or having an unrealistic, irrational view of reality that persists despite evidence to the contrary] and hallucinations [seeing, hearing, smelling, tasting, or feeling things-that seem real but are created by the mind, often due to brain chemistry changes, mental illness, neurological conditions, or drug use]), severe recurrent (occurring often or repeatedly, without psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality). During a review of Patient 13’s “Nursing Admission Assessment - ADULTS (Age 18+),” dated 10/10/2025, the “Nursing Admission Assessment - ADULTS (Age 18+)” indicated, Patient 1’s preferred language was Spanish. During an interview on 2/18/2026 at 11:47 a.m. with Charge Nurse (CN 3), CN 3 stated the patient would fill out “Authorization for Release of Protected Health Information (ROI form, the release of information form, written consent [authorization] from patient to whom and what type of health information to be disclosed or released to)” form and would give consent to whom and what type of health information would be disclosed or released. CN 3 further stated staff should utilize the facility’s translation service (provide qualified, real-time language assistance to patients with limited English proficiency (LEP) or hearing impairments. These services ensure accurate communication of medical information) to explain the ROI form to non-English speaking patients. During an interview on 2/19/2026 at 11:43 a.m. with Registered Nurse (RN 8), RN 8 stated nurses should use the facility’s translation line to communicate with Non-English patients regarding the ROI form. RN 8 further stated nurses should document the translator confirmation code on the ROI form when translation service was utilized. RN 8 further stated the ROI form was also available in Spanish. During a concurrent interview and record review on 2/19/2026 at 11:50 a.m. with RN 8, Patient 13’s “Authorization for Release of Protected Health Information (ROI form)” form, dated 10/10/2025, was reviewed. The ROI form indicated, the form was in English format. The ROI form also indicated, there was no documentation of Spanish translation service used. RN 8 stated the ROI form was not in Spanish version and there was no documentation that Spanish interpretation was used. RN 8 further stated that without utilizing the translation service, Patient 13 would not know her (Patient 13) rights and ensure Patient 13 fully understood what was being said and what was signed. During a concurrent interview and record review 2/19/2026 at 2:09 p.m. with Nurse Manager (NM 1), Patient 13’s “Psychosocial Assessment (assessment completed by social worker),” dated 10/12/2025, was reviewed. The “Psychosocial Assessment” indicated, [patient 13’s family member] was upset since patient (Patient 13) was not given an ROI form in Spanish. The “Psychosocial Assessment” also indicated, “Patient 13 stated ‘does not speak English’.” NM 1 stated a Spanish version of ROI form should have been given to Patient 13 or staff should have utilized Spanish translation service for Patient 13. During a review of the facility’s policy and procedure (P&P) titled, “[the facility] Nondiscrimination Policy,” dated 7/2025, the P&P indicated, “we provide individuals the following in a timely manner and free of charge: Language assistance services. Our facility will provide language assistance services for individuals with limited English proficiency (including individual’s companions with limited English proficiency) to ensure meaningful access to our programs, activities, services and other benefits. Language assistance services may include: electronic and written translated documents, qualified interpreters.” 5.a. During a review of Patient 14’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 10/7/2025, the “psych eval” indicated, Patient 14 was admitted to the facility on 10/6/2025 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 and treatment) to rule out bipolar affective disorder (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 15’s 5250-hold (14-day hold, allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) titled, “Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment) of the Welfare and Institutions Code,” dated 10/8/2025, the 5250-hold indicated, Patient 15 was placed on a 14-day hold on 10/8/2025. During an interview on 2/18/2026 at 2:51 p.m. with the Discharge Planner (DCP 1), DCP 1 stated patients admitted on a 5150-hold (72-hour 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) initially, would be evaluated by a psychiatrist to determine the need for extended inpatient stay before the 5150-hold expired (end). DCP 1 stated the patient would be placed on a 5250-hold for involuntary up to 14 days or converted into a voluntary admission if patient was willing to stay voluntarily. DCP 1 further stated the psychiatrist would meet and discuss with the patient about the 5250-hold. DCP 1 further stated patients on 5250-hold had the right for certification review hearing (also known as probable cause hearing, a legal proceeding with a specific purpose related to involuntary psychiatric holds to determine if there is sufficient legal justification [probable cause] to continue holding an individual involuntarily for intensive treatment due to a mental disorder) within four (4) days. During a concurrent interview and record review on 2/24/2026 at 11:49 a.m. with Nurse Manager (NM 5), the facility’s policy and procedure (P&P) titled, “Appropriate Use of Involuntary Commitment,” dated 9/2025, was reviewed. The P&P indicated, “Procedure for issuing an initial 5250 (14-day certifications) ... 2. The attending psychiatrist must complete “Notice of Certification” ... 4. The attending psychiatrist must then read and present a copy of the 5250 to the patient and must inform the patient of the right to a certification review hearing and/ or the right to file a Writ Habeas Corpus (a legal procedure invoking the jurisdiction of a court to review whether the detention or imprisonment of an individual was lawful) ... Certification Review Hearing for Patients Placed on First 14-day Certification: 1. All patients placed on a first 5250-hold shall be provided a Certification Review Hearing. 2. The patient may request judicial by Writ of Habeas Corpus instead of a Certification Review Hearing. 3. All Certification Review Hearings will be conducted in accordance with policy...” NM 5 stated per facility’s P&P, the attending psychiatrist was responsible for informing patients about the 5250-hold and the rights of having court hearings. During a concurrent interview and record review on 2/24/2026 at 11:50 a.m. with NM 5, Patient 14’s “Daily Progress Note (psychiatrist note),” dated 10/8/2025, was reviewed. The “Daily Progress Note” indicated, “legal status: 5250.” NM 5 stated the “Daily Progress Note” did not indicate the psychiatrist had discussed the 5250-hold and rights of having court hearings with Patient 14. During a review of the facility’s patient handbook titled, “Rights for Individuals in Mental Health Facilities,” dated 5/2014, the patient handbook indicated, “14-Day Certification for Intensive Treatment or ‘5250’ ... if you are held beyond 72 hours ... if you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four (4) days of the end of your 72-hour hold. You may be represented at this hearing by a patients’ rights advocate or another person of your choice ... If you request a Writ of Habeas Corpus, a legal request asking a court to determine whether you can be detained, you will give up your rights to have a certification hearing.” 5.b. During a review of Patient 15’s “Initial Psychiatric Evaluation (psych eval),” dated 2/11/2026, the psych eval indicated, Patient 15 was admitted to the facility on 2/11/2026 with 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]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 15’s 5250-hold (14-day hold) titled, “Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment) of the Welfare and Institutions Code,” dated 2/12/2026, the 5250-hold indicated, Patient 15 was placed on 14-day hold on 2/12/2026. During a concurrent observation and interview on 2/17/2026 at 11:14 a.m. with Patient 15 at Patient 15’s room, Patient 15 was observed sitting in bed and with a 5250-hold document titled, “Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment) of the Welfare and Institutions Code,” dated 2/12/2026, placed on top of the bedside cabinet. Patient 15 stated she (Patient 15) was here (admitted to the facility) since 2/11/2026. Patient 15 further stated the 5250-hold document was given by a nurse informing her (Patient 15) that she (Patient 15) was put on a 14-day hold. Patient 15 further stated she (Patient 15) was not aware there would be a court hearing. Patient 15 further stated no one had talked to her (Patient 15) about getting any court hearing. During an interview on 2/18/2026 at 2:51 p.m. with the Discharge Planner (DCP 1), DCP 1 stated patients admitted on a 5150-hold (72-hour hold) initially would be evaluated by a psychiatrist to determine the need for extended inpatient stay before the 5150-hold expired (end). DCP 1 stated the patient would be placed on a 5250-hold (14-day hold) for involuntary stay up to 14 days or converted into a voluntary admission if patient was willing to stay voluntarily. DCP 1 further stated the psychiatrist should meet and discuss with the patient about the 5250-hold. DCP 1 further stated patients on 5250-hold had the right for certification review hearing within four (4) days. During a concurrent interview and record review on 2/24/2026 at 11:49 a.m. with Nurse Manager (NM 5), the facility’s policy and procedure (P&P) titled, “Appropriate Use of Involuntary Commitment,” dated 9/2025 was reviewed. The P&P indicated, “Procedure for issuing an initial 5250 (14-day certifications) ... 2. The attending psychiatrist must complete “Notice of Certification” ... 4. The attending psychiatrist must then read and present a copy of the 5250 to the patient and must inform the patient of the right to a certification review hearing and/ or the right to file a Writ Habeas Corpus ... Certification Review Hearing for Patients Placed on First 14-day Certification: 1. All patients placed on a first 5250-hold shall be provided a Certification Review Hearing. 2. The patient may request judicial by Writ of Habeas Corpus instead of a Certification Review Hearing. 3. All Certification Review Hearings will be conducted in accordance with policy...” NM 5 stated per facility’s P&P, the attending psychiatrist was responsible for informing patients about the 5250-hold and the rights of having court hearings. During a concurrent interview and record review on 2/24/2026 at 4:01 p.m. with Nurse Manager (NM 6), Patient 15’s “Daily Progress Note (psychiatrist note),” dated 2/12/2026, was reviewed. The “Daily Progress Note” indicated, “legal status 5250 (14-day hold).” NM 6 stated the “Daily Progress Note” did not indicate that the physician had discussed the 5250-hold and rights of having court hearings with Patient 15. During a review of the facility’s patient handbook titled, “Rights for Individuals in Mental Health Facilities,” dated 5/2014, the patient handbook indicated, “14-Day Certification for Intensive Treatment or ‘5250’ ... if you are held beyond 72 hours ... if you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four (4) days of the end of your 72-hour hold. You may be represented at this hearing by a patients’ rights advocate or another person of your choice ... If you request a Writ of Habeas Corpus, a legal request asking a court to determine whether you can be detained, you will give up your rights to have a certification hearing.” 6. During an interview on 2/18/2026 at 2:51 p.m. with the Discharge Planner (DCP 1), DCP 1 stated patients admitted on a 5150-hold (72-hour 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) initially, would be evaluated by a psychiatrist to determine the need for extended inpatient stay before the 5150-hold expired (end). DCP 1 stated the patient would be placed on a 5250-hold (14-day hold, allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for involuntary stay up to 14 days or converted into a voluntary admission if patient was willing to stay voluntarily. DCP 1 further stated discharge planners had access to the facility’s tracker with information regarding the facility’s patients’ legal hold status and follow up, to ensure the patient was placed on proper legal status (5250-hold or voluntary admission) before the 5150-hold expired. During a review of Patient 16’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 2/16/2026, the “psych eval” indicated, Patient 16 was admitted on a 5150-hold for grave disability (inability to care for oneself) with diagnosis including but not limited to paranoid schizophrenia (a chronic mental illness characterized by intense, irrational suspicion, persecution delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary] and auditory hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste]) and generalized anxiety disorder (a group of mental disorders characterized by significant feelings of fear). During a concurrent interview and record review on 2/24/2026 at 3:46 p.m. with Discharge Planner (DCP 1), Patient 16’s medical record titled, “progress notes (physician note),” from the referring facility, dated 2/13/2026, was reviewed. The medical record indicated Patient 16 was placed on a 5150-hold with detainment start date on 2/13/2025 and start time at 11 p.m. DCP 1 stated the 5150-hold would expire on 2/16/2026 at 11 p.m. During a review of Patient 16’s “Daily Progress Note (physician note),” dated 2/17/2026, the “Daily Progress Note” indicated, Patient 16 was informed about being placed on a 5250-hold. The “Daily Progress Note” indicated the time of dictation (the process converting a verbally recording patient visit details into written text) was on 2/17/2026 at 2:04 p.m. During a concurrent interview and record on 2/24/2026 at 4:50 p.m. with Director of Clinical Services (DIR 2), Patient 16’s 5250-hold titled, “Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 days intensive treatment) or 5270.15 (additional 30 days intensive treatment) of the Welfare and Institutions Code,” dated 2/17/2026, was reviewed. The 5250-hold indicated, Patient 16 was placed on involuntary hold for 14 days on 2/17/2026 for being gravely disabled. DIR 2 stated the 5250-hold was written after the initial 5150-hold expired. DIR 2 stated the 5250-hold was written late. During an interview on 2/25/2026 at 11:07 a.m. with the Chief Nursing Officer (CNO), CNO stated nursing staff should have communicated with the psychiatrist when the 5150-hold was about to expire so that the psychiatrist could evaluate the need for Patient 16’s continued stay. The CNO stated the patient (Patient 16) should be released from the hospital once the 5150-hold had expired and there was no 5250-hold to extend the stay. During a review of the facility’s policy and procedure (P&P) titled, “Appropriate Use of Involuntary Commitment,” dated 9/2025, the P&P indicated, “[the facility] shall recognize and follow the laws of [the state] related to involuntary commitment. The hospital shall follow the state designated involuntary commitment process for patients presenting with documentation at the time of admission ... only one 72-hour hold may be in effect on a patient. If there are two holds issued, the time/date of the fist hold is honored. That is to ensure that the patient remains involuntary detained for no longer than 72 hours ... The following options are available at the expiration of a 72-hold hold: a. Patient is released b. Referred for further care and treatment on a voluntary basis; or c. Certified for 14 days of intensive treatment ... Procedure for issuing an initial 5250 (14-day certifications, same as 5250-hold): 1. An initial 5250 (14-day certification) may be issued based on the LPS Criteria and after a 72-hour hold has been issued ... 4. The attending psychiatrist must then read and present a copy of the 5250 to the patient and must inform the patient of the right to a certification review hearing and/ or the right to file a Writ Habeas Corpus (a legal procedure invoking the jurisdiction of a court to review whether the detention or imprisonment of an individual was lawful) ...””

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to: 1. Ensure that one of 32 sampled patients (Patient 19), who was mute (unable to speak) and catatonic (state of significantly decreased responsiveness to the environment, often characterized by lack of movement, rigid posture, minimal interaction, or being unresponsive despite being awake), had a legally appropriate representative involved in the development and implementation of the plan of care, in accordance with regulatory requirements regarding participation in the development and implementation of a patient’s treatment plan (a written, collaborative, and evolving document that outlines a patient’s diagnosis, specific health goals, and the interventions necessary to achieve them) or plan of care. The facility did not contact or involve Patient 19’s listed family representative during multiple episodes of medical deterioration, including dehydration (a condition in which the body loses more fluids than it takes in), seizure (a sudden, uncontrolled electrical disturbance in the brain), and a subsequent hospital transfer. This deficient practice violated the patient’s rights (the protections guaranteeing a patient’s ability to participate in care decisions, receive safe treatment, and have a representative act on their behalf when incapacitated) regarding participation in the development and implementation of the plan of care for Patient 19, which may result in treatment non-adherence leading to the worsening of Patient 19’s health condition. 2. Ensure one of 32 sampled patient’s (Patient 14) family member (FM 14) was involved in Patient 14’s care and treatment plan development, when nursing staff failed to follow up with the psychiatrist (MD 5) in order to address Patient 14’s family member’s concern, in a timely manner, in accordance with the facility’s policy regarding physician notification and the regulatory requirements regarding a patient’s or a patient’s family member’s participation in the development and implementation of a patient’s treatment plan (a written, collaborative, and evolving document that outlines a patient’s diagnosis, specific health goals, and the interventions necessary to achieve them) or plan of care. Patient 14’s family member (FM 14) requested to speak with the psychiatrist (MD 5) on multiple days (from 10/8/2025 to 10/11/2025), to discuss Patient 14’s triggers (stimulus that causes an intense, involuntary emotional or behavioral reaction, often bringing on or worsening symptoms of a mental health condition) and medications. This deficient practice could delay communication between Patient 14, Patient 14’s family and the healthcare team, potentially affecting Patient 14’s care planning and treatment plan by overlooking Patient 14’s triggers and medication need. Findings: 1. During a review of Patient 19’s Initial Psychiatric Evaluation (Psych Eval , a comprehensive assessment completed by a mental-health professional to determine a patient’s psychiatric condition, needs, risks, and treatment plan), dated 8/8/2025, the Psych Eval indicated that Patient 19 was not communicating, refused to make eye contact, and was admitted to the facility due to a risk of self-harm. During a concurrent interview and record review on 2/19/2026 at 11:05 a.m. with Registered Nurse (RN 1), Patient 19’s admission record, dated 8/8/2025 to 8/18/2025, was reviewed. RN 1 stated that on 8/11/2025, Patient 19 was seen in the emergency department (ED, a hospital department that provides immediate evaluation and treatment for urgent or life-threatening conditions) for dehydration (a condition in which the body loses more fluids than it takes in). RN 1 also said that on 8/17/2025, Patient 19 experienced a seizure (a sudden, uncontrolled electrical disturbance in the brain) and was sent to the ED for evaluation but was released the same day, only to have another seizure shortly after. Patient 19 was subsequently admitted to the hospital on 8/18/2025 for seizures. RN 1 stated that the patient (Patient 19) did not have a Release of Information (ROI) consent form completed for the admission, which meant the family (of Patient 19) was not notified of the patient’s (Patient 19) treatment plan (a written, collaborative, and evolving document that outlines a patient’s diagnosis, specific health goals, and the interventions necessary to achieve them) and was not informed of any transfers to the emergency department. During a concurrent interview and record review on 2/19/2026 at 12:05 p.m. with Registered Nurse (RN 1), Patient 19’s medical record for the admission from 8/8/2025 to 8/18/2025, was reviewed. RN 1 verified that the nursing progress notes did not contain documentation of family notification regarding Patient 19’s emergency department visits on 8/13/2025 and 8/17/2025. During a review of Patient 19’s medical record for the admission from 8/8/2025 to 8/18/2025, the record indicated that there was no Release of Information (ROI) consent form on file. This information was verified by Registered Nurse (RN 1) during the record review. During an interview on 2/19/2026 at 11:47 a.m. with Registered Nurse (RN 1), RN 1 stated that if a patient refused to have anyone (family or any other significant person) notified, this was the patient’s right. During a review of Patient 19’s psychosocial assessment (a clinical evaluation completed by social services to identify a patient’s mental-health needs, social supports, risks, and barriers to care), dated 8/11/2025, the record indicated that Patient 19 did not respond to questions, remained mute, and did not provide a support person at that time. The psychosocial assessment record indicated “SW (Social Worker) is to follow up (regarding completion of the psychosocial assessment form) ...” This record was reviewed with Registered Nurse (RN 1) on 2/19/2025. During a review of the Nursing Progress Note, dated 8/13/2025, the note indicated that Patient 19 was catatonic (a state of significantly decreased responsiveness, often involving immobility, lack of speech, and minimal interaction with the environment) and mute, and was exhibiting bizarre behavior such as walking into walls. The note stated, “Patient keeps head down when walking and is unable to verbalize understanding of situation.” This record was reviewed on 2/20/2026 with Registered Nurse (RN 1), who verified the accuracy of the documentation. During an interview on 2/19/2026 at 1:33 p.m. with the Director of Social Services (Dir 2), Dir 2 stated that based on her (Dir 2) review of Patient 19’s chart, Dir 2 verified that the patient (Patient 19) was mute and not engaging with staff and that Patient 19 had refused to interact with the social workers. During the same interview on 2/19/2026 at 1:33 p.m. with the Director of Social Services (Dir 2), Dir 2 explained that during Patient 19’s admission, the facility attempted to identify a legal representative if there was an advance directive or other documentation. Dir 2 then said, “Patient 19 was mute or catatonic, the patient met medical necessity criteria, and nursing, not social services, was responsible for communicating with family regarding transfers and changes in medical condition.” Dir 2 stated that the social worker documented attempts to obtain a Release of Information (ROI) and documented daily that the patient remained mute and non?engaging, which indicated they (the facility staff) were unable to obtain any information from the patient (Patient 19). During a review of Patient 19’s Social Worker (SW) notes, dated 8/13/2025, the notes indicated that the SW received a call from Patient 19’s family. The note further stated that no information could be released to the family because there was no signed consent for release of information for Patient 19. This information was verified with the Director of Social Services (Dir 1) during the record review on 2/19/2026. During a review of the Federal regulation, Tag A-0130, the regulatory statement indicated that patients had the right to participate in the development and implementation of their plan of care. When a patient was unable to communicate or was incapacitated, the hospital must identify and involve a legally appropriate representative-such as a family member, domestic partner, or other individual permitted under State law-to participate on the patient’s behalf. The regulation clarified that if no advance directive or written authorization were available, and a family member asserted they are the patient’s representative, the hospital must generally accept this assertion and involve the family in care planning and updates, unless there were conflicting claims or State law prohibited recognition. This meant that in situations where the patient could not provide consent for information release due to their condition, the facility still had an obligation to involve an appropriate representative, so the patient’s care, condition changes, and transfers were not carried out without someone legally acting in the patient’s interest. During a review of the facility’s policy titled, “Format and Content of the Record,” dated 7/2024, the policy indicated that the medical record shall contain a section that documents the patient’s family members and/or significant others involved in the patient’s treatment program. 2. During a review of Patient 14’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 10/7/2025, the “psych eval” indicated, Patient 14 was admitted to the facility on 10/6/2025 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 and treatment) to rule out bipolar affective disorder (a mental illness that causes unusual shifts in mood, energy, and concentration). During an interview on 2/18/2026 at 11:51 a.m. with Charge Nurse (CN 3), CN 3 stated nursing staff would facilitate communication between a patient’s family and the psychiatrist by documenting the patient’s family’s message on a communication log. CN 3 stated the psychiatrist would look at the communication log and sign off to acknowledge the message. CN 3 further stated nursing staff could call the psychiatrist directly for any urgent matter or if the psychiatrist did not sign off the log. CN 3 further stated it was important to maintain good communication among patients, patient’s family and the healthcare team to alleviate any stress and ensure a smooth hospital experience and care transition. During a concurrent interview and record review on 2/24/2026 at 11:25 a.m. with Nurse Manager (NM 5), Patient 14’s release of information form titled, “Authorization for Release of Protected Health Information (ROI form, the release of information form, written consent [authorization] from patient to whom and what type of health information to be disclosed or released to)” form, dated 10/8/2025, was reviewed. The “ROI form” indicated, Patient 14 signed on 10/8/2025 to give authorization to Patient 14’s family member (FM 14) access to Patient 14’s health information. NM 5 stated based on the ROI form, FM 14 was authorized (by Patient 14) to discuss Patient 14’s care with the physicians. During a concurrent interview and record review on 2/24/2026 at 11:29 a.m. with Nurse Manager (NM 5), Patient 14’s psychiatrist communication log titled, “Physician Communication Sheet (communication log completed by staff to leave message for the psychiatrist to call back),” form dated from 10/8/2025 to 10/23/2205, was reviewed. The “Physician Communication Sheet,” form indicated the following entries: -on 10/8/2025: Patient 14’s family member (FM 14) requested to speak with psychiatrist (MD 5) to discuss putting Patient 14 on lithium and olanzapine to manage Patient 14’s manic state, no physician signed off; -on 10/9/2025: FM 14 requested to discuss medications with MD 5, a physician signed off 10/9/2025’s entry; -on 10/10/2025: FM 14 requested to speak with psychiatrist (MD 5) on 10/10/2025 to discuss Patient 14’s triggers, no physician signed off; -on 10/11/2025: FM 14 requested call back from MD 5, no physician signed off. NM 5 stated it was unclear if physician had called back FM 14 on 10/8/2025, 10/10/2025 and 10/11/2025 because there was no physician sign off. During the same concurrent interview and record review on 2/24/2026 at 11:29 a.m. with NM 5, NM 5 stated FM 14 wanted to speak with MD 5 regarding Patient 14’s medications management and triggers. NM 5 stated nursing staff should have followed the chain of command and escalated to the medical director so FM 14’s concerns could be addressed in a timely manner. NM 5 further stated the delay in communication between the physician and FM 14 could affect Patient 14’s care planning. NM 5 also stated FM 14 would become upset for not getting a call back from the physician. During an interview on 2/25/2026 at 10:46 a.m. with the Chief Nursing Officer (CNO), CNO stated the “Physician Communication Sheet” form was used to communicate with the psychiatrist. CNO further stated if nurses did not hear back from the psychiatrist, the nurses should follow the chain of command to escalate the concerns to the nursing leader and/or the psychiatry medical director. During a review of the facility’s policy and procedure (P&P) titled, “Chain of Command,” dated 5/2025, the P&P indicated, “The Hospital will have a process in which patient care/treatment conflicts and emergencies are resolved ... 1. Charge Nurse will Nursing Leader or their designee (House Supervisor) of the specific treatment issue or emergency need, Nursing Leader will provide consultation to Charge Nurse of the steps to be employed. Nursing Leader will provide oversight to the process. 2. For psychiatric need: a. Attending Psychiatric Physician will be notified; if unavailable, first the Unit Medical Director, and then Hospital Medical Director until assistance is secured.” During a review of the facility’s policy titled, “Format and Content of the Record,” dated 7/2024, the policy indicated that the medical record shall contain a section that documents the patient’s family members and/or significant others involved in the patient’s treatment program.”

“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: 50594 Based on interview and record review, the facility failed to: 1. Ensure its psychiatrist provided information and obtained informed consents (a process by which a patient is informed of any antipsychotic medication that have been prescribed to him or her and the patient’s consent is obtained) prior to ordering psychotropic medications (chemical substances that affect brain function, altering mood, perception, consciousness, and behavior to treat mental illnesses or disorders) for one of 32 sampled patients (Patient 14), in accordance with the facility’s policy regarding medication consent, when Patient 14 received lithium (mood-stabilizing medication to treat and prevent acute [new onset] manic episode and maintenance of bipolar disorder), olanzapine (antipsychotic medication to treat schizophrenia, and bipolar disorder), hydroxyzine (medication to treat anxiety), trazodone (antidepressant medication to treat insomnia [difficulty falling asleep] and depression) and lorazepam (sedative-hypnotic medication to manage anxiety), without an informed consent from 10/6/2025 to 10/23/2025. This deficient practice had the potential to result in Patient 14 not knowing the medications’ purpose, and side effects when receiving the psychotropic medications during hospitalization. 2. Ensure one of 32 sampled patients (Patient 23) had an Informed Consent (a process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) form for Medication, properly filled out either with a patient’s signature to indicate agreement to a medication prescribed or notation of patient refusal, in accordance with the facility’s policy and procedure (P&P) titled “Informed Consent for Psychotropic Medications (chemical substances that affect brain function, altering mood, perception, consciousness, and behavior to treat mental illnesses or disorders),” when Patient 23’s “Medication Consent forms for: Anti-Manic (high energy)/Mood Stabilizers (medications designed to reduce extreme emotional highs [mania] and lows [depression])” and “Medication Consent for: Sedatives (to make someone sleepy), Hypnotics (make someone focused, sleepy and relaxed), and Anti-Anxiety (relaxation) Agents,” did not indicate Patient 23’s agreement or refusal to take the medications prescribed, and did not indicate the dosage range of psychotropic medications being prescribed. This deficient practice had the potential for Patient 23 not being able to exercise the right to be fully informed about their medication, the dosage, benefits and risks of taking the medication, which may lead to poor medication compliance, mistrust of providers, and unmanaged side effects. 3. Ensure a complete informed consent (a process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) process for one of 32 sampled patients (Patient 27), when Patient 27’s medication consent form for Prazosin (medication used to treat Post Traumatic Stress Disorder [PTSD, mental health condition caused by extremely stressful or terrifying event] related nightmares) did not indicate the dosage and the dosage range (recommended span between the lowest effective dose and highest safe dose of a medication), in accordance with the facility’s policy and procedure (P&P) titled, “Informed Consent for Psychotropic Medications (chemical substances that affect brain function, altering mood, perception, consciousness, and behavior to treat mental illnesses or disorders), MM-20,” This deficient practice had the potential to result in Patient 27 and/or the patient’s representative not being adequately informed of the proposed medication treatment, thereby impairing their ability to make an informed decision regarding what would be in the patient’s best interest. Findings: 1. During a review of Patient 14’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 10/7/2025, the “psych eval” indicated, Patient 14 was admitted to the facility on 10/6/2025 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 and treatment) to rule out bipolar affective disorder (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 14’s “Physician Medication Orders,” dated from 10/7/2025 to 10/17/2025, the “Physician Medication Orders” indicated, lithium (mood-stabilizing medication to treat and prevent acute [new onset] manic episode and maintenance of bipolar disorder [a mental illness that causes unusual shifts in mood, energy, and concentration]) 300 milligrams (mg, unit of measure) by mouth twice daily with indication for labile mood (mood swing) starting 10/9/2025, then increased to three times daily starting 10/15/2025. The “Physician Medication Order” also indicated, lithium was changed to 600 mg by mouth twice daily starting 10/17/2025. During a review of Patient 14’s “Physician Medication Order, dated 10/21/2025, the “Physician Medication Order” indicated, olanzapine (antipsychotic 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 bipolar disorder)10mg by mouth twice daily with indication for psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality) starting 10/20/2025. During a concurrent interview and record review on 2/20/2026 at 2:02 p.m. with Nurse Manager (NM 5), Patient 14’s “Medication Administration Record (MAR, record of medications given to patients),” dated from 10/9/2025 to 10/20/2025, was reviewed. The “MAR” indicated, Patient 14 received lithium on 10/10/2025, 10/13/2025, 10/14/2025, 10/15/2025, 10/16/2025, 10/17/2025, 10/18/2025, and 10/20/2025. The “MAR” also indicated, Patient 14 received olanzapine on 10/20/2025, 10/21/2025, 10/22/2025 and 10/23/2025. NM 5 confirmed that Patient 14 received lithium and olanzapine during the hospital stay. During a concurrent interview and record review on 2/20/2026 at 2:17 p.m. with NM 5, Patient 14’s medication consents, dated 10/7/2025, were reviewed. The medication consents indicated, Patient 14 had signed three (3) medication consents and gave consent for Wellbutrin (medication to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest in life]), Latuda (medication to treat schizophrenia and depressive episode in bipolar disorder) and Neurontin (medication to treat anxiety disorder [a group of mental disorders characterized by significant feelings of fear]). NM 5 confirmed there were no other medication consents found in Patient 14’s medical chart. NM 5 stated there was no medication consent for lithium and olanzapine. During an interview on 2/20/2026 at 2:42 p.m. with a Registered Nurse (RN 3), RN 3 stated the physician would provide informed consent for medications to patients and should discuss with the patient regarding the purpose, side effects and positive and negative effects of taking the medication. During a review of Patient 14’s “Physician Medication Order, dated 10/6/2025, the “Physician Medication Order” indicated, hydroxyzine (medication to treat anxiety) 50 mg by mouth every six (6) hours as needed for anxiety, trazodone (antidepressant medication to treat insomnia [difficulty falling asleep] and depression) 50 mg by mouth at bedtime as needed for insomnia. During a review of Patient 14’s “Physician Medication Order, dated 10/7/2025, the “Physician Medication Order” indicated, lorazepam (sedative-hypnotic medication to manage anxiety) 1 mg by mouth every 6 hours for agitation (feeling of irritability or severe restlessness). During a concurrent interview and record review on 2/25/2026 at 10:51 a.m. with the Chief Nursing Office (CNO), Patient 14’s “MAR,” dated from 10/6/2025 to 10/22/2025, was reviewed. The “MAR” indicated, Patient 14 received hydroxyzine on 10/6/2025; trazodone on 10/6/2025, 10/10/2025, 10/12/2025, 10/13/2025, 10/14/2025, 10/15/2025, 10/16/2025, 10/16/2025, 10/19/2025, 10/20/2025, 10/21/2025, 10/22/2025; and lorazepam on 10/8/2025, 10/15/2025 and 10/16/2025. CNO confirmed Patient 14 received hydroxyzine, trazodone and lorazepam during the hospital stay. CNO stated hydroxyzine, trazodone and lorazepam were given as needed per physician order but would still require informed consent. CNO further stated the ordering physician was responsible for discussing and obtaining medication consents from the patient. During a concurrent interview and record review on 2/25/2026 at 10:55 a.m. with CNO, Patient 14’s three medication consents, dated 10/7/2025, were reviewed. The Medication Consents indicated Patient 14 had signed and gave consent for Wellbutrin, Latuda and Neurontin. NM 5 stated there was no medication consent for hydroxyzine, trazodone and lorazepam. During an interview on 2/25/2026 at 11:46 a.m. with physician (MD 3), MD 3 stated all psychotropic medications including routine and as needed medications required informed consents. During a review of the facility’s patient handbook titled, “Rights for Individuals in Mental Health Facilities,” dated 5/2014, the patient handbook indicated, “Medication and the Informed Consent Process ... Before you give your consent to take any antipsychotic medication, your doctor must first explain to you the following: 1. The reasons for you taking this medication and the benefits that you can expect; 2. Your right to withdraw your consent at any time; the type and amount of medication and how often you must take it; 4. The common side effects from taking the medication, the effects that you are most likely to experience, and how long the doctor expects you will need to take the medication; 5. Alternative treatments that are available (if any); 6. The potential long-term side effects of taking the medication ... Definitions ... Informed Consent: a process by which a patient is informed of any antipsychotic medication that have been prescribed to him or her and the patient’s consent is obtained. The informed consent form states that the patient was informed about the prescribed medication(s), including the type of medication, the quantity, the benefits or side effects of the medication, and other forms of treatment that are available. The mental health facility is required to keep the signed consent form in the patient’s record.” During a review of the facility’s policy and procedure (P&P) titled, “Informed Consent for Psychotropic Medications,” dated 2/2026, the P&P indicated, “The treating practitioner has the legal responsibility for obtaining the Patient’s (or the Legal Representative’s) informed consent and approval to proceed with the proposed medication including risks, benefits and alternatives, prior to administration, except in emergencies. The treating practitioner will then document that the informed consent process occurred. The Patient or Legal Representative shall either sign the informed consent attached here to, confirming that he/she has given informed consent, or the treating practitioner shall document that the Patient or Legal Representative gave informed consent but indicate on the form ‘Refused (or Unable) to sign: Verbal consent given’ in the blank for the Patient’s signature. The Treating Practitioner may alternatively document the Patient’s or Legal Representative’s informed consent and the substance of the informed consent process in the medical record ... informed consent is required for the following (list is not all-inclusive): A. Psychotropic medications also previously referred to as ‘antipsychotic medications’ 1. Any medication customarily used to treat psychosis or sever mental or emotional disorder including, the following classes of medication: a. anti-manic and mood stabilizers; b. sedative, hypnotic and anti-anxiety agents; c. anticonvulsants; d. antidepressants; e. antipsychotics; f. stimulants; g. miscellaneous ...” 2. During a record review of Patient 23’s “Initial Psychiatric Evaluation,” dated 2/11/2026, the record indicated Patient 23 was admitted to the facility for “Evaluation of her (Patient 23) mood state.” During an interview on 2/20/2026 at 2:42 p.m. with Registered Nurse (RN) 3, RN 3 stated that informed consent for medications (such as psychotropic medications [chemical substances that affect brain function, altering mood, perception, consciousness, and behavior to treat mental illnesses or disorders]) was done by the physician or psychiatric nurse practitioner, who will go over the purpose, side effects and positive and negative effects of taking the psychotropic medication. RN 3 stated the patient would sign the informed consent form, and if the patient refused to sign, the staff would notate that the patient refused. RN 3 stated if the patient refused to sign but agreed to take the medication, the doctor had to indicate on the informed consent form regarding the patient’s verbal consent to take the medication and the nurse had to sign as witness. RN 3 stated it was important to get verbal consent because “we are verifying that it is okay for the patient to take the medication.” RN 3 further stated it was important to notate that the patient did not want to take the medication. During a concurrent interview and record review on 2/20/2026 at 2:52 p.m. with Charge Nurse (CN) 7, Patient 23’s “Medication Consent for: Anti-Manic (high energy)/Mood Stabilizers (medications designed to reduce extreme emotional highs [mania] and lows [depression]),” and “Medication Consent for: Sedatives (to make someone sleepy), Hypnotics (make someone focused, sleepy and relaxed), and Anti-Anxiety Agents (relaxation agents),” both dated 2/13/2026, were reviewed. The records indicated Patient 23 had a medication consent form for “Depakote (type of medication used to stabilize mood).” CN 7 confirmed there was an “X” on the patient signature line. CN 7 stated the medication consent form did not indicate if Patient 23 consented (gave permission) to receive Depakote. CN 7 stated there should be a signature from Patient 23, or verbal consent documentation on the medication consent form. CN 7 stated he (CN 7) would have confirmed consent (agreement to take psychotropic medication) with the patient, and without the patient’s (Patient 23) signature on the medication consent form, it could not be determined if she (Patient 23) consented to receive Depakote. During a continued interview and record review on 2/20/2026 at 2:52 p.m. with CN 7, Patient 23’s “Medication Consent for: Anti-Manic/Mood Stabilizers,” dated 2/13/2026, and “Medication Consent for: Sedatives, Hypnotics, and Anti-Anxiety Agents,” dated 2/14/2026, were reviewed. CN 7 stated the purpose of obtaining a medication consent was for a patient to be made aware of their treatment in the hospital and to document the patient’s agreement for the medication being prescribed. CN 7 also confirmed that the dosages for the medications Trazodone (a prescription antidepressant medication) and Vistaril (a prescription antihistamine used to treat anxiety, tension, itching from allergic reactions, and as a sedative before or after surgery) on the Medication consent form, dated 2/13/2026, and Ambien (a prescription sedative-hypnotic medication used for the short-term treatment of insomnia [difficulty falling asleep]) and Ativan (medication to manage severe anxiety) for the Medication consent form, dated 2/14/2026, were missing. During a review of the facility’s policy and procedure (P&P) titled, “Informed Consent for Psychotropic Medications,” dated 2/2026, the P&P indicated, “The patient shall be provided an opportunity to sign the form that is witnessed and signed by the physician 3. If the patient refuses to sign the consent, the physician shall document in the patient’s chart the patient’s refusal to consent ...The Treating Practitioner shall document the following as part of the informed consent process: a. Each medication prescribed should have a distinct and separate medication consent form (including dosing range).” 3. During a review of Patient 27’s,”Initial Psychiatric Evaluation (Psych eval, a mental health assessment used to diagnose emotional, behavior, and cognitive conditions),” dated 10/28/2025, the psych eval indicated Patient 27 was admitted to the facility on 5585 hold (72 hour involuntary psychiatric hold for minors under 18 who presents a danger to themselves or others) for danger to self. During a review of Patient 27’s, “Physician Medication Orders (an order by a physician to prescribe medication),” dated 10/28/2025, the physician medication order indicated Patient 27 had a physician order for Prazosin (medication used to treat Post Traumatic Stress Disorder [PTSD, mental health condition caused by extremely stressful or terrifying event] related nightmares)1 milligram (mg, a unit of weight or mass) capsule by oral (mouth) at HS (at bedtime or hour of sleep) to start on 10/28/2025 at 9:00 p.m. with indication for PTSD nightmares. During a concurrent interview and record review on 2/20/2026 at 1:16 p.m. with Charge Nurse (CN) 1, Patient 27’s “Medication Consent For Miscellaneous,” undated, was reviewed. The Medication Consent form indicated a medication named Prazosin which was prescribed by a physician for Patient 27 and dated 10/28/2025. CN 1 confirmed there was no dosage range indicated for Prazosin. CN 1 stated that there should be a parameter of dosage (the specific, measurable, and actionable factors defining how a medication is administered to achieve the desired therapeutic effect while minimizing risks) from minimum to maximum dose and that the dosage information should be indicated in the medication consent form. This would ensure awareness of not exceeding the recommended dose and would clarify the appropriate range for Patient 27. During an interview on 2/20/2026 at 1:50 p.m. with the Medical Director (MD) 1, MD 1 stated that if Prazosin was prescribed for nightmares, the medication consent must include the dosage and dosage range as required by Centers for Medicare and Medicaid Services (CMS, federal agency that provides health coverage to people). During an interview on 2/20/2026 at 2:08 p.m. with CN 7, CN 7 stated Patient 27’s family member had the right to be informed of the medication to be administered, including the name, dosage and the initial dose of medication prescribed. During a review of the facility’s policy and procedures (P&P) titled, “Informed Consent for Psychotropic Medications, MM-20,” last revised 2/2026, the P&P indicated, “The Treating Practitioner shall document the following as part of the informed consent process: a. Each medication prescribed should have a distinct and separate medication consent form (including dosing range).””

“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: 46333 Based on observation, interview, and record review, the facility failed to: 1. Ensure a safe care setting for three (3) of thirty two (32) sampled patients (Patient 1, Patient 25, and Patient 32) by not implementing the documented intervention of bathroom supervision (continuous staff presence while a patient uses the bathroom) for Patient 1, by not differentiating monitoring or intervention levels for high, moderate, or low suicide-risk patients (levels describing a patient’s likelihood of attempting self-harm) for Patients 1, 25 and 32 (who had access to private bathrooms in their rooms without bathroom supervision, which require being on one-to-one observation), and when the Registered Nurse (RN, a licensed nurse responsible for clinical assessment and interventions) did not notify the physician or obtain the required physician order for bathroom supervision after documenting the intervention regarding bathroom supervision for Patient 1, in accordance with the facility’s policy “Assessment for Suicide Risk Potential II,” which directed that nurse?initiated precautions must be communicated to, and ordered by, a physician before implementation (for Patient 1) and in accordance with the facility’s policy regarding the patients’ right to be free from harm for Patients 1, 25 and 32. This deficient practice resulted in Patient 1 sustaining a life-threatening ligature event (an item wrapped tightly around the neck that restricts breathing) in the bathroom, where the patient (Patient 1) was found unresponsive (not reacting or responding), cyanotic (bluish skin color from lack of oxygen), and bleeding, requiring emergency intervention (immediate life-saving medical response). This deficient practice also placed Patients 25 and 32, and all other patients at the facility, who were at high risk for suicide and who had access to private bathrooms, without bathroom supervision, at risk for similar serious harm. 2. Ensure one of 32 sampled patients (Patient 25) was free from harm, in accordance with the facility’s policy regarding patient supervision, when Patient 25 sustained a fall and femur (thighbone) fracture (broken bone), while playing basketball with his peers without facility staff supervision. This deficient practice resulted in femur fracture for Patient 25 and also had the potential to cause severe harm and/or death to other patients due to the lack of staff supervision. On 2/19/2026 at 4:08 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s non-compliance 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 Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Risk Management (DIR 1), Director of Clinical Services (DIR 2), and an Administrator. The facility failed to provide a safe environment to ensure Patient 1 was continuously monitored while in the bathroom (continuous staff presence while a patient uses the bathroom), did not differentiate monitoring/intervention levels for high, moderate, or low suicide-risk patients (levels of likelihood for self-harm), and the Registered Nurse (RN 10) did not notify the physician or request orders for bathroom supervision after documenting the intervention regarding bathroom supervision. Patient 1 engaged in a life-threatening ligature (an item wrapped tightly around the neck that restricts breathing) event in the bathroom, resulting in cyanosis (bluish skin due to lack of oxygen), unresponsiveness (an individual who is unconscious, lacks awareness of their surroundings, and does not respond to verbal commands, light touch, or painful stimuli), and bleeding from multiple orifices (ear, nose, and mouth), conditions that pose imminent risk of hypoxic brain injury (when the brain receives insufficient oxygen, causing cells to become damaged or die) and death. The absence of required bathroom supervision and failure to transfer the patient (Patient 1) to a safer unit created a reasonable expectation of serious harm including a potential for serious harm for other high-risk patients with access to private bathrooms without direct supervision, if not corrected. Patient 1’s medical record review showed Patient 1’s Nursing Admission Assessment indicated Patient 1 achieved the highest suicide risk score of 6. The patient (Patient 1) answered “Yes” to all six critical questions on the Suicide (the act of intentionally causing one’s own death) Risk Assessment (including feelings of hopelessness, helplessness, or despair; suicidal ideations; suicidal thoughts with a plan; presence of a plan; involvement of serious or lethal intent; and all remaining required critical questions documented in the assessment. Answering “Yes” to all of these critical questions resulted in a risk score of 6, which is identified in the facility’s assessment tool as the highest possible suicide risk level), with active suicidal ideation (thoughts of self-harm), and intent during the admission assessment completed at 4:15 p.m. on 1/28/2026. Patient 1 was admitted on a 5150 hold (an involuntary psychiatric detention under California law that allows a qualified professional to hold an individual for up to 72 hours for evaluation when the person is deemed a danger to self, danger to others, or gravely disabled [requires assistance with performing activities of daily living such as hygiene or grooming]), following suicidal ideation with intent and plan. On 1/28/2026 at 11:53 p.m., Patient 1 was found in the patient bathroom with a gown wrapped around the neck, unresponsive (an individual who is unconscious, lacks awareness of their surroundings, and does not respond to verbal commands, light touch, or painful stimuli), cyanotic (bluish skin due to lack of oxygen), and bleeding from the nose, mouth, and ear. On 2/24/2026 at 2:37 p.m., the IJ was removed in the presence of the CEO, CNO, and the Regional Vice President (RVP) 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 review. The acceptable IJ Removal Plan included adopting a new policy titled, “New Patient Observation Rounds Level of Observation Policy,” which indicated that patients at high risk for suicide will require 1:1 observation (a high-level safety intervention where a staff member is assigned to directly monitor a single patient within arm’s length or continuous eyesight at all times, 24/7) including bathroom supervision. The 1:1 order will continue until the attending physician assesses the patient in person and discontinues the 1:1 order with documented justification in the patient’s electronic medical record. All licensed nurses and mental health technicians/specialists were trained on the new policy. All registered nurses responsible for completing the Columbia Lifetime Suicide Risk Assessment (an evidence-based tool used to identify and assess an individual’s risk for suicide) were retrained by way of example scenarios and return demonstration to place patients at high risk for suicide on a 1:1 observation until the attending physician assesses the patient in person. In addition, patient’s interventions checked off on the suicide risk assessments are automatically transferred to the treatment plan and include the increased level of observation and specific interventions to be followed throughout the patient’s stay. Patients placed on bathroom supervision will be documented in the patient’s treatment plan. The registered nurse will communicate with the assigned staff when patients are placed on 1:1 and the reason, by way of the change of shift report and documented on the patient’s Kardex (a centralized, quick-reference documentation system used by nurses to consolidate key patient information, medical orders, and daily care needs). The nurse will perform two oversight rounds review per 8-hour shift and sign off on the Q15 (Every 15) minute Patient Observation (often called Q15 checks or rounding, is a psychiatric nursing procedure where staff check on patients every 15 minutes to ensure safety) Sheet. Findings: 1. During a review of Patient 1’s “Nursing Admission Assessment,” dated 1/28/2026 at 4:15 p.m., the assessment indicated a Columbia Suicide Risk Assessment score of 24 (highest risk; low risk reflects passive thoughts of death, moderate risk reflects suicidal thoughts with a method but no plan or intent, and high risk reflects a specific plan, intent, or suicidal behaviors), documentation of active suicidal ideation (thoughts of self-harm), intent (desire to act on the thoughts), and a plan (a described method), and “Bathroom Supervision” listed under Interventions. During a review of Q15-minute rounding documentation (visual checks performed every 15 minutes), dated from 1/28/026 to 1/29/2026 at 6:30 p.m., the rounding sheets showed Q15?minute checks with no documentation of bathroom supervision. Patient 1 was placed on 1:1 monitoring (continuous one-to-one staff observation within arm’s reach) at 6:45 p.m. on 1/29/2026 following return from the emergency department (after attempting to suicide by strangulation). During a review of Patient 25’s “Nursing Admission Assessment,” dated 12/19/2025, the section for assessing suicidal risk using the Columbia Suicide Risk Assessment tool indicated Patient 25 had a moderate risk for suicide. The assessment indicated Patient 25 answered yes to wishing to be dead, Patient 25 had a plan to stab their artery to bleed out. The section titled “Risk Formulation,” indicated Patient 25 was placed on standard every 15 minutes observation. During a review of Patient 32’s “Nursing Admission Assessment,” dated 2/16/2025, the section for assessing suicidal risk using the Columbia Suicide Risk Assessment tool indicated Patient 32 had a high risk for suicide. The assessment indicated Patient 32 reported suicide ideation with plan to hang self. The section titled “Risk Formulation,” indicated Patient 32 was placed on standard every 15 minutes observation. During a concurrent interview and record review on 2/17/2026 at 10:20 a.m. with the Charge Nurse (CN 2), the HIJ (patient care unit identifier) unit “Patient Care Assignment Sheet,” dated 2/17/2026, was reviewed. The Assignment Sheet indicated that 14 patients on the unit were designated as being on “Suicide Precaution (intensive safety protocols implemented when a patient is deemed at risk of self-harm or suicide. These measures include constant [1:1] observation, removal of all potentially dangerous items [ligatures, sharp objects], and specialized room monitoring to ensure a secure environment while providing care).” During the same concurrent interview and record review on 2/17/2026 at 10:20 a.m. with the Charge Nurse (CN 2), CN 2 stated that as of 2/17/2026, no patients on the unit (HIJ unit) were assigned 1:1 monitoring, and that if a patient was assigned 1:1 or Q5-minute monitoring, it would be documented on the Assignment Sheet. Review of the Assignment Sheet showed no entries indicating that any patient had been assigned 1:1 or Q5-minute observation. During an observation on 2/17/2026 at 10:23 a.m. on unit HIJ (Patient care unit identifier), all patient rooms, including those of the 14 patients listed on the Assignment Sheet as being on Suicide Precaution, were observed to have private bathrooms accessible to patients without staff presence. Patients on the unit (HIJ unit) were observed wearing the same type of facility wrap-around gowns available to Patient 1. There were no staff monitoring any patients on a 1:1. During an interview on 2/17/2026 at 10:46 a.m. with Registered Nurse (RN 9), RN 9 stated suicide-risk precautions included documentation on the rounding sheet and use of the Columbia Suicide Assessment Tool (a structured screening tool for suicide risk). RN 9 stated patients at moderate and high suicide risk are placed on Q15-minute monitoring, and that 1:1 monitoring was used when a patient was actively suicidal (engaging in self-harm behaviors), requiring RN notification of the physician. RN 9 stated they (the facility staff) could not locate the facility’s de?escalation policy (procedures to calm an agitated or distressed patient) or other precaution policies and would ask the nurse manager. During an interview on 2/17/2026 at 10:55 a.m. with Nurse Manager (NM 6), NM 6 stated they (the facility staff) did not know where to locate facility policies and would go to the Chief Nursing Officer. NM 6 stated patients assessed with high suicide risk were documented in the Kardex (a clinical communication tool summarizing patient care needs) and “usually” remained on Q15-minute monitoring unless they (the patients) had an active plan for suicide; NM 6 stated patients assessed as moderate or low suicide risk were also placed on every 15-minute monitoring. During an interview on 2/17/2026 at 10:58 a.m. with the Chief Nursing Officer (CNO), the CNO stated they (the facility staff) accessed the facility’s policies via the facility computer under “Policy Stat Intranet (the facility’s electronic policy database).” The CNO stated monitoring for moderate and high suicide-risk patients was dependent on patient behavior and patients were placed on 1:1 monitoring only when staff witnessed the patient actively attempting harm to self or others. The CNO stated the facility did not have a policy titled “Level of Observation,” though this policy was referenced in the “Assessment for Suicide Risk Potential III” policy. During interviews and follow-up requests with Director of Risk Management (DIR 1) on 2/17/2026 at 3:00 p.m., 2/18/2026 at 11:00 a.m. and 4:00 p.m., and on 2/19/2026 at 11:20 a.m., DIR 1 stated they had requested an interview with the psychiatrist (MD 1, the physician responsible for psychiatric evaluation and treatment) caring for Patient 1 and that MD 1 would be calling in 15 minutes. MD 1 did not call back on any of the three in which an interview was requested. During interviews on 2/17/2026 at 3:00 p.m. and on 2/18/2026 at 10:20 a.m. with DIR 1, DIR 1 stated RN 10 (the nurse who documented bathroom supervision for Patient 1) was not available for interview after two attempts. During an interview on 2/19/2026 at 11:29 a.m. with Dir 1, DIR 1 stated RN 11 (RN who completed rounding prior to when Patient 1 was found in the bathroom) was not available for interview. During a concurrent interview and record review on 2/18/2026 at 3:12 p.m. with Nurse Manager (NM 5), Patient 1’s “Nursing Admission Assessment,” dated 1/28/2026 at 4:15 p.m., was reviewed. NM 5 stated bathroom supervision required direct and continuous staff presence during each bathroom use and confirmed that patient safety should supersede privacy. NM 5 stated the facility would be able to arrange for female staff to monitor a female patient and confirmed there was no documentation that the physician was notified of the identified intervention regarding bathroom supervision for Patient 1. During an interview on 2/18/2026 at 11:06 a.m. with RN 3, RN 3 stated Patient 1 was on Q15-minute monitoring on 1/28/2026 and was found “around midnight” seated in the shower area with a twisted gown around the neck, naked and cyanotic. RN 3 stated they (facility staff) assisted in removing the gown and obtained vital signs (basic physiological measurements), paramedics arrived and transported Patient 1 (to another facility for evaluation), and upon return (back to the facility), Patient 1 was placed on 1:1 observation and 1:1 observation was documented each shift and on rounding sheets. During a concurrent interview and record review on 2/18/2026 at 3:05 p.m. with the Chief Executive Officer (CEO), the facility’s policy “Assessment for Suicide Risk Potential III,” dated February 2026, was reviewed. The policy indicated nursing staff will screen all patients with an evidence-based tool and enact the identified intervention, all patients will be monitored at least every 15 minutes, and patients at higher suicide risk may be placed on 1:1 observation as outlined in the referenced “Level of Observation” policy. The policy further indicated that patients who scored moderate to high on the evidence-based screening tool would receive an assessment using an evidence-based assessment tool, and that the Registered Nurse (RN) would document individualized actions and precautions applicable to the patient and contact the physician for appropriate orders, including the level of observation. The CEO stated the reference to a “Level of Observation” policy was an error and that no such policy existed at the facility. During an interview on 2/18/2026 at 4:11 p.m. with Mental Health Technician (MHT 9), MHT 9 stated that during a code response (a medical emergency requiring an urgent team response) they (the facility staff) observed Patient 1 on the bathroom floor with cyanosis, stiff arms, and bleeding from the ear, nose, and mouth; scissors were used to remove the gown (Patient 1’s gown). MHT 9 also said that patients with bathroom-observation interventions should be placed on units with bathrooms located outside patient rooms, and with physician orders requested for transfer (to a room with the bathroom outside of the patient’s room for safety). During an interview on 2/18/2026 at 4:30 p.m. with Milieu Specialist (MS 1, staff overseeing patient environment and safety), MS 1 stated the incident involving Patient 1 occurred “around 11 p.m. (on 1/28/2026),” during shift handoff when MS 1 observed Mental Health Technician (MHT 1) removing a facility gown (wrap-around style without strings or buttons) from Patient 1’s neck, and MS 1 stated there were no ligature points (fixtures or objects that could be used to affix a ligature) in the bathroom. During an interview on 2/19/2026 at 10:01 a.m. with MHT 1, MHT 1 stated mental health technician responsibilities included patient safety and verifying that patients were breathing during rounds. MHT 1 stated they (the facility staff) last recalled seeing Patient 1 “around 10 p.m. (exact time not recalled).” MHT 1 stated they re-entered Patient 1’s room at approximately 11:52 p.m. after hearing a grunting sound from the bathroom and found Patient 1 leaning at a 45-degree angle against the shower wall with a facility gown wrapped around the neck, naked, unresponsive, cyanotic, and bleeding from the ears, nose, and mouth. MHT 1 stated they removed the gown by twisting it and called a Code Blue (an emergency requiring cardiopulmonary resuscitation). MHT 1 stated prior to the incident with Patient 1, there was no specific instructions received from nursing staff to increase monitoring beyond Q15-minute checks. During a concurrent observation and interview on 2/19/2026 at 11:03 a.m. with the Director of Risk Management (DIR 1), in the conference room, the surveillance footage, dated 1/28/2026 from 10:48 p.m.-12:00 a.m., was reviewed. The video displayed timestamped staff entries and exits from Patient 1’s doorway. Round Sheet entries showed MHT 1 entering Patient 1’s room at 10:52 p.m., exiting at 10:53 p.m., rounding performed by RN staff between 11:11 p.m. and 11:13 p.m., RN 11 entering and exiting between 11:29 p.m. and 11:30 p.m., MHT 1 entering again at 11:40 p.m. for approximately 35 seconds, and MHT 1 reentering at 11:52 p.m. DIR 1 stated Patient 1 was found at approximately 11:53 p.m. in the bathroom with a gown wrapped around the neck. DIR 1 confirmed that Patient 1 was not placed on Bathroom Supervision and that staff were performing only standard 15-minute observation rounds. During a review of the facility’s policy and procedure (P&P) titled, “Patient Precautions,” dated August 2025, the P&P indicated, “It is the policy of (name of the facility) to identify and assess risk factors of all patients in order to provide care in a safe and therapeutic milieu. All patients are assessed for risks for suicide/self-harm ... Once risk factors are identified the physician will determine appropriate precautions for each patient ...Any risks identified will be communicated to the physician and documented in the nursing admission assessment form. The appropriate corresponding precautions are to be implemented as ordered by the physician ...A physician or charge nurse may initiate any precaution. When a charge nurse initiates a precaution, the physician must be informed and a physician order must be obtained to place a patient on a precaution ...Suicide: Upon admission, all patients are assessed for suicide severity risk utilizing the evidenced based ‘Columbia Suicide Severity Rating Screen.’ The results of this screen are used to determine initial ‘Suicide Precautions’.” During a review of the facility’s policy and procedure (P&P) titled, “Active and Individualized Treatment,” dated February 2026, the P&P indicated, “Active Treatment interventions identified in the Master Treatment Plan and Treatment Plan Updates are delivered to patients and documented in each patient’s record in such a manner as to assure all active therapeutic efforts are included.” During a review of the facility’s policy and procedure (P&P) titled, “Nursing assessment and Reassessment of Patients,” dated July 2025, the P&P indicated, “The initial safety assessment and mental status evaluation is done by the Registered Nurse upon admission of the patient to the unit. The RN determines and prioritizes the nursing care needs ... The assessment includes the collection and analysis of data about the patient to determine ...the patient’s care needs, and the care to be provided ... The Nursing Admission Assessment must be completed within eight (8) hours of admission by a Registered Nurse ... Each patient is reassessed daily and as the patient’s condition/ needs warrant by an RN. More frequent monitoring may be ordered by the physician, including but not limited to, for detoxification assessment, neurological checks, and 1:1 supervision.” During a review of the facility’s policy and procedure (P&P) titled, “Contraband,” dated August 2025, the P&P indicated, “To enhance safety by identifying and preventing dangerous items (contraband) from entering into the therapeutic environment and to prevent patients from injuring themselves or others ... Contraband: Term used to describe prohibited or unauthorized items ...Any item that poses a safety risk may be considered contraband or if an item poses a safety risk or interferes with the rights of others.” During a review of the facility’s handbook titled “Rights for Individuals in Mental Health Facilities,” undated, the handbook indicated, “The person in charge of the facility in which you are receiving treatment is responsible for ensuring that all your rights in this handbook are protected ...You have the right to be free from ...harm ...You also have the right to be free from potential harmful situations or conditions.” 2. During a record review of Patient 25’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 12/19/2025, the record indicated Patient 25 was admitted to the facility on a 5150 (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 suicidal ideation (plan to self-harm). Patient 25 had a psychiatric history of past hospitalizations and suicide attempts (an act in which an individual tries to end their own life but survives). During a review of Patient 25’s “Multidisciplinary Treatment Plan: Potential for Falls,” dated 12/19/2025, the record indicated, “Pt (Patient 25) has risk for falls due to having left sided weakness & (and) uses a walker & wheelchair to ambulate (to walk).” The record further indicated Patient 25 had an order for “Fall Precautions (a proactive, comprehensive approach to reduce the risk of falling, combining environmental modifications, physical health management, and safety protocols. Example: removing tripping hazards like cords).” During a record review of Patient 25’s “Progress Record,” dated 1/17/2026, the record indicated Patient 25 “Lost his balance while playing basketball. Pt (Patient 25) hit his head and his left hip ...Pt (Patient 25) endorses 9.5/10 pain (represents severe pain based on a numerical pain scale of 0-10) and is unable to bear weight on left leg. Internist informed, ordered pt (Patient 25) to be transferred to (name of acute care hospital) emergency room to rule out fractures (break in the bone) and/or brain bleed.” During a record review of Patient 25’s “Progress Record,” dated 1/18/2026, the Progress Record indicated “Patient (Patient 25) was admitted due to fracture of femur (the longest, heaviest, and strongest bone in the human body, extending from the hip to the knee) and will undergo surgery.” During an interview on 2/18/2026 at 11:39 a.m. with Charge Nurse (CN) 3, CN 3 stated patients can go out into the courtyard and staff needed to watch/supervise the patients. During an interview on 2/25/2026 with the Director of Risk Management (DIR 1), DIR 1 stated Patient 25 had fallen while playing basketball, and the peers informed staff of Patient 25’s fall. DIR 1 stated staff were not supervising the patients at the time of the Patient 25’s fall while playing basketball. DIR 1 stated it was important for staff to watch/supervise the patients for safety anytime the patients were outside having their activities. During a review of the facility’s policy and procedure (P&P) titled, “Patient Precautions,” dated 8/2025, the P&P indicated, “To establish a process for supervising patients as a means to diminish the risk of harm and/or injury and to set a procedure for observing and documenting patient location and behavior based on precaution level ...All patients on a Fall Risk Precautions will have the following measures initiated ...Ensure environmental safety (no clutter, trip/fall hazards, etc).””

“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: 46333 Based on interview and record review, the facility failed to ensure that one (1) of 32 sampled patients (Patient 2) was free from abuse (intentional or unintentional physical or emotional harm), in accordance with the facility’s “Patient Precautions” policy (policy for identifying, evaluating, and mitigating risks such as assault, suicide [the act of intentionally causing one’s own death], and elopement [when a patient left a healthcare facility or supervised setting without authorization or permission]), when the facility did not perform a risk assessment (a clinical evaluation of danger to self or others), did not increase monitoring (raising the frequency of staff checks such as from every 15 minutes to every 5 minutes or direct line-of-sight observation [a high-level safety protocol where a dedicated staff member keeps a patient within their direct, unobstructed view at all times to prevent harm), and did not separate the patients (by placing them in different rooms or units), after Patient 2 was assaulted (physical attack) by Patient 5 (Patient 2 was struck with a closed fist in the jaw [first incident] and struck with Patient 5’s fist on the left side of the head [second incident]). These failures occurred despite nursing notes indicating that the physician was notified regarding the incidents of assault. This deficient practice resulted in Patient 2 having been physically assaulted twice within 24 hours by the same patient (Patient 5). Patient 2 experienced repeated exposure to physical aggression (hitting or striking) and emotional distress (fear, anxiety, or psychological harm), increased vulnerability, and contributed to an unsafe treatment environment for other patients and staff. Findings: During a review of Patient 2’s Initial Psychiatric Evaluation (a physician’s diagnostic assessment performed on admission), dated 12/03/2024, the Initial Psychiatric Evaluation indicated that Patient 2 was admitted on a 5150 hold (a California involuntary mental health detention for danger to self, danger to others, or grave disability [inability to care for one’s self]). During a review of Patient 2’s “Progress Note,” dated 12/8/2024, the note indicated “At 7:15 a.m., the patient (Patient 2) was struck on the jaw with closed fist by peer (Patient 5) ...” During a review of Patient 2’s Progress Note, dated 12/9/2024 at 8:40 a.m., the note indicated Patient 2 was walking in the hallway when he (Patient 2) was struck by peer (Patient 5) in the left side of his (Patient 2) head. Patient 2 was assessed by a provider, who ordered transfer to the hospital due to swelling (inflammation) near the left eye and jaw pain (of Patient 2). During a concurrent interview and record review on 2/19/2026 at 10:53 a.m. with Registered Nurse (RN 5), Patient 2’s “My Safety Crisis Plan (a patient-specific safety plan used to identify triggers and coping strategies),” dated 12/04/2024, was reviewed. RN 5 stated the Crisis Plan must be reviewed after any assaultive event (violent or aggressive incident); However, record review indicated there was no documented review after 12/08 or 12/09 (the two incident dates of the abuse on Patient 2). During a concurrent interview and record review on 2/19/2026 at 2:38 p.m. with Registered Nurse (RN 5), Patient 2’s “Rounding sheet (a structured tool used by nursing staff to document regular, proactive checks on patients at scheduled intervals),” dated 12/5/2024 -12/10/2024, was reviewed. The rounding sheet indicated that Patient 2 remained on standard every 15 minutes monitoring. RN 5 confirmed that Patient 2’s monitoring did not increase after the two assaultive incidents (first incident on 12/8/2024 and the second incident on 12/9/2024). During a concurrent interview and record review on 2/19/2026 at 2:38 p.m. with Registered Nurse (RN 5), Patient 2’s “Orders (Physician Orders),” dated 12/4/2024 -12/10/2024, was reviewed. The orders indicated Patient 2’s Orders (physician instructions), from dates 12/04/2024-12/10/2024, had the following information: no transfer order or other documented separation after the 12/08/2024 assault (first incident of assault). Transfer for Patient 2 (the victim) was not ordered until 11:59 p.m. on 12/09/2024. RN 5 confirmed that no order was placed to separate Patient 2 from Patient 5 (the perpetrator). During a concurrent interview and record review on 2/23/2026 at 10:53 a.m. with Nurse Manager (NM 6), Patient 5’s (the perpetrator) “Orders,” dated 12/4/2024 -12/10/2024, was reviewed. The order indicated no transfer order for Patient 2 (the victim) or a separation from Patient 5 (the perpetrator) after the first assault on 12/08/2024. RN 5 confirmed that a transfer order was not entered until 11:59 p.m. on 12/09/2024-over 15 hours after the second assault (in which Patient 2 was struck for the second time by Patient 5 earlier at 8:40 a.m.). During a concurrent interview and record review on 02/23/2026 at 11:00 a.m. with Nurse Manager (NM 6), Patient 5’s Progress Note, dated 12/09/2024, was reviewed. The documentation showed that after Patient 5 assaulted Patient 2 at 8:40 a.m. (second incident of assault involving Patients 2 and 5), Patient 5 continued to engage in multiple additional unprovoked assaults on other peers (patients) throughout the day. At 3:00 p.m. (on 12/9/2024), the note indicated Patient 5 entered the observation room and struck another peer in the face, causing the peer to fall and land on his head; Patient 5 was placed in PRT (physical restraint techniques- emergency interventions used as a last resort to safely restrict a patient’s movement, protecting them or others from immediate harm. Techniques involve manual holding, mechanical devices (e.g., soft limb restraints, leather restraints), or seclusion, requiring specialized training, medical assessment, and strict adherence to safety regulations) from 2:55 p.m. to 2:59 p.m., and the physician was notified and medication was administered. A later note at 8:20 p.m. indicated that Patient 5 again struck a peer in the back of the head without provocation. Despite these repeated assaults and the earlier assaults on Patient 2, Patient 5 was not placed on 1:1 observation (continuous one staff to one patient supervision) until 8:45 p.m. on 12/09/2024, which was more than 37 hours after the first assault on Patient 2 at 7:15 a.m. on 12/08/2024, and over 12 hours after the second assault on Patient 2 at 8:40 a.m. on 12/09/2024. During a review of the facility’s policy and procedure (P&P) titled, “Abuse and Neglect,” dated 6/2025, the P&P indicated, “The hospital treatment team will assess and reassess patients for signs of abuse ... upon intake, admission and throughout hospitalization ... If the patient is admitted with physical injuries, bruising, scarring or abrasions, the cause will be assessed and documented in writing ... Staff will reassess patients throughout their hospitalization for any signs and symptoms of abuse ... Any suspected abuse will be reported per hospital policy ... ‘Physical abuse’ includes any non?accidental physical trauma ... including burning, beating ... punching ... and includes use of a physical or chemical restraint or psychotropic medication for punishment or for any purpose not authorized by the physician.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Precautions,” (undated), the P&P indicated, “During a review of the facility’s policy and procedure (P&P) titled, “Patient Precautions,” (undated), the P&P indicated, “All patients will be assessed on admission and reassessed daily ... staff will reassess patients whenever there is an abrupt change in behavior ... assault precautions will include close monitoring, consideration of room assignment, and separating patients when aggression is directed at a specific individual ... If an assault occurs, staff will intervene immediately to separate patients and re?establish safety using least restrictive methods ... the RN will assess the patient for injuries or need for medical attention ... the RN will consult with the attending psychiatrist for additional interventions including ... room or unit change ... medication adjustment ... change in observation level ... 1:1 therapy ....” During a review of the facility’s patient handbook titled, “Rights for Individuals in Mental Health Facilities,” dated 5/2014, the patient handbook indicated, “You have the right to be free from abuse, neglect, or harm ... You also have the right to be free from potentially harmful situations or conditions ...””

“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: 36206 Based on interview and record review, the facility failed to: 1.a. Assess the blood sugar levels, as ordered by the physician, for one of 32 sampled patients (Patient 6), in accordance with the physician’s order and the facility’s policy regarding blood glucose (blood sugar) monitoring. This deficient practice left Patient 6’s blood sugar levels unmonitored and had the potential to result in adverse effects (negative or undesirable effect) if high or low sugar levels remained undetected and/or untreated. 1.b. Assess the vital signs (VS- temperature, blood pressure, pulse [heartbeat], respiratory rate [number of breaths per minute]) for one of 32 sampled patients (Patient 6), in accordance with the physician’s order and the facility’s policy regarding vital signs assessment. This deficient practice had the potential for changes in Patient 6’s condition to be unidentified by staff, which may delay the implementation of necessary interventions to treat negative changes in Patient 6’s condition such as sudden drop in blood pressure leading to patient harm and/or death. 2. Ensure one of 32 sampled patient’s (Patient 11) neuro-checks (neurological [pertaining to brain] assessments done at regular intervals to check the patient’s alertness, thinking, and how well the brain is working), were completed every 4 hours, as ordered by the physician, after Patient 11 attempted to strangulate (to compress or constrict a body part [like the throat] to stop airflow or blood circulation) herself. This deficient practice had the potential to result in Patient 11 developing neurological complications (decline in brain function) that are not promptly assessed or treated. 3. Ensure its nursing staff assessed one of 32 sampled patient’s (Patient 13) compliance (to follow) with a prescribed psychotropic medication (chemical substances that affect brain function, altering mood, perception, consciousness, and behavior to treat mental illnesses or disorders) regime (prescribed medication plan) and did not notify the psychiatrist (physician specializes in mental health), when Patient 13 refused to take the prescribed psychotropic medication duloxetine (medication to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest in life], anxiety [a group of mental disorders characterized by significant feelings of fear] and various pain conditions), as ordered by the psychiatrist during Patient 13’s hospitalization. Patient 13 was discharged with duloxetine prescription on 10/16/2025. This deficient practice resulted in the physician not being able to evaluate Patient 13’s compliance with the treatment plan or considering alternative psychotropic medications for Patient 13 to manage Patient 13’s mental illness before discharge, which had the potential for Patient 13’s continued noncompliance with medication regimen after discharge from the facility, worsening of Patient 13’s mental illness and possible rehospitalization. Findings: 1.a. During a review of Patient 6’s History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/12/2024, the H&P indicated the following: Patient 6’s past medical history included Diabetes mellitus (high blood sugar), asthma (a chronic, non-curable lung disease that causes inflammation, swelling, and narrowing of the airways, making it difficult to breathe), and elevated blood pressure. During a review of Patient 6’s “Final Ancillary Orders,” dated 9/14/2024 at 5:04 p.m., the Final Ancillary Orders indicated blood glucose (sugar) monitoring twice a day (BID). During a review of Patient 6’s “Medication Administration Record (MAR),” with a start date of 9/14/2024, the MAR indicated that Blood Glucose Monitoring - Hypoglycemic (low blood sugar) checks, were scheduled twice a day (BID) at 9 a.m. and at 9 p.m. The MAR indicated blood glucose monitoring was not completed on 9/18/2024 at 9 a.m. During a concurrent interview and record review on 2/23/2026 at 11:21 a.m. with Registered Nurse (RN) 1, RN 1 stated the following: Patient 6’s blood sugar levels should be monitored twice a day, at 9 a.m., and at 9 p.m., as ordered by the physician, to determine whether or not Patient 6 needed insulin (a medication to reduce sugar levels in the blood) or if Patient 6 needed other interventions to address low sugar levels. RN 1 verified that Patient 6’s blood sugar level was not checked on 9/18/2024 at 9 a.m., and there was no documentation in the MAR indicating that Patient 6 refused a blood sugar check. During a review of the facility’s policy and procedure (P&P) titled, “Blood Glucose Monitoring with Accu-Chek Inform II Meter,” dated 5/2025, the P&P indicated the following: “Purpose: To provide accurate and reliable blood glucose monitoring using capillary or venous blood ...Document the reading appropriately in the patient chart ...” 1.b. During a review of Patient 6’s “History and Physical (H&P),” dated 9/12/2024, the H&P indicated the following: Patient 6’s past medical history included Diabetes mellitus, asthma, and elevated blood pressure. During a review of Patient 6’s “Final Ancillary Orders,” dated 9/12/2024 at 9 a.m., the Final Ancillary Orders indicated Vital Signs (VS- temperature, blood pressure, pulse [heartbeat], respiratory rate [number of breaths per minute]) Daily. During a review of Patient 6’s “Medication Administration Record (MAR),” dated 9/12/2024, the MAR indicated under “section: Vital Signs Once a Day” that there were no Vital signs documented on 9/12/2024 at 9 a.m. During a review of Patient 6’s “Final Ancillary Orders,” dated 9/12/2024 at 1 p.m., the Final Ancillary Orders indicated Vital Signs Three Times A Day (TID). During a review of Patient 6’s “Medication Administration Record (MAR),” with start date and time on 9/12/2024 at 1 p.m., the MAR indicated under “section: Vital Signs Three Times A Day,” that there were no documented vital signs or documented reasons why vital signs were not done on the following days and times: -9/12/2024 at 1 p.m., and 9 p.m., -9/14/2024 at 1 p.m., -9/15/2024 at 9 a.m., and 1 p.m., -9/16/2024 at 9 p.m., -9/17/2024 at 9 a.m., and 1 p.m., -9/18/2024 at 9 a.m., 1 p.m., and 9 p.m., -9/19/2024 at 9 a.m., 1 p.m. During a concurrent interview and record review on 2/23/2026 at 11:21 a.m. with Registered Nurse (RN) 1, RN 1 stated the following: Patient 6 initially had orders for vital signs to be checked once a day on 9/12/2024 at 9 a.m. Then, on 9/12/2024 at 1 p.m., Patient 6 had orders for vital signs to be checked three times a day (at 9 a.m., 1 p.m., and 9 p.m.). RN 1 verified that Patient 6’s vital signs were not checked as ordered by the physician and verified many vital signs had not been done and were not documented. RN 1 stated it was important to check vital signs to identify any changes in the patient’s condition. RN 1 further stated that vital signs should be checked in accordance with the physician’s order. During a review of the facility’s policy and procedure (P&P) titled, “Vital Signs,” dated 5/2025, the P&P indicated the following: “Vital signs (blood pressure, temperature, pulse, respirations) will be obtained at least once per day, documented, and evaluated by nursing staff in an appropriate manner to aid in diagnosis and treatment. Abnormal vital signs will be reported timely to the physician or licensed independent practitioner (LIP). Vital signs will be recorded in the medical record per facility policy ...To ensure that each patient’s vital signs are monitored upon admission and throughout the hospital stay ...Acute: All patients will have vital signs taken as part of the initial assessment and daily thereafter until discharge, unless ordered more frequently by the physician / LIP ...” 2. During a review of Patient 11’s Initial Psychiatric Evaluation (Psych Eval, a formal assessment done by a psychiatrist), dated 1/27/2026, the Psych Eval indicated that Patient 11 was admitted to the facility’s Youth Services unit (an inpatient behavioral health unit for patients ages 13 to 17) after an attempt to overdose on pills (meaning the patient took more medication than was safe or intended in order to harm herself). During a review of Patient 11’s Nursing Progress Note, dated 2/16/2026 at 9:00 pm., the note indicated that “at approximately 1904 (7:04 p.m.), patient (Patient 11) was found in her room sitting at the edge of the bed with a ripped bedsheet tied around her neck. Staff were present and were able to loosen the sheet enough to fit fingers between the sheet and the patient’s neck. The sheet was removed from the patient’s neck immediately ...The internist (a physician who specializes in diagnosing and treating medical conditions) was called and ordered neuro-checks (regular neurological checks that look at how awake the patient is, how they respond, and whether their brain is working normally) every 4 hours for 24 hours ...” During an interview on 2/20/2026 at 1:41 p.m. with charge nurse (CN 7), CN 7 said that the neuro?check record was not filed in the medical record. CN 7 said the purpose of the neuro-checks was “to ensure that the patient is not altered (an unexpected change in mental function, awareness, or behavior compared to the patient’s established baseline) and to ensure patient safety and send her (Patient 11) out (to another hospital for evaluation and treatment) if needed.” During a concurrent interview and record review on 2/20/2026 at 4:03 p.m. with charge nurse (CN 7), at the nurses’ station, CN 7 said that Patient 11’s neuro-check record, dated 2/16/2026, was found and reviewed the record with the surveyor. The neuro-check record indicated that on 2/16/2026, neuro-check documentation started at 7:00 p.m. (according to the nursing note, dated 2/16/2026, Patient 11 was found in her room at 7:04 p.m.) and the neuro-check assessments were documented as completed at 11:00 p.m. (2/16/2026), then on 2/17/2026 at 1:00 a.m., 5:00 a.m., 9:00 a.m., and 1:00 p.m. There was no time documented for the last neuro-check. The 9:00 p.m. time (for 2/17/2026) was crossed out in error, and the appropriate documentation of the neuro-check time, replacing the omitted 9 p.m. entry, was not provided. The 1:00 p.m. documentation also did not contain the signature of the person who performed the assessment. This finding was confirmed by CN 7. During a review of the facility’s policy titled “Assessment and Reassessment,” dated 7/2025, the policy indicated that: “Each patient is reassessed daily and as the patient’s condition or needs require by an RN. More frequent monitoring may be ordered by the physician, including, but not limited to, detoxification assessments, neurological checks... . Reassessment is done to determine the patient’s response to treatment and the need for further interventions. Reassessment is done when a significant change occurs in the patient’s diagnosis, medical status, or presenting condition.” 3. During a review of Patient 13’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 10/11/2025, the “psych eval” indicated, Patient 13 was admitted to the facility on 10/10/2025 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 and treatment) for danger to self for overdosing (when a person consumes a toxic amount of a substance such as prescription medications or alcohol) on medications after having an argument with family members. The Psych Eval also indicated that Patient 13 was admitted with diagnosis 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) with psychotic features (delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary] and hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste]), severe recurrent (occurring often or repeatedly), without psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality). During a review of Patient 13’s “Daily Progress Note (psychiatrist note),” dated 10/13/2025, the “Daily Progress Note” indicated, Patient 13 was started on duloxetine (medication to treat depression, anxiety and various pain conditions) and discontinued escitalopram (medication to treat depression and anxiety) because Patient 13 refused to take escitalopram. During a review of Patient 13’s “Physician Medication Order,” dated 10/13/2025, the “Physician Medication Order” indicated, on 10/13/2025, physician (MD 4) ordered duloxetine 30 milligrams (mg, unit of measure) every morning by mouth starting 10/14/2025. During an interview on 2/17/2026 at 10:37 a.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated patients had rights to refuse taking psychotropic medication. LVN 2 further stated when a patient refused to take medication, the nurse must document and notify the psychiatrist. During a concurrent interview and record review on 2/19/2026 at 2:13 p.m. with the Nurse Manager (NM 1), Patient 13’s “Medication Administration Record (MAR, record of medications given to patients),” dated from 10/14/2025 to 10/16/2025, was reviewed. The “MAR” indicated, duloxetine 30 mg was not given on 10/14/2025 and 10/15/2025 with reason of “patient (Patient 13) refused.” The “MAR” also indicated, duloxetine 30 mg was not documented as given on 10/16/2025. NM 1 stated Patient 13 did not receive duloxetine on 10/14/2025, 10/15/2025 and 10/16/2025 (total of 3 days). During a concurrent interview and record review on 2/19/2026 at 2:31 p.m. with NM 1, Patient 13’s “Daily Nurse Progress Notes (nurse assessment),” dated from 10/14/2025 to 10/16/2025, was reviewed. The “Daily Nurse Progress Notes” indicated, “Medical assessment ... Medication compliance: as prescribed.” NM 1 stated “as prescribed” meant the patient (Patient 13) was compliant with taking medications as ordered by the physician. NM 1 further stated, the assessment documented on the daily progress note was not correct for Patient 13 because Patient 13 had been refusing to take duloxetine (Patient 13 refused Duloxetine for three days on 10/14/2026, 10/15/2026, and 10/16/2026). NM 1 further stated Patient 13 was non-compliant with the psychotropic medications (Duloxetine). NM 1 also said there was no documentation about the physician being notified regarding Patient 13’s refusal to take duloxetine (for three days from the date the medication was ordered on 10/13/2026). During an interview on 2/20/2026 at 2 p.m. with the Medical Director (MD 1), MD 1 stated it was a fail-safe mechanism (system to limits damage or harm) for nurses to report to provider when a patient refused a psychotropic medication. MD 1 further stated if patients were not taking medications as prescribed, they (the patients) would not get better. During an interview on 2/20/2026 at 2:39 p.m. with Charge Nurse (CN 7), CN 7 stated nurses should notify the physician every time a patient refused to take the psychotropic medication. CN 7 stated the refusal of psychotropic medication should be documented on a refusal list as well as in the patient’s medical record. CN 7 stated the psychiatrist needed to know that the patient was refusing the medication so that the psychiatrist could address it by talking to the patient, providing more education or changing the medication regimen. CN 7 further stated, if the psychiatrist was not informed, the psychiatrist would assume patient was taking the medication as ordered. During an interview on 2/20/2026 at 3:06 p.m. with Registered Nurse (RN 3), RN 3 stated it was the facility’s practice to notify the physician every time a patient refused to take the psychotropic medication and to document so that the team could keep track of how many times the patient had refused to take the medication. RN 3 further stated if patients were not taking medication as prescribed, their mental illness would not be managed, could return to previous behavior and would come back to the hospital. During an interview on 2/20/2026 at 3:20 p.m. with Director (DIR 1) of Risk Management, DIR 1 stated there was no facility policy or protocol covering the process of what nurses should do when a patient refused taking psychotropic medication. During an interview on 2/25/2026 at 10:58 a.m. with the Chief Nursing Officer (CNO), the CNO stated it was a nursing responsibility to notify the physician that a patient refused to take the prescribed psychotropic medications. CNO further stated that the physician needed to know so that the physician could evaluate the patient if there was a need for a Riese hearing (a capacity hearing to determine whether one can refuse treatment with medications) to ensure medication compliance. During a review of Patient 13’s “Discharge Summary,” dated 10/17/2025, the “Discharge Summary,” indicated Patient 13 was placed on duloxetine 30 mg by mouth every morning per Patient 13’s preference. The “Discharge Summary” also indicated, “medication response: patient (Patient 13) took medications ...” The “Discharge Summary” also indicated, Patient 13 was discharged home on 10/16/2025 with prescription of thirty-day supply of duloxetine. During a review of the facility’s policy and protocol (P&P) titled, “Nursing Assessment and Reassessment of Patient,” dated 7/2025, the P&P indicated, “An effective and comprehensive nursing assessment of each patient’s needs is made in order to determine and provide an optimal level of nursing care ... Reassessment is done to determine the patient’s response to treatment and need for further interventions.” During a review of the facility’s policy and procedure (P&P) titled, “Chain of Command,” dated 5/2025, the P&P indicated, “The Hospital will have a process in which patient care/treatment conflicts and emergencies are resolved ... 1. Charge Nurse will Nursing Leader or their designee (House Supervisor) of the specific treatment issue or emergency need, Nursing Leader will provide consultation to Charge Nurse of the steps to be employed. Nursing Leader will provide oversight to the process. 2. For psychiatric need: a. Attending Psychiatric Physician will be notified; if unavailable, first the Unit Medical Director, and then Hospital Medical Director until assistance is secured.””

“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: 46333 Based on observation, interview, and record review, the facility failed to ensure the nursing staff developed and kept current a nursing care plan (a structured, written document that outlines a personalized, holistic approach to a patient’s care) that reflected the patient’s nursing care needs for one (1) of 32 sampled patients (Patient 1). On 1/28/2026 at 4:15 p.m., Patient 1 was assessed using the Columbia Suicide Severity Rating Scale (C-SSRS, a standardized suicide [the act of causing one’s own death]-risk screening tool) and received a score of 24, the highest-risk category. The Nursing Admission Assessment indicated the intervention “Bathroom Supervision (continuous staff presence while a patient uses the bathroom to prevent self-harm).” The intervention regarding bathroom supervision was required based on the assessment findings (on the C-SSRS), but it (the bathroom supervision intervention) was not included in the interdisciplinary Treatment Plan (a collaborative, patient-centered roadmap created by a team of experts-including psychiatrists, nurses, social workers, and therapists-to address a patient’s comprehensive mental, physical, and social needs), and there was no documentation explaining why the intervention regarding bathroom supervision was omitted. As a result, the nursing care plan did not include an intervention identified as necessary during Patient 1’s admission. This deficient practice resulted in the nursing care plan not having included the suicide-risk intervention, regarding bathroom supervision, which was identified by nursing staff for Patient 1. Without the intervention (on bathroom supervision) documented in the plan of care, nursing staff lacked a plan-based direction for providing the required supervision during bathroom use, creating the potential for unmonitored bathroom access and exposure to ligature (any fixture or objects in an environment that could be used to anchor a cord, rope, or clothing for strangulation or hanging)-related harm for Patient 1 and for other patients whose assessed interventions are not incorporated into their plans of care. Findings: During a review of Patient 1’s “Initial Psychiatric evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]), “dated 1/29/2026, the evaluation note indicated, Patient 1 was brought to the facility on a 5150 hold (an involuntary psychiatric detention under California law) due to attempting to jump off a cliff, and had attempted suicide (the act of causing one’s own death) by strangulation (application of external pressure to the neck of a patient, resulting in the obstruction of blood vessels or airways) shortly after admission on 1/28/2026. During a record review of Patient 1’s “Nursing Admission Assessment,” dated 1/28/2026 at 4:15 p.m., the assessment using the C?SSRS (Columbia Suicide Severity Rating Scale, a standardized suicide-risk screening tool) indicated that Patient 1’s C-SSRS score was 24 (highest risk) with documented indication of active suicidal ideation (plan to self-harm), intent, and a plan. The Interventions section following the high risk for suicide score was documented by nursing staff as “Bathroom Supervision (continuous staff presence while a patient uses the bathroom to prevent self-harm).” During an interview on 2/17/2026 at 10:46 a.m. with Registered Nurse (RN 9), RN 9 stated that suicide-risk interventions documented on admission were required to be included in the plan of care to ensure staff were aware of the precautions (such as suicide precautions) to be implemented. During an interview on 2/17/2026 at 10:55 a.m. with the Nurse Manager (NM 6), NM 6 stated that the nursing care plan should include suicide-risk interventions and should be updated based on the assessment. During a concurrent observation, interview, and surveillance record review on 2/19/2026 at 11:03 a.m. with \the Director of Risk Management (DIR 1), in the unit conference room, the surveillance footage, dated 1/28/2026 from 10:48 p.m.-12:00 a.m., was reviewed. The video displayed timestamped staff entries and exits from Patient 1’s doorway. DIR 1 confirmed that Patient 1 was not placed on Bathroom Supervision and that staff were performing only standard 15?minute observation rounds (check on patients every 15 minutes to monitor their location, safety, and well-being). During a concurrent interview and record review on 2/18/2026 at 3:12 p.m. with Nurse Manager (NM 5), Patient 1’s “Master Treatment Plan,” dated 1/28/2026, was reviewed. NM 5 confirmed that “Bathroom Supervision” was not included in the plan of care. Patient 1’s “Master Treatment Plan,” dated from 1/28/2026 to 1/29/2026, indicated there was no documentation explaining its absence (the lack of documentation regarding bathroom supervision), no reassessment, and no indication that the intervention (regarding bathroom supervision) was evaluated for inclusion in the Master Treatment Plan. NM 5 confirmed that no additional documentation existed that addressed the “Bathroom Supervision” intervention, its rationale (reason or basis), its implementation, or any reason for its omission. During the same concurrent interview and record review on 2/18/2026 at 3:12 p.m. with NM 5, Patient 1’s “Round Sheet (a paper or electronic log used by mental-health staff to document required observation checks at assigned intervals, such as every 15 minutes, including the patient’s location, activity, and safety status),” dated 1/28/2026 to 1/29/2026, was reviewed. The Round Sheet indicated entries documenting 15-minute safety observations, with no documentation of continuous staff presence during bathroom use of Patient 1, and no documentation explaining why the admission-identified intervention regarding bathroom supervision was not carried into the care plan. NM 5 stated the Round Sheet indicated that after Patient 1 returned from the emergency department (for evaluation following a suicide attempt by strangulation on 1/28/2026), Patient 1 was placed on one-to-one (1:1) supervision (continuous one staff to one patient supervision); however, this post-incident assignment of 1:1 supervision for Patient 1 was not in the pre-incident (of suicide attempt by strangulation) nursing care plan as “Bathroom Supervision,” and no rationale for the earlier omission was documented. During a review of the facility’s policy and procedure (P&P) titled “Nursing Assessment and Reassessment of Patients,” dated July 2025, the P&P indicated, “The RN determines and prioritizes the nursing care needs ... The assessment includes the collection and analysis of data about the patient to determine the patient’s care needs, and the care to be provided.” During a review of the facility’s policy and procedure (P&P) titled “Active and Individualized Treatment,” dated February 2026, the P&P indicated, “Active Treatment interventions identified in the Master Treatment Plan and Treatment Plan Updates are delivered to patients and documented in each patient’s record in such a manner as to assure all active therapeutic efforts are included.””

“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: 48212 Based on observation, interview and record review, the facility failed to: 1. Ensure its staff conducted standard rounding (Q15-min rounding, refer to patient safety rounds [scheduled checks performed by staff at regular intervals, such as every 15 minutes, to monitor patient location, behavior, and overall safety, ensuring that precautions are in place to prevent harm to the patient or others]) every fifteen (15) minutes and identified any contraband (prohibited, banned) items, including linens, in accordance with the facility’s policy regarding patient rounds and contraband checks for its psychiatric (mental illness) patients. Staff did not conduct Q15 min rounding on one of 32 sampled patients (Patient 11) for 38 minutes on 2/16/2026 from 6:24 p.m. to 7:02 p.m. Patient 11 was then found with a ripped flat sheet tied around her (Patient 11’s) neck. This deficient practice had the potential to result in Patient 11 suffering from severe injuries and/or death. 2. Ensure its staff separated one of 32 sampled patients (Patient 12, the victim) from another patient (Patient 26, the perpetrator), in accordance with the facility’s policy regarding patient precautions, when Patient 12 and Patient 26 were still assigned to the same room after Patient 12 was physically assaulted (physical attack) by Patient 26 on 9/10/2025. Patient 12 was hit on the back of head five (5) times as per patient (Patient 12), on the right temple (right side of the head between forehead and ear), chin, and nose. This deficient practice resulted in Patient 12 experiencing anxiety (a feeling of fear, unease, and restlessness) when seeing Patient 26, thus putting Patient 12 at risk of additional emotional distress. 3. Ensure nursing staff performed a suicide risk assessment (a daily check that evaluates whether a patient has thoughts or behaviors showing they may try to harm themself) on 2/17/2026, for one of 32 sampled patients (Patient 11), as required by the facility’s policy for SI screening (SI means suicidal ideation, which refers to thoughts of wanting to harm or kill oneself). This deficient practice had the potential to result in Patient 11 experiencing another self?harm attempt that could have gone unnoticed, especially because Patient 11 had attempted suicide (act of causing one’s own death) in the facility on 2/16/2026 around 7 p.m. On 2/24/2026 at 9:21 a.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 Executive Officer (CEO) and the Regional Vice President (RVP). The facility failed to ensure its nursing staff conducted standard every fifteen (Q15) minutes patient rounding (a high-frequency safety protocol in behavioral health and psychiatric settings where staff observe and document each patient’s location, safety status, and activity every 15 minutes) on 2/16/2026 at 6:30 p.m. and at 6:45 p.m. and identify any contraband (prohibited, banned) items, including linens, as per facility’s policy on its psychiatric (mental illness) patients. Staff did not conduct Q15-min rounding on Patient 11 for 38 minutes (min) on 2/16/2026 from 6:24 p.m. to 7:02 p.m. Patient 11 was then found with a ripped flat sheet tied around her (Patient 11’s) neck. Patient 11 was admitted to the facility’s Youth Services (inpatient Behavioral Health Unit [inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders] servicing patients age 13 to 17) on 1/27/2026 for evaluation of mood state and self-harm behavior. Patient 11 reportedly had a history of suicide (the act of intentionally causing one’s own death) attempt by hanging and jumping from a bridge. Patient 11 was placed on linen restriction per physician order on 1/28/2026. Nurse Manager (NM 2) of Youth Services stated patients with linen restriction order were only allowed to have one blanket and one pillow, any extra linens would be taken away. Upon reviewing the facility’s security footage, date-stamped 2/16/2026 from 6 p.m. to 7:02 p.m., with the Director (DIR 1) of Risk Management, Patient 11 was seen in her (Patient 11’s) room and there was no staff who rounded on Patient 11 from 6:24 p.m. to 7:02 p.m. for a total of 38 minutes. Charge Nurse (CN 1) of Youth Services stated Patient 11 was found crying, by the evening shift charge nurse, with linens tied around her (Patient 11’s) neck on 2/16/2026 around change of shift (around 7 p.m.). CN 1 stated Patient 11 knotted the ripped flat sheet and tied it to her (Patient 11’s) neck. The failure to perform Q15-min rounding resulted in staff not being able to identify contraband items and remove them from patients thus putting patients at risk for self-harm or harm to others leading to serious injuries. On 2/25/2026 at 1:42 p.m., the IJ was removed in the presence of the Chief Executive Officer (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 by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that for immediate action taken by the facility, the facility has revised and implemented the “Patient Observation Rounds Level of Observation Policy” to strengthen suicide-prevention practices, including requiring one-to-one (1:1) observation for patients identified as high risk through the “Columbia Lifetime Suicide Risk Assessment (an evidence-based tool used to identify and assess an individual’s risk for suicide across their entire life span).” Based on the RN’s assessment at admission and daily thereafter, the attending physician reviews findings and determines the need for linen restrictions, which limit the patient to a “Suicide Risk Linen Bundle” consisting of two paper gowns, one pair of facility socks, one disposable pillow, and one safety blanket, exchanged on a one-for-one basis when soiled. Linen restrictions remain in effect until the physician assesses the patient in person and documents discontinuation. Staff are required to visually inspect patients and their immediate environment during assigned rounding intervals for ligature-risk (any fixture or objects in an environment that could be used to anchor a cord, rope, or clothing for strangulation or hanging) contraband items and remove and report any findings to the Registered Nurse (RN). Rounding sheets (records used by staff to document patient checks every 15 minutes to ensure continuous safety monitoring) have been updated to include linen restriction documentation, and all nursing staff, licensed nurses, and Mental Health Technicians (MHTs) have been trained on the revised policy and the new “Standard Operating Procedure” starting 2/24/2026. Staff absent on 2/24/2026 would be trained at the beginning of their next worked shift. The revised policy reinforces that patient observations must be documented in real time, conducted at least every 15 minutes, and performed within the patient’s room close enough to confirm identity and respirations of patients. Additionally, interventions identified through the “Columbia Lifetime Suicide Risk Assessment” must be incorporated into the patient’s individualized treatment plan, including the date and time of interventions, modality and focus, patient response, and progress toward goals. Registered Nurses are responsible for communicating linen restriction status during shift report, documenting it in the Kardex (a quick-reference tool that summarizes a patient’s current care plan, medications and medical history), updating rounding sheets, and performing two oversight reviews per shift, with sign-off on the Q15-min rounding sheet to ensure compliance. Findings: 1. During a review of Patient 11’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 1/27/2026, the “psych eval” indicated, Patient 11 was admitted to the facility’s Youth Services (inpatient Behavioral Health Unit [inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders] servicing patients age 13 to 17) for evaluation of mood state and self-harm behavior. The initial psych eval also indicated, Patient 11 reportedly had a history of suicide (the act of intentionally causing one’s own death) attempt by hanging and jumping from a bridge. During a review of Patient 11’s “Master Treatment Plan (a comprehensive, individualized, and written document outlining a patient’s diagnosis, treatment goals, and therapeutic interventions),” finalized on 1/28/2026, the “Master Treatment Plan” indicated, “Problem Name: Linen Restriction with history of attempting to hang herself (Patient 11) ... had one blanket and one pillow.” During a review of Patient 11’s physician order (orders written by physicians to direct care and treatment), dated 1/28/2026, the physician order indicated, “misc. (miscellaneous [mixed, other]) nursing - linen restriction.” During a review of Patient 11’s “progress notes (nursing note),” dated 2/16/2026, the “progress notes” indicated, “at approximately 1904 (7:04 p.m.) patient (Patient 11) was seen in her (Patient 11’s) room at the edge of her (Patient 11’s) bed with her (Patient 11’s) sheet ripped and tied around her (Patient 11’s) neck. Staff was present and able to loosen sheet and fit fingers between the sheet and her (Patient 11’s) neck. The sheet was removed from her (Patient 11’s) neck immediately.” During an interview on 2/17/2026 at 11:01 a.m. with Charge Nurse (CN 1), CN 1 stated Patient 11 was found crying by the evening shift charge nurse on 2/16/2026 during rounding and Patient 11 had linens tied around her (Patient 11’s) neck. Patient 11 was agitated (feeling of irritability or severe restlessness) and combative. CN 1 stated Patient 11 knotted the ripped flat sheet and tied it to her (Patient 11’s) neck. During an interview on 2/23/2026 at 11:18 a.m. with Nurse Manager (NM 2) of Youth Services, NM 2 stated she (NM 2) was made aware of the incident on 2/17/2026 during morning shift report. She (NM 2) had spoken with Patient 11 regarding the incident but Patient 11 did not tell her (NM 2) what happened. NM 2 spoke with CN 1 but did not talk to other staff. NM 2 reported the incident to Chief Nursing Officer (CNO) the same morning of 2/17/2026. NM 2 was unable to give any information regarding the investigation status of the incident involving Patient 11. During a concurrent interview and record review on 2/23/2026 at 11:39 a.m. with NM 2, Patient 11’s physician order, dated 1/28/2026, was reviewed. The physician order indicated, “misc. nursing - linen restriction.” NM 2 confirmed Patient 11 had a physician order for linen restriction since 1/28/2026. NM 2 stated patients with linen restriction were only allowed to have one blanket and one pillow, any extra linens would be taken away. NM 2 stated NM 2 did not know how Patient 11 got a hold of the flat sheet. During an interview on 2/23/2026 at 11:43 a.m. with NM 2, NM 2 stated all nursing staff including charge nurses, nurses and Mental Health Technicians (MHTs) were responsible to ensure patients were compliant (to follow) with linen restriction. NM 2 also said that Staff should remove the extra linens whenever they see patients in possession of extra linen. During a concurrent observation, interview, and surveillance video review on 2/23/2026 at 2:41 p.m. with the Director (DIR 1) of Risk Management, the facility’s security footage, date-stamped 2/16/2026 from 6 p.m. to 7:02 p.m., was reviewed. In the security footage, Patient 11 was seen in her (Patient 11’s) room and no staff rounded on Patient 11 from 6:24 p.m. to 7:02 p.m. for a total of 38 minutes. DIR 1 stated standard rounding (Q15-min rounding, refer to patient safety rounds [scheduled checks performed by staff at regular intervals, such as every 15 minutes, to monitor patient location, behavior, and overall safety, ensuring that precautions are in place to prevent harm to the patient or others]) was to be performed by staff every 15 minutes. During an interview on 2/24/2026 at 12:05 p.m. with Nurse Manager (NM 5), NM 5 stated the assigned Mental Health Technicians (MHTs) should conduct rounding on all patients every fifteen (15) minutes. NM 5 further stated the purpose of Q15-min rounding was to ensure patient safety. NM 5 also said the assigned MHTs would check on patients to make sure patients were not doing anything inappropriate and to make sure there were no contraband (prohibit, banned) items in the patient rooms. During a review of the facility’s policy and procedure (P&P) titled, “Supervision of Patients/Patient Rounds,” dated 7/2025, the P&P indicated, “All patients require supervision and rounds, are conducted continuously with each patient’s location, and behavior documented every 15 minutes ... the staff member assigned to Rounds is to ... identify and report any findings while conducting observation rounds: contraband or physical plant damage ... report any findings to the charge nurse.” During a review of the facility’s policy and procedure (P&P) titled, “Contraband,” dated 8/2026, the P&P indicated, “to enhance safety by identifying and preventing dangerous items (contraband) from entering into the therapeutic environment and to prevent patients from injuring themselves or others ... the following items are considered CONTRABAND and are NOT allowed on the Units ... pillows, blanket, linens, stuff animals ...” During a review of the facility’s policy and procedure (P&P) titled, “Active and Individualized Treatment,” dated 2/2026, the P&P indicated, “1. Active Treatment interventions are to be developed by the treatment team in coordination with the patient, based on the patient’s assessed needs, and documented in the Master Treatment Plan and subsequent Treatment Plan Updates ... 2. Active Treatment interventions identified in the Master Treatment Plan and Treatment Plan Updates are delivered to patients and documented in each patient’s record in such a manner as to assure all active therapeutic efforts are included ... 4. Progress notes are recorded by the group leader and address: active treatment modalities, assessment, intervention, evaluation of the effectiveness of the intervention, progress towards treatment plan goals ... 9. The treatment team will review and revise the treatment plan as often as needed, but at a minimum every seven (7) days.” 2. During a review of Patient 12’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 9/10/2025, the “psych eval” indicated, Patient 12 was admitted to the facility on 9/9/2025 on a 5585-hold (allows a minor [under 18 of age] 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 by taking six to seven Ativan (medication to manage severe anxiety) tablets. The psych eval also indicated Patient 12 had an admitting diagnosis of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 26’s “Initial Psychiatric Evaluation (psych eval),” dated 9/10/2025, the “psych eval” indicated, Patient 26 was admitted to the facility on 9/9/2025 on 5585-hold for danger to self and danger to others with diagnoses including but not limited to depressed mood (feeling of sadness, tearfulness, or hopelessness) and disruptive mood dysregulation disorder (DMDD, a childhood condition characterized by severe, chronic irritability and frequent, intense temper outbursts [verbal or physical] that are disproportionate to the situation). During an interview on 2/20/2026 at 11:32 a.m. with Nurse Manager (NM 2) of Youth Services (inpatient Behavioral Health Unit [inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders] servicing patients age 13 to 17), NM 2 stated that after a patient-to-patient altercation (patient-to-patient aggression) occurred, both patients (victim and perpetrator [aggressor]) would be separated and not allowed to be placed in the same room to prevent another altercation (verbal argument that can easily escalate into a physical fight) from happening. NM 2 further stated the victim might feel uneasy and scared when seeing the perpetrator. During a concurrent interview and record review on 2/20/2026 at 11:38 a.m. with NM 2, Patient 12’s “Progress Record (nurse note),” dated 9/10/2025, was reviewed. The “Progress Record” indicated, “at 1745 (5:45 p.m.), while eating dinner at the cafeteria, patient (Patient 12) was attacked by another male patient (Patient 26) unprovoked (not caused by anything done or said). Patient (Patient 12) was hit on the back of head five (5) times as per patient (Patient 12), on right temple (right side of the head between forehead and ear), chin, and nose.” The “Progress Record” also indicated, Patient 12 was sent to another facility emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) for further care. NM 2 stated Patient 12 was the victim and Patient 26 was the perpetrator. During a review of Patient 12’s “Out of Hospital Consultation Report (consultation report completed by the outside facility ED physician),” dated 9/10/2025, the consultation report indicated, Patient 12 had nasal (nose) swelling and bruising, tenderness to nose, left elbow, and abrasion at right lower leg. The consultation report also indicated Patient 12 had a non-displaced fracture (a stable broken bone) at nasal (nose) bone per the X ray (an imaging procedure to create detailed image of the body’s internal structure such as bones, tissues and organs) report. During a concurrent interview and record review on 2/20/2026 at 11:42 a.m. with NM 2, Patient 12’s “Progress Record (nurse note),” dated 9/11/2025, was reviewed. The “Progress Record” indicated, Patient 12 returned from outside emergency department and informed the nurse “I (Patient 12) feel fine now. Did you hear what happened? I (Patient 12) hope he (Patient 26) is not in the room with me (Patient 12).” NM 2 stated Patient 12 did not want to be in the same room with Patient 26. During a concurrent interview and record review on 2/20/2026 at 11:48 a.m. with NM2, Patient 12’s and Patient 26’s rounding record (records used by staff to document patient checks every 15 minutes to ensure continuous safety monitoring) titled, “[the facility] Round Sheet (High Risk),” dated from 9/10/2025 to 9/17/2025, were reviewed. Patient 12’s rounding sheet indicated, Patient 12 was in Room (Room 1, bed A) from 9/10/2025 to 9/17/2025. Patient 26’s rounding record indicated, Patient 26 was in Room (Room 1, bed B) from 9/10/2025 to 9/17/2025. NM 2 confirmed that Patient 12 and Patient 26 were in the same room (Room 1) from 9/10/2025 to 9/17/2025. NM 2 stated Patient 12 (the victim) could be in fear and caused him (Patient 12) anxiety being in the same room with Patient 26 (the perpetrator). During a review of Patient 12’s “Daily Progress Note (psychiatrist note),” dated 9/14/2025, the “Daily Progress Note” indicated, “On evaluation today, patient (Patient 12) stated that he (Patient 12) was very anxious last night and almost having a panic attack (a sudden episode of intense fear that triggers [stimulus that causes an intense, involuntary emotional or behavioral reaction, often bringing on or worsening symptoms of a mental health condition] severe physical reactions including fast heart rate, sweating, trembling, breathing difficulties, and sensation of dying or losing control). He (Patient 12) was triggered by one of the other patients (Patient 26) on the unit who had previously hit him (Patient 12) on the nose ... he (Patient 12) saw him (Patient 26) and felt anxious.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Precaution,” dated 8/2025, the P&P indicated, “If an assault occurs: staff will intervene immediately to separate patients ... RN will assess and consult with attending psychiatrist for additional interventions including but not limited to: perpetrator or victim room or unit change, review crisis safety plan, refocus program, medication adjustment, change in observation level, behavioral contract, 1:1 therapy, any other individual interventions after thorough assess of precipitating factors and events.” 3. During a review of Patient 11’s Initial Psychiatric Evaluation (Psych Eval, a formal assessment done by a psychiatrist), dated 1/27/2026, the Psych Eval indicated that Patient 11 was admitted to the facility’s Youth Services unit (an inpatient behavioral health unit for patients ages 13 to 17) after an attempt to overdose on pills (meaning the patient took more medication than was safe or intended in order to harm themselves). During a review of Patient 11’s Nursing Progress Note, dated 2/16/2026, the note indicated that “at approximately 1904 (7:04 p.m.), patient (Patient 11) was found in her room sitting at the edge of the bed with a ripped bedsheet tied around her neck. Staff were present and were able to loosen the sheet enough to fit fingers between the sheet and the patient’s neck. The sheet was removed from the patient’s neck immediately.” During a concurrent interview and record review on 2/20/2026 at 1:43 p.m. with the charge nurse (CN 7), the Columbia Suicide Severity Rating Scale (C-SSRS, a short screening tool that helps staff check whether a patient has thoughts of suicide or behaviors that could lead to self-harm. It identifies the patient’s level of risk so that the right safety steps can be taken) risk assessments for Patient 11, dated 2/15/2026, 2/16/2026, and 2/17/2026, were reviewed. The record indicated the following: -The record (dated 2/15/2026) showed that the C-SSRS risk assessment was completed on both the 7 a.m. to 3 p.m. shift and the 3 p.m. to 11 p.m. shift, and Patient 11 was documented as denying suicidal ideation (SI). -The record for 2/16/2026 showed that the C-SSRS risk assessment was completed during the 7 a.m.to 3 p.m. shift but was not completed during the 3 p.m. to 11 p.m. shift. -The record for 2/17/2026 showed that no C-SSRS risk assessment was completed at all. CN 7 stated that the C?SSRS should have been completed twice a day, not once a day. -CN 7 said that not screening a patient for suicide risk could place the patient in danger. CN 7 further stated that “Without a proper suicide screen, staff may not recognize that a patient is thinking about self-harm.” CN 7 said that the Columbia screen helped identify whether a patient was at low, moderate, or high risk for suicide, so the team could start the right safety steps. CN 7 said that if the suicide risk screen was not done, the team may have missed warning signs, and important interventions, such as increased monitoring or that suicide precautions may not be started. CN 7 also said that this (referring to lack of or incomplete suicide risk screen) could have increased the chance of patient self-harm. During an interview on 2/20/2026 at 4:03 p.m. with the charge nurse (CN 7), CN 7 said that after reviewing the suicide-screening policy, he (CN 7) confirmed that the C?SSRS only needed to be completed once a day, not twice a day. During an interview on 2/24/2026 at 3:04 p.m. with the Nurse Manager (NM 2), NM 2 explained that the Columbia suicide screening (C-SSRS), had to be completed for every patient on admission (the extended version) and then done daily. NM 2 said that if a patient had an incident involving suicide risk, the nurse should have reassessed the patient. NM 2 stated that the screening results helped the nurse decide whether the patient was low, moderate, or high risk for suicide, and this guided the safety measures that were needed. NM 2 explained that if a patient was identified as high risk, the nurse should contact the physician to request for 1:1 monitoring (one staff member stays with one patient at all times), and the patient was checked daily for suicide risk. NM 2 also said that the psychiatrist could start, continue, or stop the 1:1 order based on ongoing assessments. NM 2 also explained that accurate screening was important for patient safety because it helped nurses notice changes in the patient’s condition, which could change quickly, especially for teenagers. During a review of the facility’s policy titled “Assessment for Suicide Risk Potential,” dated February 2025, the policy stated that the facility’s suicide-prevention activities included not only individual patient assessment and care beginning at admission and continuing through discharge, but also organization-wide actions to maintain a safe environment with well-trained staff. The policy further stated that reassessment of suicidality was required daily for any patient placed on suicide precautions.””

“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: 36206 Based on interview and record review, the facility failed to: 1. Administer venlafaxine (a medication used to treat depression [a common, serious mood disorder characterized by persistent sadness, loss of interest in activities, and low energy, lasting for at least two weeks]), as ordered by the physician, for one of 32 sampled patients (Patient 6), in accordance with the physician’s orders and the facility’s policy and procedure regarding medication administration. This deficient practice resulted in Patient 6 not receiving medication on the day it was ordered and resulted in a delay in providing treatment for Patient 6’s depression. 2. Ensure one of 32 sampled patient’s (Patient 27) medication Prazosin (medication used to treat Post Traumatic Stress Disorder [PTSD, mental health condition caused by extremely stressful or terrifying event] related nightmares), was administered in a timely manner, in accordance with the physician’s order and the facility’s policy regarding medication administration. This deficient practice had the potential for Patient 27 to experience a return of severe nightmares due to delayed treatment. 3. Ensure nursing staff notified the physician (medical practitioner responsible for patient care) of a change in condition related to medication administration for one (1) of thirty two (32) sampled patients (Patient 2). After an increased dosage of Risperidone (an antipsychotic medication used to treat mood or thought disorders), Patient 2 reported worsening symptoms, including restlessness (an inability to sit still), inability to sleep (insomnia), and overall deterioration. Nursing staff documented the concern but did not notify the physician and did not document any provider notification, in accordance with the facility’s “Chain of Command” policy (a policy requiring staff to contact the responsible physician when a patient has a medical need or change in condition). This deficient practice had the potential for Patient 2’s symptoms to worsen without timely clinical intervention; delay in adjusting or discontinuing the medication; and unnecessary discomfort or distress. The failure to notify the physician also had the potential to compromise safe medication management and continuity of care (ensuring treatment plans remain consistent and communicated). Findings: 1. During a review of Patient 6’s “Initial Psychiatric History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/12/2024, the H&P indicated the following: Patient 6 was admitted on a 5150 Hold (a 72-hour involuntary hold) for danger to self. The H &P also indicated “Patient (Patient 6) came here, suicidal (thoughts or actions related to killing oneself). Patient (Patient 6) states ...plan to ingest helium (a colorless and odorless gas) to kill herself (Patient 6).” The H&P further indicated that Patient 6’s past medical history included Diabetes mellitus (high blood sugar), admitting diagnosis included major depression (a serious mental health condition causing a persistent, low mood, or a total loss of interest in activities). During a review of Patient 6’s “Physician Medication Orders,” dated 9/12/2024 at 10:01 a.m., the Order indicated venlafaxine (a medication used to treat depression) 75 milligrams (mg, a unit of measure) “PO (by mouth) NOW (start at 11 a.m. on 9/12/2024).” During a review of Patient 6’s “Medication Administration Record (MAR),” dated 9/12/2024, the MAR indicated venlafaxine 75 mg was scheduled to be given on 9/12/2024 at 11 a.m. However, the time and date administered was blank, the time and date of administration was not documented. During a concurrent interview and record review on 2/23/2026 at 10:56 a.m. with Registered Nurse (RN) 1, RN 1 stated that the physician ordered venlafaxine to be started for Patient 6 on 9/12/2024 at 11 a.m. RN 1 verified that venlafaxine had not been given to Patient 6 on 9/12/2024. RN 1 stated venlafaxine was used to treat depression. RN 1 further stated that nurses should follow the doctor’s order. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 8/2024, the P&P indicated the following: “Medications shall be prepared and administered in a safe and timely manner by a licensed nursing staff ...Check the HCS (electronic medical record) and validate medications ordered for patients to include name, strength, dose, route and times ...Safely prepare and administer all medications by using the “five rights”: right drug, right dose, right time, right route, and right patient.” 2. During a review of Patient 27’s “Initial Psychiatric Evaluation (Psych eval, a mental health assessment used to diagnose emotional, behavior, and cognitive conditions),” dated 10/28/2025, the psych eval indicated Patient 27 was admitted to the facility on a 5585 hold (72 hour involuntary psychiatric hold for minors under 18 who presents a danger to themselves or others) for danger to self. During a review of Patient 27’s “Physician Medication Orders (an order by a physician to prescribe medication),” dated 10/28/2025, the physician medication order indicated Patient 27 had a physician order for Prazosin 1 milligram (mg, a unit of weight or mass) capsule by oral (mouth) at HS (at bedtime or hour of sleep) to start on 10/28/2025 at 9:00 p.m. with a documented indication for PTSD (Post Traumatic Stress Disorder, mental health condition caused by extremely stressful or terrifying event) nightmares. During a concurrent interview and record review on 2/19/2026 at 2:38 p.m. with Charge Nurse (CN 3), Patient 27’s “Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient),” dated 10/28/2025-10/29/2025, was reviewed. The MAR indicated Prazosin capsule 1mg by oral at bedtime for PTSD-Nightmares to start 10/28/2025 at 9:00 p.m. CN3 confirmed Prazosin was administered to Patient 27 at 10:50 p.m. (1 hour and 50 minutes late) instead of at 9 p.m. as ordered, and there was no additional comment documented for late administration of the medication Prazosin. CN3 stated nurses had a one-hour window to administer this medication after 9:00 p.m., however, it was administered to Patient 27 at 10:50 p.m. During a concurrent interview and record review on 2/19/2026 at 2:47 p.m. with Nurse Manager (NM) 2, Patient 27’s “Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient),” dated 10/28/2025-10/29/2025 was reviewed. NM 2 confirmed Prazosin 1 mg by mouth at bedtime, was administered late on 10/28/2025 at 10:50 p.m. NM 2 highlighted that timely administration of medications was essential to uphold the “five rights” of medication administration practice which included the right time of administration, and nurses had to follow physician orders to stay compliant. NM 2 further said that the nursing expectation was to administer medications on time. During an interview on 2/20/2026 at 12:10 p.m. with NM 2, NM 2 stated Patient 27 had the right to receive medication at times prescribed by the physician. NM 2 further stated that Prazosin was given as part of Patient 27’s treatment regimen to improve sleep and prevent nightmares. During a review of the facility’s policy and procedures (P&P) titled, “Medication Administration, MM-22,” last revised 8/2024, the P&P indicated, “Medication shall be prepared and administered in a safe and timely manner by a licensed nursing staff ...The licensed staff will ensure safe and accurate administration of medication ...Routine medications are administered at the following times (or as specifically ordered by medical practitioner): a. 9:00 A.M. b. 1:00 P.M. c. 5:00 P.M. d. 9:00 P.M ...Safely prepare and administer all medications by using the “five rights”: a. Right drug, b. Right dose, c. Right time, d. Right route, e. Right patient ...” 3. During a concurrent interview and record review on 2/23/2026 at 10:53 a.m. with Nurse Manager (NM 6), Patient 2’s “Progress Note,” dated 12/7/2024, was reviewed. Inside the record was a handwritten message from Patient 2: “The increased dosage of prescribed medicine (Risperidone, an antipsychotic medication used to treat mood or thought disorders) from 1 mg (milligram, a unit of measure) to 2 mg is making me feel harder to sleep, restless, and overall worse. May I please have my usual prescribed medicine.” NM 6 confirmed Patient 2 authored this note on 12/07/2024 and that the medical record contained no documentation that the provider (physician) was notified of these symptoms or of the request to revert to the prior dose. During record review of Patient 2’s provider’s “Daily Progress Note,” dated 12/9/2024, the note indicated, “Patient was seen in the hallway, appears somewhat guarded, has refused medications yesterday. Patient states that he will only take medications if it is at a lower dose.” During a concurrent interview and record review on 2/23/2026 at 11:10 a.m. with NM 6, Patient 2’s Medication Administration Record (MAR, a chart showing when medications were given or refused) for 12/03/2024-12/10/2024, was reviewed. The MAR showed Risperidone was increased from 1 mg to 2 mg on 12/06/2024, with 2 mg administered on 12/06 at 9:20 a.m. and 8:27 p.m., 12/07 at 8:36 a.m. and 8:57 p.m.; and on 12/08/2024, Patient 2 refused the medication. NM 6 confirmed these dates align with Patient 2’s 12/07/2024 report of adverse symptoms. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 8/2024, the P&P indicated the following: “Medications shall be prepared and administered in a safe and timely manner by a licensed nursing staff ...Check the HCS (electronic medical record) and validate medications ordered for patients to include name, strength, dose, route and times ...Safely prepare and administer all medications by using the “five rights”: right drug, right dose, right time, right route, and right patient.” During a review of the facility’s policy and procedure (P&P) titled, “Chain of Command,” dated 5/2025, the P&P indicated the following: To ensure appropriate and timely care is delivered to the patient when situations such as the following arise: Nurse is unable to carry out a physician’s order due to concern over appropriateness for patient ... 3. For medical need: a. Internal Medicine Physician of record or their identified covering Physician will be notified. b. For treatment conflicts, the Attending Psychiatric Physician and Supervising On-Call Internal Medicine Physician will be consulted.”

“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: 1. Ensure medical records included a completed discharge summary (a critical clinical document prepared by healthcare professionals upon a patient’s release, outlining the entire hospital stay. It summarizes the reason for admission, diagnostic results, treatments, medication changes, and follow-up plans, serving as a vital handover tool to ensure safe, continuous care) within thirty (30) days after discharge, for one of 32 sampled patients (Patient 7), in accordance with the facility’s policies and procedures regarding format and content of the medical record. This deficient practice had the potential to compromise the patient’s next level of care, without knowing the summary of the course of the patient’s hospitalization. 2. Ensure its staff documented accurately, on the standard every fifteen (Q15) minute rounding form (records used by staff to document patient checks every 15 minutes to ensure continuous safety monitoring), for one of 32 sampled patients (Patient 11), in accordance with the facility’s rounding policy, when a Mental Health Technician (MHT 8) documented that patient rounding on 2/16/2026 at 6:30 p.m. and at 6:45 p.m., were completed without actually performing the rounding. This deficient practice resulted in Patient 11’s rounding record being inaccurate and failing to represent Patient 11’s actual activity and behavior during that time. This deficient practice also increased Patient 11’s safety risk for undetected condition change, due to lack of patient rounding. Findings: 1. During a review of Patient 7’s “Patient Demographic Profile,” the Profile indicated Patient 7 was admitted to the facility on 9/19/2025 for major depressive disorder (a common, serious mood disorder characterized by persistent sadness, loss of interest in activities, and low energy, lasting for at least two weeks) and was discharged on 9/27/2025. During a concurrent interview and record review on 2/18/2026 at 2:36 p.m. with the Medical Records Manager (MRM), the MRM clarified that the discharge summary (a critical clinical document prepared by healthcare professionals upon a patient’s release, outlining the entire hospital stay. It summarizes the reason for admission, diagnostic results, treatments, medication changes, and follow-up plans, serving as a vital handover tool to ensure safe, continuous care) should be completed by the Psychiatrist within 14 days of a patient’s discharge per the Medical Staff Bylaws (are the legally mandated, governing documents that outline the structure, responsibilities, and rules for physicians and providers within a hospital or healthcare organization. They establish the framework for self-governance, credentialing, peer review, and due process, ensuring quality patient care while defining the relationship between the medical staff and the hospital’s governing board) and Rules and Regulations, and the facility’s policies and procedures. The MRM verified that Patient 7 was discharged on 9/27/2025 and Patient 7’s discharge summary had not been completed. The MRM stated the facility had a tracking system to ensure medical records were completed, however, Patient 7’s medical records had been checked out by someone and Patient 7’s medical records had not been returned to the department (medical records department). The MRM further stated that the medical record was a legal document and should be completed. During an interview on 2/25/2026 at 11:35 a.m. with the Psychiatrist (MD 3), MD 3 stated that the discharge summary should be completed within fourteen (14) days after a patient was discharged. MD 3 stated that the discharge summary was a summary of a patient’s course of treatment while hospitalized. MD 3 further stated that the discharge summary supported and reinforced the patient’s plan of care. MD 3 also said that the discharge summary was for staff and next level providers to review and have a better understanding of the patient’s care. During a review of the facility’s policy and procedure (P&P) titled, “Documentation Standards,” dated 3/2022, the P&P indicated the following: “All clinical personnel authorized to document in the medical record shall adhere to the documentation policies and will receive training to ensure competencies are met ...The medical record is a legal document ...is subject to discipline specific Hospital’s standard ...Service documentation should include ...Discharge Summary.” During a review of the facility’s policy and procedure (P&P) titled, “Format and Content of the Record,” dated 7/2024, the P&P indicated the following: “Purpose: To ensure Hospital meets ...Federal and State and/or hospital policy meets documentation timeframe requirements and provides uniformity in the content of the record ...The content of the medical record shall include, but not limited to, the following ...Discharge Summary: The record of each discharged patient must include a discharge summary of the patient’s hospitalization and recommendations concerning follow-up or aftercare, as well as a brief summary of the patient’s condition on discharge ...All discharge summaries must be authenticated by the attending physician as detailed within the Rules and Regulations of the hospital. All discharge summaries shall be completed within 30 days following the patient’s discharge. Discharge summaries will include the following elements: Reason for admission ... course of treatment ...findings ...patient’s condition and disposition upon discharge ...final diagnosis ...anticipated problems after discharge ... discharge recommendations/instructions ...” During a review of the facility’s “Medical Staff Bylaws Rules and Regulations,” dated 7/2025, the Medical Staff Bylaws Rules and Regulations indicated the following: “Basic responsibilities of medical staff members ...Prepare and complete in a timely manner the medical and other required records for all patients they admit or for whom they provide care in the Hospital.” 2. During a review of Patient 11’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 1/27/2026, the “psych eval” indicated, Patient 11 was admitted to the facility’s Youth Services (inpatient Behavioral Health Unit [inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders] servicing patients age 13 to 17) for evaluation of mood state and self-harm behavior. The initial psych eval also indicated, Patient 11 reportedly had a history of suicide (the act of intentionally causing one’s own death) attempt by hanging and jumping from a bridge. During a review of the facility’s staffing assignment of Youth Services titled, “YS Patient Care Assignment,” dated 2/16/2026, the staffing assignment indicated, Mental Health Technician (MHT 8) was assigned to perform Q15 min rounding (Q15-min rounding, refer to patient safety rounds [scheduled checks performed by staff at regular intervals, such as every 15 minutes, to monitor patient location, behavior, and overall safety, ensuring that precautions are in place to prevent harm to the patient or others]) for the unit from 4 p.m. to 6:45 p.m. on 2/16/2026. During a concurrent observation, interview, and video surveillance review on 2/23/2026 at 2:41 p.m. with the Director (DIR 1) of Risk Management, the facility’s security footage, date-stamped 2/16/2026 from 6 p.m. to 7:02 p.m., was reviewed. Patient 11 was seen in her (Patient 11’s) room and showed that no staff, including MHT 8 (who was assigned to conduct Q 15-min rounding), rounded on Patient 11 from 6:24 p.m. to 7:02 p.m. for a total of 38 minutes. DIR 1 stated standard rounding was supposed to be performed by staff every 15 minutes. During a concurrent interview and record review on 2/23/2026 at 3:20 p.m. with DIR 1, Patient 11’s Q15-min rounding record (records used by staff to document patient checks every 15 minutes to ensure continuous safety monitoring) titled, “[the facility] Round Sheet (High Risk),” dated 2/16/2026, was reviewed. The Q15-min rounding record indicated, patient rounding at 6:30 p.m. and at 6:45 p.m., were completed. The Q15-min rounding record indicated, Patient 11 was observed sitting at 6:30 p.m. and lying at 6:45 p.m., with location indicated as “R” for both times. DIR 1 stated no one performed rounding for Patient 11 at 6:30 p.m. and at 6:45 p.m. per facility’s security footage review. DIR 1 also stated “R” did not match any location code predefined by the facility. DIR 1 stated the location code should be “BR” for bedroom. DIR 1 said the documentation on the rounding sheet was not accurate. During an interview on 2/25/2026 at 10:22 a.m. with the Chief Executive Officer (CEO), the CEO stated that during Q15 min rounding, the staff was expected to observe the patient and document concurrently, otherwise, it was considered as falsification of document. During a review of the facility’s policy and procedure (P&P) titled, “Supervision of Patients/Patient Rounds,” dated 7/2025, the P&P indicated, “All patients require supervision and rounds, are conducted continuously with each patient’s location, and behavior documented every 15 minutes ... the staff member assigned to Rounds is to ... 3. Observe each patient, a minimum of every 15 minutes and document observation (location and behavior) on the patient Rounds sheet at time of observation. Rounds must not begin prior to the specified time. Each set of rounds must be completed within the allotted 15 minutes timeframe ... 6. Document patient location and behavior when the observation occurs on the Rounds Sheet and initial in the appropriate section for your observation.””

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure medical record entries were legible (readable handwriting or text), complete (containing all required information), and authenticated (signed by the person who wrote the entry), in accordance with the facility’s “Documentation Standards” policy, for one (1) of 32 sampled patients (Patient 3). Medical record entries written by the social worker (SW) and psychiatrist (MD-medical doctor) were not legible, contained multiple un-initialed cross-outs (corrections without staff initials indicating who made the change), and lacked clear authorship (inability to determine who wrote the note). This deficient practice had the potential to result in misinterpretation of clinical information (incorrect understanding of the patient’s condition or care), interfere with continuity of care (coordination of care between healthcare providers), and compromise safe discharge planning (ensuring a patient is medically and psychiatrically stable for discharge) for Patient 3. Findings: During a concurrent interview and record review on 02/17/2026 at 3:15 p.m. with Nurse Manager 2 (NM 2), Patient 3’s Social Worker “Progress Notes (documentation of the patient’s clinical status and care),” dated 12/15/2025 at 8:51 a.m. and 10:54 a.m., were reviewed. The entries were not legible (not readable by staff). Multiple cross-outs (handwritten strike-through corrections) were present without initials (no staff identification showing who made the correction). The signature was illegible, and NM 2 stated she could not determine who wrote the notes. NM 2 stated, “I cannot read the note ... It is important that social worker notes are clear as we must facilitate continuity of care, know how the patient was discharged, and ensure a safe discharge.” During a concurrent interview and record review on 02/18/2026 at 2:37 p.m. with the Medical Record Manager (NM 3), Patient 3’s 12/15/2025 discharge ‘Progress Note’ authored by the psychiatrist (MD 1), was reviewed. The note was not legible to NM 3 or surveyors. NM 3 stated, “There must be a progress note at discharge ... This progress note must be readable because it includes instructions for discharge and confirms the patient was medically cleared.” NM 3 confirmed the entry could not be interpreted due to illegibility. During a concurrent interview and record review on 02/19/2026 at 1:50 p.m. with MD 1, Patient 3’s discharge Progress Note, dated 12/15/2025, was reviewed. Although MD 1 verbally explained the content “Patient denies SI/HI (suicide ideation, thought of harming self/homicidal ideation (thoughts of harming others), psychosis (loss of contact with reality) medication side effects,” MD 1 confirmed the written entry was not legible, preventing clinical staff from confirming this information independently. During a review of the facility’s policy and procedure (P&P) titled, “Documentation Standards,” dated 3/2022, the P&P indicated, “Documentation ... will be neat and legible ... Entries shall be signed with the full first and last name of the staff member with their credential ... To correct error: The word ‘error’ shall be written above the entry and initialed by the staff member making the correction.””

“CONTENT OF RECORD: CONSULTATIVE RECORDS CFR(s): 482.24(c)(4)(iii) [All records must document the following, as appropriate:] Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. This Standard is not met as evidenced by: 46238 Based on interviews and record reviews, the facility failed to ensure the medical record contained the results of consultative evaluations by Internal Medicine physicians for two of 32 sampled patients (Patient 11 and Patient 18) following a significant medical event when: 1. The Internal Medicine physician (a physician responsible for evaluating and treating medical health issues in a psychiatric hospital) did not document the consultative evaluation for the assessment of Patient 18’s skin injury, which was sustained after a fall in the shower on 11/27/2024, in accordance with the facility’s Medical Bylaws (are the legally mandated, governing documents that outline the structure, responsibilities, and rules for physicians and providers within a hospital or healthcare organization. They establish the framework for self-governance, credentialing, peer review, and due process, ensuring quality patient care while defining the relationship between the medical staff and the hospital’s governing board) pertaining to timely completion of required medical records. This deficient practice regarding lack of documentation had the potential for the clinicians not to be able to track the progress of Patient 18’s skin injury leading to possible missed infection, improper treatment plan, and poor continuity of care. 2. The Internal Medicine physician did not complete a progress note, in accordance with the facility’s Medical Bylaws, for Patient 11, who was found with a ripped bed sheet tied around her (Patient 11) neck in an attempt to strangle herself on 2/16/2026. This deficient practice compromised Patient 11’s health and safety because no medical evaluation was completed to rule out hidden neck injuries, breathing difficulties, or other medical complications that can occur after a strangulation attempt. Findings: 1. During a review of Patient 18’s Initial Psychiatric Evaluation (Psych Eval, a formal assessment done by a psychiatrist), dated 11/5/2024, the Psych Eval indicated that Patient 18 was admitted on a hold due to danger to others (meaning the patient’s behavior or statements indicated that they posed a risk of causing harm to another person and required involuntary psychiatric evaluation for safety) and was diagnosed with bipolar disorder (a mental health condition that causes significant shifts in mood, energy, and activity levels, resulting in alternating periods of elevated or irritable mood [mania- extreme emotional highs or hypomania- extreme emotional lows] and periods of depression [a serious mental health condition causing a persistent, low mood, or a total loss of interest in activities]). During a review of Patient 18’s Nursing Admission Assessment, dated 11/25/2024, the record indicated that Patient 18 was admitted to the facility with no skin issues or injuries noted. During a concurrent interview and record review on 2/18/2026 at 2:37 p.m. with registered nurse (RN 1), Patient 18’s medical record, titled “Nursing Note,” indicated that on 11/27/2024, Patient 18 fell in the shower and sustained a skin injury (the skin was scraped off, and visible blood was shown in the photograph). The photograph did not include a description of the side of the body involved (left or right), and the nursing note indicated that the nurse applied antibiotic ointment (a medicated topical cream used to prevent infection in minor wounds) to the wound per the physician’s order and placed a dressing. RN 1 stated that, based on the documentation, the nurse notified the physician about Patient 18’s skin injury. RN 1 did not provide a comment regarding the lack of documentation describing the side of the wound or the absence of a complete wound assessment. During a review of Patient 18’s Nursing Note, dated 11/28/2024, the note indicated that on 11/28/2024, registered nurse (RN), reassessed Patient 18’s wound and encouraged to comply with antibiotic ointment and dressing changes to prevent infection. During a concurrent interview and record review on 2/18/2026 at 3:30 p.m. with registered nurse (RN 1), Patient 18’s medical record for the admission on 11/25/2024, was reviewed to locate an Internal Medicine physician note regarding Patient 18’s skin wound evaluation sustained after a fall on 11/27/2024. RN 1 stated that there was no Internal Medicine note in Patient 18’s medical record. RN 1 explained that the expectation for nursing staff was to notify the physician, and that the physician should have seen and evaluated the patient (Patient 18) after the fall on 11/27/2024. RN 1 also confirmed that there were no physician orders entered for skin care, including triple antibiotic ointment and dressing changes, and further confirmed that nurses required a physician’s order to apply triple antibiotic ointment to a patient. During an interview on 2/20/2026 at 3:35 p.m. with the nurse practitioner (NP 2, Internal Medicine), NP 2 stated that Internal Medicine progress notes typically included the patient’s report, any complaints the patient had for the day, and a full body assessment. NP 2 stated that anything new about the patient, such as a newly sustained skin injury or wound, should be documented in the progress note, along with whether the patient was improving or not. NP 2 also said that progress notes included the patient’s vital signs, medical diagnoses, and the plan for treatment or monitoring. During an interview on 2/24/2026 at 3:09 p.m. with the internist (MD 2), MD 2 stated that an Internal Medicine physician was expected to evaluate a patient after an incident or an injury such as a skin wound from a fall. MD 2 explained that Internal Medicine providers were available onsite during daytime hours and would normally have assessed the patient on the same day if a transfer to a higher level of care (meaning transfer to an emergency department or medical hospital for advanced diagnostic evaluation or treatment) had not been required. MD 2 explained that timing could have affected when the progress note appeared in the record, but the expectation was that an assessment was conducted either immediately after the patient returned from evaluation or within the same day. MD 2 stated that ongoing recommendations were based on the findings, such as wound care, suture removal, or other medical precautions. During the same interview on 2/24/2026 at 3:09 p.m. with the internist (MD 2), MD 2 said that the physician progress notes were important because Internal Medicine served as a consulting service. MD 2 said that progress notes must include the patient’s medical condition, any acute concerns, and the rationale for medical decisions. MD 2 stated that documentation also supported communication with both the medical team and the psychiatric team, ensuring they were aware of any medical risks or precautions the patient might require. MD 2 said that progress notes should be filed within 24 hours, but in practice, documentation had been done much sooner. During a review of the facility’s policy and procedure titled “Documentation Standards,” dated 3/2022, the policy indicated that services were to be charted immediately or within eight hours following completion. During a review of the facility’s “Medical Staff Bylaws Rules and Regulations,” dated 7/2025, the Medical Staff Bylaws Rules and Regulations indicated the following: “Basic responsibilities of medical staff members ...Prepare and complete in a timely manner the medical and other required records for all patients they admit or for whom they provide care in the Hospital”. During a complaint validation survey conducted from 2/17/2026 through 2/25/2026, the facility was asked to provide its policy for skin injury assessment, prevention, and management. The facility did not provide a skin?injury prevention or skin?care policy for review, nor did the facility confirm that such a policy did not exist. During a review of the facility’s policy titled, “Format and Content of the Record,” dated 7/2024, the policy indicated that the credentialed medical staff performs the consultation reports. The consultation reports performed by PAs and NPs are co-signed by the supervising physician, and the attending physician signs the report after review. The content of the consultation report will contain the following: CONSULTING PHYSICIAN REASON FOR CONSULTATION FINDINGS DIAGNOSIS RECOMMENDATIONS 2. During a review of Patient 11’s Initial Psychiatric Evaluation (Psych Eval, a formal assessment done by a psychiatrist), dated 1/27/2026, the Psych Eval indicated that Patient 11 was admitted to the facility’s Youth Services unit (an inpatient behavioral health unit for patients ages 13 to 17) after an attempt to overdose on pills (meaning the patient took more medication than was safe or intended in order to harm themself). During a review of Patient 11’s Nursing Progress Note, dated 2/16/2026, the note indicated that “at approximately 1904 (7:04 p.m.), patient (Patient 11) was found in her (Patient 11) room sitting at the edge of the bed with a ripped bedsheet tied around her (Patient 11) neck. Staff were present and were able to loosen the sheet enough to fit fingers between the sheet and the patient’s neck. The sheet was removed from the patient’s (Patient 11) neck immediately.” During an interview on 2/17/2026 at 3:02 p.m. with registered nurse (RN 1), RN 1 stated that psychiatric and internal medicine progress notes were completed by providers either by handwriting or by dictation, and that it was the provider’s responsibility to complete these notes. During a concurrent interview and record review on 2/20/2026 at 11:48 a.m. with charge nurse (CN 7), Patient 11’s medical record for the admission on 1/7/2026, was reviewed. CN 7 said that no progress note from internal medicine (the medical doctor who handled the patient’s physical health needs) was found, either on 2/16/2026 or on 2/17/2026, in the medical record, to show that an assessment and evaluation (a check of the patient’s medical condition after the incident) was done by the physician on Patient 11 after the attempt to strangle herself (tightening something around the neck to prevent breathing) on 2/16/2026. CN 7 stated that, according to the nursing progress note, dated 2/16/2026, internal medicine had been notified about the incident in which Patient 11 was found in the room (Patient 11’s room) with a linen sheet around her (Patient 11) neck in an attempt to strangle herself. CN 7 also said that the internist should have come to the unit to assess the patient after the incident of attempted suicide involving Patient 11, since it was documented that the internist was notified. During an interview on 2/20/2026 at 3:35 p.m. with the nurse practitioner (NP 2, Internal Medicine), NP 2 stated that Internal Medicine acted as a consulting service, completed the history and physical (H&P, the physician’s comprehensive evaluation of the patient’s medical history and current physical condition performed at the time of admission), and monitored patients’ medical progress. NP 2 explained that Internal Medicine progress note documentation and follow?up typically included the patient’s report, any complaints for the day, and a full body assessment. NP 2 said that anything new regarding the patient was documented in the progress note, along with whether the patient was improving or not. NP 2 also stated that progress notes typically included the patient’s vital signs, medical diagnoses, and the plan for treatment or ongoing monitoring. During an interview on 2/24/2026 at 3:09 p.m. with internal medicine physician (MD 2), MD 2 explained that an internal medicine doctor should assess a patient after an incident such as an attempted self-strangulation, even if the patient did not appear physically injured. MD 2 stated that the need for evaluation depended on the timing of the incident and the available diagnostic information. For injuries such as self-harm attempts or skin injuries from a fall, MD 2 stated that they (the internal physicians) typically evaluated the patient regardless of how minor the injury seemed. MD 2 stated that a progress note should be completed unless the patient had been admitted to an outside hospital very late in the day. MD 2 stated that in those cases, the note might be written the next morning. MD 2 also added that that progress notes were important because they indicated the patient’s medical condition, any urgent concerns, and the plan of care, and helped communicate this information to both the medical team and the psychiatric team. During a review of the facility’s policy and procedure titled “Documentation Standards,” dated 3/2022, the policy indicated that services were to be charted immediately or within eight hours following completion. During a review of the facility’s “Medical Staff Bylaws Rules and Regulations,” dated 7/2025, the Medical Staff Bylaws Rules and Regulations indicated the following: “Basic responsibilities of medical staff members ...Prepare and complete in a timely manner the medical and other required records for all patients they admit or for whom they provide care in the Hospital.” During a review of the facility’s policy titled, “Format and Content of the Record,” dated 7/2024, the policy indicated that the credentialed medical staff performs the consultation reports. The consultation reports performed by PAs and NPs are co?signed by the supervising physician, and the attending physician signs the report after review. The content of the consultation report will contain the following: CONSULTING PHYSICIAN REASON FOR CONSULTATION FINDINGS DIAGNOSIS RECOMMENDATIONS”

“CONTENT OF RECORD: DISCHARGE SUMMARY CFR(s): 482.24(c)(4)(vii) [All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that a physician’s discharge progress note was completed and a discharge summary (a document that explains what happened during the hospital stay, the treatment provided, the patient’s condition at discharge, and what follow-up care is needed) was filed, for one of 32 sampled patient’s (Patient 17) medical record, in accordance with the facility’s policy regarding the format and content of a patient’s medical record. This deficient practice had the potential to compromise Patient 17’s well-being and continuity of care because future healthcare providers would not have important information about the patient’s treatment, diagnosis, and follow-up needs. In addition, this deficient practice (not completing and filing the discharge summary) could also lead to delays or mistakes in follow?up care for Patient 17 and make communication between care teams more difficult. Findings: During a review of Patient 17’s Psychiatric Evaluation (Psych Eval, a mental health assessment used to understand a person’s thoughts, feelings, and behaviors), dated 11/16/2025, the Psych Eval showed that Patient 17 was admitted because he (Patient 17) was “feeling suicidal” (meaning the patient was having thoughts about ending their own life). The Psych Eval also showed that Patient 17 was diagnosed with bipolar disorder (a mental health condition that causes strong mood swings, including very low moods called depression and very high moods called mania). In addition, the Psych Eval showed that Patient 17 was placed on a hold for danger to self (meaning the patient was kept in the hospital for safety because they were at risk of harming themselves and needed immediate mental health care). During a concurrent interview and record review on 2/17/2026 at 2:53 p.m. with registered nurse (RN 1), Patient 17’s medical chart, was reviewed for the admission from 11/15/2025 through 12/09/2025. RN 1 confirmed that Patient 17’s chart did not have a filed “discharge summary (a document written by a doctor that explains the patient’s hospital stay, treatment, condition at discharge, and follow-up needs),” and the doctor’s discharge progress note was not completed after Patient 17 was discharged on 12/9/2025. RN 1 said that every medical chart should have a discharge summary after a patient was discharged. RN 1 also said that completing the discharge summary was the doctor’s responsibility, and RN 1 did not know the timeframe for when the discharge summary had to be completed. During an interview on 2/20/2026 at 10:46 a.m. with the director of utilization review and medical records (Dir 4), Dir 4 said that the physician should complete and file the discharge summary within fourteen (14) days after the patient was discharged. During an interview on 2/25/2026 at 11:35 a.m. with the psychiatrist (MD 3), MD 3 explained that a discharge summary should be completed within fourteen (14) days after a patient left the hospital. MD 3 stated that a discharge summary was a short report that explained the patient’s treatment while they were in the hospital. MD 3 also said that the discharge summary helped support the patient’s care plan and gave future healthcare providers the information they needed to understand what happened during the patient’s stay. During a review of the facility’s policy and procedure (P&P) titled “Documentation Standards,” dated 3/2022, the P&P indicated the following: “All clinical staff who write in the medical record must follow the documentation rules and receive training to make sure they can meet these requirements. The policy also stated that the medical record is a legal document and must meet the hospital’s professional standards. The policy further stated that required documentation includes a “Discharge Summary.” During a review of the facility’s policy and procedure (P&P) titled, “Format and Content of the Record,” dated 7/2024, the P&P indicated the following: “Purpose: To ensure Hospital meets ...Federal and State and/or hospital policy meets documentation timeframe requirements and provides uniformity in the content of the record ...The content of the medical record shall include, but not limited to, the following ...Discharge Summary: The record of each discharged patient must include a discharge summary of the patient’s hospitalization and recommendations concerning follow-up or aftercare, as well as a brief summary of the patient’s condition on discharge ...All discharge summaries must be authenticated by the attending physician as detailed within the Rules and Regulations of the hospital. All discharge summaries shall be completed within 30 days following the patient’s discharge. Discharge summaries will include the following elements: Reason for admission ... course of treatment ...findings ...patient’s condition and disposition upon discharge ...final diagnosis ...anticipated problems after discharge ... discharge recommendations/instructions ...” During a review of the facility’s “Medical Staff Bylaws Rules and Regulations,” dated 7/2025, the Medical Staff Bylaws Rules and Regulations indicated the following: “Basic responsibilities of medical staff members ...Prepare and complete in a timely manner the medical and other required records for all patients they admit or for whom they provide care in the Hospital.””

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to: 1. Ensure that necessary medical information were updated and provided at the time of discharge, in accordance with the facility’s discharge planning policy, for one of 32 sampled patients (Patient 18), when: 1.a. The preferred pharmacy (the pharmacy chosen by the patient for filling prescriptions after discharge) was not updated prior to Patient 18’s discharge to ensure access to necessary medications. This deficient practice had the potential to compromise Patient 18’s well-being and result in worsening psychiatric symptoms, withdrawal effects, or destabilization in the community during the vulnerable transition period immediately following hospitalization. Failure to update the preferred pharmacy may result in prescriptions being routed to the wrong location, causing delays or preventing the patient from obtaining essential medications after discharge. 1.b. Patient 18 was discharged with a documented skin injury without providing wound-care instructions, follow-up recommendations, or treatment guidance to the patient or to the post-acute care provider. This deficient practice had the potential to result in Patient 18 developing an infection, experiencing delayed healing, or having the wound worsen after discharge. Documentation from the medical record indicated the presence of a skin wound, but no medical evaluation, treatment orders, or wound-care instructions were provided at discharge. 2. Ensure its nursing staff provided a complete discharge medication list to one of 32 sampled patient (Patient 14) upon discharge on 10/23/2025, when the discharge medication list was missing three (3) of five (5) prescribed medications: gabapentin (medication to treat anxiety [a group of mental disorders characterized by significant feelings of fear]), losartan (medication to treat high blood pressure) and metformin (medication to treat high blood sugar), in accordance with the facility’s policy regarding discharge planning. This deficient practice had the potential to result in Patient 14 not taking medications as prescribed leading to worsening of current illness and return to the hospital. Findings: 1.a. During a review of Patient 18’s Initial Psychiatric Evaluation (Psych Eval, a formal assessment done by a psychiatrist), dated 11/5/2024, the Psych Eval indicated that Patient 18 was admitted on a 5150 hold due to danger to others (meaning the patient’s behavior or statements indicated that they posed a risk of causing harm to another person and required involuntary psychiatric evaluation for safety for up to 72 hours in a psychiatric facility and was diagnosed with bipolar disorder (a mental health condition that causes significant shifts in mood, energy, and activity levels, resulting in alternating periods of elevated or irritable mood [mania- extreme emotional highs or hypomania- extreme emotional lows] and periods of depression [a serious mental health condition causing a persistent, low mood, or a total loss of interest in activities]). During a review of Patient 18’s Initial Psychiatric Evaluation (Psych Eval), dated 11/5/2024, the record indicated that Patient 18 was admitted for being non-compliant (failure to adhere to or follow) with the medication regimen. The Psych Eval also indicated that Patient 18 admitted to lowering her dose of Lithium (a mood?stabilizing medication used to treat bipolar disorder) medication intake from 900 mg to 600 mg (milligrams, a unit of measurement) and admitted “it was not a good idea.” The psych eval also indicated that Patient 18 was manic (experiencing an abnormally elevated or irritable mood). During a concurrent interview and record review on 2/18/2026 at 11:19 a.m. with Registered Nurse (RN 1), Patient 18’s Discharge Summary (the formal document completed at the end of a patient’s stay that outlines the course of treatment, condition at discharge, and aftercare instructions) and Discharge/Aftercare Plan, dated 11/14/2024, were reviewed. The record indicated that Patient 18 was discharged to a “homeless” (meaning the patient had no fixed or stable residence at the time of discharge) shelter in the Riverside County at [location]. The Discharge/Aftercare Plan, dated 11/14/2024, indicated that Patient 18’s e-script (an electronic prescription sent directly to a pharmacy) was routed to [location], which was approximately 75 miles away from the discharge destination. RN 1 stated that Patient 18 was prescribed Lithium 900 mg daily at bedtime. During the same concurrent interview and record review on 2/18/2026 at 11:19 a.m. with Registered Nurse (RN 1), RN 1 verified that the record contained no explanation for selecting that pharmacy. RN 1 stated that nursing obtained the preferred pharmacy directly from the patient, and nursing “would not put in any random pharmacy without verifying with the patient ... if the patient tells me they want the medications sent to a specific pharmacy, I go with the pharmacy the patient insists on. I would not necessarily document that the pharmacy is in a different county.” During an interview on 2/19/2026 at 2:42 p.m. with Charge Nurse (CN 7), CN 7 stated that nurses typically ask the patient which pharmacy they prefer, and sometimes the preferred pharmacy was already listed in the system. CN 7 explained that prescriptions were not physically written at the facility; instead, all prescriptions were electronically sent, and nurses must verify both the pharmacy and the medications, while physicians send the actual prescriptions. CN 7 stated that it was important for patients to have access to their medications after discharge so they can continue treatment and avoid another crisis. CN 7 further explained that there should be a discussion regarding the location of the pharmacy, and that prescriptions should be sent to a local pharmacy. Nurses may also confirm with the social worker to determine the best pharmacy location, and this was done collectively as part of the discharge process. During the same interview on 2/19/2026 at 2:42 p.m. with Charge Nurse (CN 7), CN 7 stated that medications should not be sent to a pharmacy in another county, and if that occurred, the reason should be documented. CN 7 added that ensuring the patient received medications at an appropriate location was part of a safe discharge, allowing the patient to continue treatment without interruption. During a concurrent interview and record review on 2/18/2026 at 2:37 p.m. with registered nurse (RN 1), RN 1 stated that Patient 18 was readmitted on 11/25/2024 (after being discharged initially on 11/14/2024) and was placed on a hold due to danger to others and aggressive behavior. During review of a complaint received on 12/9/2025 by the Department of Public Health (a state agency responsible for licensing, inspecting, and overseeing healthcare facilities to ensure patient safety and regulatory compliance), the complaint indicated that Patient 18 was prematurely discharged from the facility while still manic, confused, and not stable, and had nowhere to go, but was released nevertheless. The complaint further indicated that Patient 18 was then arrested and returned to the facility for readmission. During a review of the facility’s policy titled “Discharge Planning,” dated 2/2026, the policy indicated the following: “All patients are evaluated at admission and throughout their stay to determine what care they will need after leaving the hospital. The policy states that the team assesses patient needs such as therapy, medications, follow-up programs, support groups, housing, financial concerns, legal issues, social activities, spiritual needs, and any other assistance the patient may require. Discharge planning is ongoing and reviewed by the team at least once a week during treatment team meetings. Patients, or their legal guardian, will receive recommendations and referrals for care after discharge. All referrals and discharge-planning contacts must be documented in the patient’s record ...” 1.b. During a review of Patient 18’s Initial Psychiatric Evaluation (Psych Eval, a formal assessment done by a psychiatrist), dated 11/25/2024, the Psych Eval indicated that Patient 18 was re-admitted (after an initial discharge on 11/14/2024) on a hold due to danger to others (meaning the patient’s behavior or statements indicated that they posed a risk of causing harm to another person and required involuntary psychiatric evaluation for safety) and was diagnosed with bipolar disorder (a mental health condition that causes significant shifts in mood, energy, and activity levels, resulting in alternating periods of elevated or irritable mood (mania or hypomania) and periods of depression). During a review of Patient 18’s Nursing Admission Assessment, dated 11/25/2024, the record indicated that Patient 18 was admitted to the facility with no skin issues or injuries noted. During a concurrent interview and record review on 2/18/2026 at 2:37 p.m. with registered nurse (RN 1), Patient 18’s medical record, titled “Nursing Note,” indicated that on 11/27/2024, Patient 18 fell in the shower and sustained a skin injury (the skin was scraped off, and visible blood was shown in the photograph). The photograph did not include a description of the side of the body involved (left or right), and the nursing note indicated that the nurse applied antibiotic ointment (a medicated topical cream used to prevent infection in minor wounds) to the wound per the physician’s order and placed a dressing. RN 1 stated that, based on the documentation, the nurse notified the physician about Patient 18’s skin injury. RN 1 did not provide a comment regarding the lack of documentation describing the side of the wound or the absence of a complete wound assessment. During a review of Patient 18’s Nursing Note, dated 11/28/2024, the note indicated that on 11/28/2024, registered nurse (RN), reassessed Patient 18’s wound and encouraged Patient 18 to comply with antibiotic ointment and dressing changes to prevent infection. During a concurrent interview and record review on 2/18/2026 at 3:30 p.m. with registered nurse (RN 1), Patient 18’s medical record for the admission on 11/25/2024, was reviewed to locate an Internal Medicine physician note regarding Patient 18’s skin wound evaluation sustained after a fall on 11/27/2024. RN 1 stated that there was no Internal Medicine note in Patient 18’s medical record. RN 1 explained that the expectation for nursing staff was to notify the physician, and that the physician should have seen and evaluated the patient after the fall. RN 1 also confirmed that there was no physician orders entered for skin care, including antibiotic ointment and dressing changes, and further confirmed that nurses required a physician’s order to apply antibiotic ointment to a patient. During an interview on 2/18/2026 at 3:30 p.m. with registered nurse (RN 1), RN 1 stated that, based on experience, photographs of skin injuries were typically not obtained prior to patient discharge. RN 1 said that staff would not take photographs of a wound unless there was a specific physician order to do so. During a review of Patient 18’s discharge instructions, dated 12/5/2024, the discharge instructions contained no information regarding wound-care, no follow-up recommendations, and no treatment guidance related to the skin injury that Patient 18 sustained on 11/27/2024 after falling in the shower. This record review was conducted with RN 1 on 2/18/2026. During an interview on 2/20/2026 at 3:35 p.m. with the nurse practitioner (NP 2, Internal Medicine), NP 2 stated that Internal Medicine progress notes typically included the patient’s report, any complaints the patient had for the day, and a full body assessment. NP 2 stated that anything new about the patient, such as a newly sustained skin injury or wound, was documented in the Internal Medicine progress note, along with whether the patient was improving or not. NP 2 further stated, “It should be addressed prior to discharge, any wounds, especially if they were sustained in the facility. It should be in the computer and in the chart, and in the orders, such as follow?up for a wound with the primary care provider, and the orders for the wound can be a separate order and can be done in the chart.” During an interview on 2/19/2026 at 11:30 a.m. with charge nurse (CN 7), CN 7 stated the following: “If a patient sustains an injury during admission, the medical provider should be notified. Based on the nursing assessment, the provider will give orders, complete their own assessment, and decide if the patient needs to be sent out (to another hospital for evaluation). If the injury is manageable, the provider will give treatment orders and will be involved in discharge planning, including providing follow-up orders before discharge. An order is needed for treatment. First aid does not require an order, but routine treatment does. We have triple antibiotic ointment, but if it is applied daily, we need a physician’s order to determine the frequency. For cutting or bleeding, we expect an order. We get all treatment orders from the doctors and follow their recommendations.” During an interview on 2/19/2026 at 11:30 a.m. with charge nurse (CN 7), CN 7 said, “We take photos of bruising, cuts, sutures, abrasions, and any injuries on admission and as needed. We also take pictures of new scars so we can compare them. Photos are taken before discharge, especially if the injury occurred in the facility. This is our practice and has always been our practice. The purpose is to document the incident, the treatment provided, and to give the patient education on what to do after discharge to prevent complications.” During a review of the complaint received by the Department of Public Health (the state agency that oversees health?care facilities) on 12/9/2025, the complaint indicated that Patient 18 was discharged from the facility with an open, infected wound on their leg, which required Patient 18 to be evaluated by a medical provider and led to nearly a year of medical treatment. During a review of the facility’s policy called “Discharge Planning,” dated 2/2026, the policy indicated the following: “All patients are evaluated at admission and throughout their stay to determine what care they will need after leaving the hospital. The policy states that the team assesses patient needs such as therapy, medications, follow-up programs, support groups, housing, financial concerns, legal issues, social activities, spiritual needs, and any other assistance the patient may require. Discharge planning is ongoing and reviewed by the team at least once a week during treatment team meetings. Patients, or their legal guardian, will receive recommendations and referrals for care after discharge. All referrals and discharge?planning contacts must be documented in the patient’s record ...” During a complaint validation survey conducted from 2/17/2026 through 2/25/2026, the facility was asked to provide its policy for skin injury assessment, prevention, and management. The facility did not provide a skin?injury prevention or skin?care policy for review, nor did the facility confirm that such a policy existed. 2. During a review of Patient 14’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 10/7/2025, the “psych eval” indicated, Patient 14 was admitted to the facility on 10/6/2025 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 and treatment) to rule out bipolar affective disorder (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 14’s face sheet (face sheet, document provides patient’s demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance) titled, “Patient Demographic Profile,” dated 10/24/2025, the face sheet indicated, Patient 14 was discharged from the facility on 10/23/2025 at 10:04 a.m. During a concurrent interview and record review on 2/24/2026 at 10:53 a.m. with Nurse Manager (NM 5), Patient 14’s “Discharge Medication Order (physician order of medications),” dated 10/23/2025, was reviewed. The “Discharge Medication Order” indicated, Patient 14 to be discharged with the following medications: gabapentin (medication to treat anxiety [a group of mental disorders characterized by significant feelings of fear]) 1200 milligrams (mg, unit of measure) three times a day by mouth for anxiety; losartan (medication to treat high blood pressure) 25 mg by mouth daily for hypertension (high blood pressure); metformin (medication to treat high blood sugar)1000 mg by mouth twice daily for diabetes (high blood sugar); olanzapine (medication to treat psychosis ([severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality])10 mg by mouth twice daily for psychosis; and trazodone (antidepressant medication to treat insomnia [difficulty falling asleep] and depression [mood disorder that causes a persistent feeling of sadness and loss of interest in life]) 50 mg by mouth daily as needed for insomnia. NM 5 stated the nurse should provide instructions to Patient 14 on taking these five (5) medications at home as part of the discharge instruction. During a concurrent interview and record review on 2/24/2026 at 11 a.m. with NM 5, Patient 14’s “Discharge Medication Summary for Patient,” dated 10/23/2025, was reviewed. The discharge medication list indicated, Medications to take after discharge: olanzapine 10 mg orally twice a day for psychosis and trazodone 50 mg orally at bedtime as needed for insomnia. NM 5 stated the discharge medication list was missing gabapentin, losartan and metformin. NM 5 further stated Patient 14 might not know that Patient 14 needed to take gabapentin, losartan and metformin. NM 5 further stated Patient 14’s medical condition might decline if Patient 14 did not take the medications as prescribed. NM 5 further stated Patient 14’s blood pressure, blood sugar and anxiety might get worse. During an interview on 2/25/2026 at 10:32 a.m. with the Chief Nursing Officer (CNO), CNO stated it was the nurses’ responsibility to check with the physician order to ensure all discharge medications were on the discharge medication list as ordered. CNO further stated if a patient did not take medications as prescribed, patient’s condition might get worse and might lead to rehospitalization. During a review of the facility’s policy and procedure (P&P) title, “Discharge Planning,” dated 2/2026, the P&P indicated, “A written aftercare plan will be provided to all patients upon discharge individualized to meet the patient’s discharge needs ... All patients are assessed upon admission and throughout hospitalization for after care needs by the interdisciplinary team. The psychosocial assessment will address the following areas: continued care (therapy, medication management ...) ... Upon discharge, all patients will receive a written copy of their aftercare plan.””

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its multi-disciplinary team (a group of professionals including physicians, nurses, social workers and therapists who collaborate to provide comprehensive and coordinated patient care) addressed all active problems identified on the master treatment plan (a comprehensive, individualized, and written document outlining a patient’s diagnosis, treatment goals, and therapeutic interventions), on a weekly basis, for one of 32 sampled patients (Patient 11), in accordance with the facility’s policy regarding active and individualized treatment plan, when the multi-disciplinary team did not discuss Patient 11’s progress and continued need for linen restriction during three (3) treatment plan review meetings: 2/4/2026, 2/11/2026, and 2/18/2026. This deficient practice could have resulted in insufficient monitoring of compliance with linen restrictions, potentially leading to unmet patient care needs or overlooked discussions about further requirements. As a consequence, Patient 11 was able to access prohibited linens (flat sheet) and engage in self-harming behavior. On 2/16/2026, Patient 11 was found with a torn flat sheet tied around her (Patient 11’s) neck. Findings: During a review of Patient 11’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 1/27/2026, the “psych eval” indicated, Patient 11 was admitted to the facility’s Youth Services (inpatient Behavioral Health Unit [inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders] servicing patients age 13 to 17) for evaluation of mood state and self-harm behavior. The initial psych eval also indicated, Patient 11 reportedly had a history of suicide (the act of intentionally causing one’s own death) attempt by hanging and jumping from a bridge. During a review of Patient 11’s “progress notes (nurse note),” dated 2/16/2026, the “progress notes” indicated, “at approximately 1904 (7:04 p.m.), patient (Patient 11) was seen in her (Patient 11’s) room at the edge of her (Patient 11’s) bed with her (Patient 11’s) sheet ripped and tied around her (Patient 11’s) neck. Staff was present and able to loosen sheet and fit fingers between the sheet and her (Patient 11’s) neck. The sheet was removed from her (Patient 11’s) neck immediately.” During a concurrent interview and record review on 2/23/2026 at 11:44 a.m. with Nurse Manager (NM 2) of Youth Services, Patient 11’s “Initial & Master Treatment Plan (treatment plan, a comprehensive, individualized, and written document outlining a patient’s diagnosis, treatment goals, and therapeutic interventions),” finalized on 1/28/2026, was reviewed. The treatment plan had identified six active problems including Number (#) 1 Depressed Mood (feelings of sadness, tearfulness, emptiness or hopelessness) with Suicidality (having suicidal thoughts, behavior and plans), #2 Self-Injurious Behavior (intentional behavior to direct harm of one’s own body), #3 Mood Swings/Labile Mood (sudden intense shifts in emotion from highs to lows), #4 Pain Management, #5 Potential for Falls (suddenly go down onto the ground), and #6 Linen Restriction. NM 2 stated every active problem listed on the treatment plan should be addressed weekly by the multi-disciplinary team until the set goal of the problem was achieved. NM 2 further stated Problem #6 Linen Restriction was still an active problem (at the time of the suicide attempt on 2/16/2026). During a review of the “Initial & Master Treatment Plan (treatment plan),” finalized on 1/28/2026, the treatment plan indicated, “Number (#) 6 Linen Restriction - behavioral manifestations (to display): patient (Patient 11) had history of attempting to hang herself ... short term goals: patient (Patient 11) would verbalize feelings and notify staff, and patient (Patient 11) would identify two (2) to three (3) triggers to urges to self-harm via hanging ... long term goal: patient (Patient 11) would demonstrate improve impulse control and utilize coping skills remaining free from harm before discharge.” During a concurrent interview and record review 2/23/2026 at 11:48 a.m. with NM 2, Patient 11’s “Treatment Plan Review/ Weekly Summary Progress Report (weekly treatment plan review report),” dated 2/4/2026, 2/11/2026, and 2/18/2026, were reviewed. All three weekly treatment plan review reports indicated Patient 11’s active problems #6 Linen Restriction was not discussed in any weekly treatment plan reviews meeting. NM 2 stated Problem #6 Linen Restriction was still an active problem, and it should be discussed during the weekly meeting. NM 2 further stated without the discussion, the multi-disciplinary team would not know Patient 11’s progress and would not know if the set goals were achieved or not. During an interview on 2/23/2026 at 11:52 a.m. with Nurse Manager (NM 6) of ITU (Intensive Treatment Unit, one of the facility’s behavioral health unit), NM 6 stated patients with linen restrictions would only be allowed to have one blanket and one pillow (Patient 11 was found with a flat sheet on 2/16/2026). During an interview on 2/24/2026 at 12:29 p.m. with Director (DIR 2) of Clinical Services, DIR 2 stated the multi-disciplinary team would identify a patient’s active problems and address all active problems on the treatment plan throughout the hospital stay. The team would meet weekly to discuss patient’s progress and adjust the treatment plan as needed to meet patient’s need and to achieve set goals. During an interview on 2/24/2026 at 2:25 p.m. with DIR 2, DIR 2 stated it was the responsibility of the multi-disciplinary team to ensure all active problems were addressed in the weekly treatment plan review. During a review of the facility’s policy and procedure (P&P) titled, “Active and Individualized Treatment,” dated 2/2026, the P&P indicated, “1. Active Treatment interventions are to be developed by the treatment team in coordination with the patient, based the patient’s assessed needs, and documented in the Master Treatment Plan and subsequent Treatment Plan Updates ... 2. Active Treatment interventions identified in the Master Treatment Plan and Treatment Plan Updates are delivered to patients ... 9. The treatment team will review and revise the treatment plan as often as needed, but at a minimum every seven (7) days.””

“Recording Progress Notes CFR(s): Standard: Recording Progress Progress notes must be recorded by the physician(s), psychologists, or other licensed independent practitioner(s) responsible for the care of the patient as specified in §482.12(c); nurse, social worker and, when appropriate, others significantly involved in active treatment modalities. The frequency of progress notes is determined by the condition of the patient but must be recorded at least weekly for the first 2 months and at least once a month thereafter and must contain recommendations for revisions in the treatment plan as indicated as well as precise assessment of the patient’s progress in accordance with the original or revised treatment plan. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that one of 32 sampled patient’s (Patient 11) progress note was recorded when: 1. The Internal Medicine physician (the medical doctor who checks the patient’s physical health) did not complete a progress note after Patient 11 was found with a ripped bedsheet tied around her neck in an attempt to strangle herself on 2/16/2026. This deficient practice resulted in Patient 11’s health being compromised because there was no medical check or evaluation to make sure the patient did not have hidden neck injuries, breathing problems, or other medical issues that can happen after a strangulation attempt. 2. The psychiatrist (a medical doctor specializing in diagnosing and treating mental health conditions) did not complete a daily progress note (a written update about the patient’s treatment, response, and any changes in their condition) for Patient 11, in accordance with the facility’s medical record requirements. This deficient practice had the potential to compromise Patient 11’s continuity of care because missing progress notes can create gaps in communication, delay treatment decisions, and prevent timely adjustments to the patient’s care and treatment goals. Findings: 1. During a review of Patient 11’s Initial Psychiatric Evaluation (Psych Eval, a formal assessment done by a psychiatrist), dated 1/27/2026, the Psych Eval indicated that Patient 11 was admitted to the facility’s Youth Services unit (an inpatient behavioral health unit for patients ages 13 to 17) after an attempt to overdose on pills (meaning the patient took more medication than was safe or intended in order to harm themself). During a review of Patient 11’s Nursing Progress Note, dated 2/16/2026, the note indicated that “at approximately 1904 (7:04 p.m.), patient (Patient 11) was found in her (Patient 11) room sitting at the edge of the bed with a ripped bedsheet tied around her neck. Staff were present and were able to loosen the sheet enough to fit fingers between the sheet and the patient’s (Patient 11) neck. The sheet was removed from the patient’s neck immediately.” During an interview on 2/17/2026 at 3:02 p.m. with registered nurse (RN 1), RN 1 stated that psychiatric and internal medicine progress notes were completed by providers either by handwriting or by dictation, and that it was the provider’s responsibility to complete these progress notes. During a concurrent interview and record review on 2/20/2026 at 11:48 a.m. with charge nurse (CN 7), Patient 11’s medical record for the admission, dated 1/7/2026, was reviewed. CN 7 said that no progress note from internal medicine (the medical doctor who handled the patient’s physical health needs) was found in the medical record (of Patient 11) either on 2/16/2026 or on 2/17/2026, to show that an assessment and evaluation (a check of the patient’s medical condition after the incident) was done on Patient 11 after the attempt to strangle herself (tightening something around the neck to prevent breathing) on 2/16/2026. CN 7 stated that, according to the nursing progress note dated 2/16/2026, internal medicine had been notified about the incident in which Patient 11 was found in the room with a linen sheet around their neck in an attempt to strangle themself. CN 7 also said that the internist should have come to assess the patient after the incident since it was documented that the internist was notified. During an interview on 2/20/2026 at 3:35 p.m. with the nurse practitioner (NP 2, internal medicine), the NP 2 said that internal medicine progress notes typically included the patient’s report, any complaints the patient had for the day, and the full body assessment. The NP 2 stated that anything new (about the patient) was written in the note, along with whether the patient was improving or not. The NP 2 also said that progress notes included the patient’s vital signs, medical diagnosis, and the plan for treatment or monitoring. During an interview on 2/24/2026 at 3:09 p.m. with internal medicine physician (MD 2), MD 2 explained that an internal medicine doctor should assess a patient after an incident such as an attempted self-strangulation, even if the patient did not appear physically injured. MD 2 stated that the need for evaluation depended on the timing of the incident and the available diagnostic information. For injuries such as self-harm attempts or skin injuries from a fall, MD 2 stated that they typically evaluated the patient regardless of how minor the injury seemed. MD 2 stated that a progress note should be completed unless the patient had been admitted to an outside hospital very late in the day. MD 2 said that in those cases, the note might be written the next morning. MD 2 also added that that progress notes were important because they indicated the patient’s medical condition, any urgent concerns, and the plan of care, and helped communicate this information to both the medical team and the psychiatric team. During a review of the facility’s policy and procedure titled “Documentation Standards,” dated 3/2022, the policy indicated that services were to be charted immediately or within eight hours following completion. During a review of the facility’s “Medical Staff Bylaws Rules and Regulations,” dated 7/2025, the Medical Staff Bylaws Rules and Regulations indicated the following: “Basic responsibilities of medical staff members ...Prepare and complete in a timely manner the medical and other required records for all patients they admit or for whom they provide care in the Hospital.” 2. During a review of Patient 11’s Initial Psychiatric Evaluation (Psych Eval, a formal assessment done by a psychiatrist), dated 1/27/2026, the Psych Eval indicated that Patient 11 was admitted to the facility’s Youth Services unit (an inpatient behavioral health unit for patients ages 13 to 17) after an attempt to overdose on pills (meaning the patient took more medication than was safe or intended in order to harm herself). During a review of Patient 11’s Nursing Progress Note, dated 2/16/2026, the note indicated that “at approximately 1904 (7:04 p.m.), patient (Patient 11) was found in her (Patient 11) room sitting at the edge of the bed with a ripped bedsheet tied around her neck. Staff were present and were able to loosen the sheet enough to fit fingers between the sheet and the patient’s neck. The sheet was removed from the patient’s (Patient 11) neck immediately.” During an interview on 2/17/2026 at 3:02 p.m. with registered nurse (RN 1), RN 1 stated that psychiatric and internal medicine progress notes were completed by providers either by handwriting or by dictation, and that it was the provider’s responsibility to complete these progress notes. During a review of Patient 11’s Daily Progress Note (Psychiatry), dated 2/17/2026, the progress note showed that Patient 11 remained depressed (feeling very sad and hopeless). The note also indicated that the planned discharge was going to be canceled because Patient 11 needed 1:1 supervision (a staff member always staying with the patient for safety) due to self?harm behavior after the attempt to strangle herself on 2/16/2026. During a review of Patient 11’s Daily Progress Note (Psychiatry), dated 2/18/2026, the progress note indicated that Patient 11 continued to require one-to-one supervision because of ongoing self-harm behavior. The progress note also indicated that Patient 11 still had unresolved suicidal impulses (meaning the patient continued to feel the urge to harm or kill herself). During a concurrent interview and record review on 2/20/2026 at1:43 p.m., with charge nurse (CN 7), Patient 11’s daily psychiatric progress notes, dated 2/16/2026 through 2/20/2026, were reviewed. CN 7 verified that Patient 11 had psychiatric progress notes for 2/16/2026, 2/17/2026, and 2/18/2026. CN 7 said there were no other psychiatric progress notes found in Patient 11’s medical record (there was no daily psychiatric progress note for 2/19/2026). During an interview on 02/25/2026 at 3:55 p.m. with Psychiatrist (MD 3), MD 3 stated that daily psychiatric progress notes were required and needed to be documented on the same day when a patient was evaluated by the physician. MD 3 explained that the purpose of daily progress notes was to allow the interdisciplinary team to communicate in real time and remain aligned regarding the patient’s care and treatment. Notes were expected to be completed on the same day as the evaluation, with information added throughout the day as needed. MD 3 stated that delayed or missing notes typically should not have compromised safety because the psychiatrist met with staff daily; however, timely notes helped new or rotating team members understand and support the patient’s care. During a review of the facility’s policy and procedure titled “Documentation Standards,” dated 3/2022, the policy indicated that services were to be charted immediately or within eight hours following completion. During a review of the facility’s “Medical Staff Bylaws Rules and Regulations,” dated 7/2025, the Medical Staff Bylaws Rules and Regulations indicated the following: “Basic responsibilities of medical staff members ...Prepare and complete in a timely manner the medical and other required records for all patients they admit or for whom they provide care in the Hospital.””

“Progress Notes Recommendations and Revisions CFR(s): ...and must contain recommendations for revisions in the treatment plan as indicated as well as This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that the master treatment plan (a document that lists the patient’s goals, risks, symptoms, and the interventions staff will use to treat and keep the patient safe) was updated timely, in accordance with the facility’s policy regarding treatment plan revisions, for one of 32 sampled patients (Patient 11), after Patient 11 attempted to strangulate herself (an attempted suicide while hospitalized, meaning the patient tried to harm themself in a way that could have resulted in death) on 2/16/2026. This deficient practice had the potential to place Patient 11 at continued risk of self-harm because the treatment plan did not reflect the new and urgent safety needs. In addition, Patient 11’s safety, well-being, and continuity of care could have been compromised due to delayed interventions, inconsistent staff actions, and lack of coordinated treatment planning. Findings: During a review of Patient 11’s Initial Psychiatric Evaluation (Psych Eval, a formal assessment done by a psychiatrist), dated 1/27/2026, the Psych Eval indicated that Patient 11 was admitted to the facility’s Youth Services unit (an inpatient behavioral health unit for patients ages 13 to 17) after an attempt to overdose on pills (meaning the patient took more medication than was safe or intended in order to harm herself). During a review of Patient 11’s Nursing Progress Note, dated 2/16/2026, the note indicated that “at approximately 1904 (7:04 p.m.), patient (Patient 11) was found in her room sitting at the edge of the bed with a ripped bedsheet tied around her neck. Staff were present and were able to loosen the sheet enough to fit fingers between the sheet and the patient’s (Patient 11) neck. The sheet was removed from the patient’s neck immediately.” During a concurrent interview and record review on 2/20/2026 at 12:23 p.m. with charge nurse (CN 7), Patient 11’s Master Treatment Plan (the comprehensive plan that outlines patient problems, goals, and interventions), dated 1/27/2026, was reviewed. The plan contained no documentation of Patient 11’s attempt to strangulate herself on 2/16/2025. CN 7 stated that the treatment plan did not include the patient’s (Patient 11) recent behaviors or observations (self-injurious behavior). CN 7 stated that treatment plans could be updated as needed, but this treatment plan (for Patient 11 following a suicide attempt on 2/16/2026) had not been revised. During an interview on 2/20/2026 at 12:23 p.m. with charge nurse (CN 7), CN 7 said that the interventions in the treatment plan should have addressed the patient’s (Patient 11’s) recent incident in which Patient 11 attempted to strangle herself by wrapping a linen sheet around her neck, an event that staff interrupted in time. CN 7 also said that no treatment plan had been completed after 1/27/2026 (when the initial Master Treatment Plan was developed), leaving the patient (Patient 11) without an updated master treatment plan following Patient 11’s suicide attempt on 2/16/2026. CN 7 said that a treatment plan was necessary to identify risk factors, document the interventions being used, and guide ongoing care. During an interview on 2/24/2026 at 3:43 p.m. with the Director for Social Services (Dir 2), Dir 2 stated that the initial Master Treatment Plan was typically completed within 72 hours. Dir 2 stated that the plan was developed and updated when new problems were identified or when the patient was not meeting treatment plan goals. Dir 2 stated that during the weekly review, the social worker reviewed the treatment goals and wrote progress notes. Dir 2 said that the plan was not rewritten, but the interventions could be revised for short-term and long-term goals based on how the patient was progressing. Dir 2 stated that the treatment plan needed to address the patient’s specific needs, risks, and behaviors. Dir 2 stated that the treatment plan must include a goal, interventions, a target date, and individualized interventions to achieve both short?term and long-term goals. During the same interview on 2/24/2026 at 3:43 p.m. with the Director for Social Services (Dir 2), Dir 2 was asked if the Master Treatment Plan should be revised after a patient attempted self-harm while in the facility. Dir 2 stated that it should be revised. Dir 2 stated that if the goal was not being met, it would be discussed in the treatment team meeting. If the patient had a self-harm attempt that was not previously addressed, it should be added to the plan. Dir 2 stated that the team would continue working on it as a goal that the patient was not meeting. Dir 2 stated that it was important to ensure the patient (Patient 11) received treatment for symptoms and self-injurious behavior. These issues had to be addressed with interventions in the treatment plan, and the goals were expected to be resolved by discharge. During the same interview on 2/24/2026 at 3:43 p.m. with the Director for Social Services (Dir 2), Dir 2 said that if the patient had a self-harm incident, it would be added in the treatment plan, and the team would continue working on it as a short-term goal that was not met. Dir 2 stated that the team had to ensure the patient received treatment for symptoms and self-injurious behavior and that interventions were in place to meet the patient’s goals. Dir 2 stated that the treatment team discussed the patient weekly. For example, if the patient had a 1:1 order, the case might be discussed more than once a week. During the same interview on 2/24/2026 at 3:43 p.m. with the Director for Social Services (Dir 2), Dir 2 was asked how outdated or incomplete treatment plans could affect patient safety, regulatory compliance, or continuity of care. Dir 2 stated that it depended on the issue, but patient safety was always the priority. Dir 2 stated that the treatment plan should be updated to ensure the patient received appropriate care. Dir 2 stated that all problems must be addressed, and safety must come first. Dir 2 stated that updated interventions needed to be included in the Master Treatment Plan. During a review of the facility’s policy and procedure titled “Documentation Standards”, dated 3/2022, the policy indicated that staff were required to record any change in patient condition, unusual symptoms, incidents, actions taken, results, and progress toward treatment goals as identified in the treatment plan. During a review of the facility’s policy titled, “Format and Content of the Record,” dated 7/2024, the policy indicated that, “MASTER TREATMENT PLAN AND REVIEW: The attending physician shall be present at treatment team meetings on all of their patients and shall participate in, review, and approve all treatment plans formulated by the treatment team.” During a review of the facility’s policy titled “Assessment and Reassessment,” dated 7/2025, the policy indicated that: “Reassessment is done when a significant change occurs in the patient’s diagnosis, medical status, or presenting condition. Treatment Planning Meetings are held at least weekly. During this meeting, the patient’s condition is reassessed, and the treatment plan and progress goals are evaluated and revised, as appropriate.””

“Discharge Summary CFR(s): The record of each patient who has been discharged must have a discharge summary that includes a recapitulation of the patient’s hospitalization… This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that a completed discharge summary (a document that explains what happened during the hospital stay, the treatment provided, the patient’s condition at discharge, and what follow-up care is needed), was filed in the medical record, for one of 32 sampled patients (Patient 17), in accordance with the facility’s policy regarding format and content of medical records. This deficient practice had the potential to compromise Patient 17’s well-being and continuity of care because future healthcare providers would not have important information about the patient’s treatment, diagnosis, and follow-up needs. In addition, this deficient practice (not completing and filing the discharge summary) could also lead to delays or mistakes in follow-up care for Patient 17 and make communication between care teams more difficult. Findings: During a review of Patient 17’s Psychiatric Evaluation (Psych Eval, a mental health assessment used to understand a person’s thoughts, feelings, and behaviors), dated 11/16/2025, the Psych Eval showed that Patient 17 was admitted because he (Patient 17) was “feeling suicidal (meaning the patient was having thoughts about ending his own life).” The Psych Eval also indicated that Patient 17 was diagnosed with bipolar disorder (a mental health condition that causes strong mood swings, including very low moods called depression and very high moods called mania). In addition, the Psych Eval indicated that Patient 17 was placed on a hold for danger to self (meaning the patient was kept in the hospital for safety because they were at risk of harming themselves and needed immediate mental health care). During a concurrent interview and record review on 2/17/2026 at 2:53 p.m. with registered nurse (RN 1), Patient 17’s medical chart, was reviewed for the admission from 11/15/2025 through 12/09/2025. RN 1 confirmed that Patient 17’s chart did not have a filed “discharge summary (a document written by a doctor that explains the patient’s hospital stay, treatment, condition at discharge, and follow?up needs),” and the doctor’s discharge progress note was not completed. RN 1 said that every medical chart should have a discharge summary after a patient was discharged. RN 1 also said that completing the discharge summary was the doctor’s responsibility, and RN 1 did not know the timeframe for when the discharge summary had to be completed. During an interview on 2/20/2026 at 10:46 a.m. with the Director of Utilization Review and Medical Records (Dir 4), Dir 4 said that the physician should complete and file the discharge summary within fourteen (14) days after the patient was discharged. During an interview on 2/25/2026 at 11:00 a.m. with the psychiatrist (MD 3), MD 3 said the following, “Completing a discharge summary is critical because it ensures continuity of care. It tells the next provider what treatment the patient received, what was ineffective, and what should not be repeated. A proper summary includes all pertinent information such as what transpired during the stay, how the patient presented, medications and their effects, any restrictions, abnormal labs, and the level of care needed at discharge. This helps the next clinician provide effective care and prevents unnecessary retreatment. The mandated timeframe is typically 14 days. If it’s not completed on time, it disrupts continuity of care and makes it harder for the next psychiatrist to treat the patient effectively.” During a review of the facility’s policy and procedure (P&P) titled “Documentation Standards,” dated 3/2022, the P&P indicated the following: “All clinical staff who write in the medical record must follow the documentation rules and receive training to make sure they can meet these requirements. The policy also indicated that the medical record is a legal document and must meet the hospital’s professional standards. The policy further stated that required documentation includes a “Discharge Summary.” During a review of the facility’s policy and procedure (P&P) titled, “Format and Content of the Record,” dated 7/2024, the P&P indicated the following: “Purpose: To ensure Hospital meets ...Federal and State and/or hospital policy meets documentation timeframe requirements and provides uniformity in the content of the record ...The content of the medical record shall include, but not limited to, the following ...Discharge Summary: The record of each discharged patient must include a discharge summary of the patient’s hospitalization and recommendations concerning follow-up or aftercare, as well as a brief summary of the patient’s condition on discharge ...All discharge summaries must be authenticated by the attending physician as detailed within the Rules and Regulations of the hospital. All discharge summaries shall be completed within 30 days following the patient’s discharge. Discharge summaries will include the following elements: Reason for admission ... course of treatment ...findings ...patient’s condition and disposition upon discharge ...final diagnosis ...anticipated problems after discharge ... discharge recommendations/instructions ...” During a review of the facility’s “Medical Staff Bylaws Rules and Regulations,” dated 7/2025, the Medical Staff Bylaws Rules and Regulations indicated the following: “Basic responsibilities of medical staff members ...Prepare and complete in a timely manner the medical and other required records for all patients they admit or for whom they provide care in the Hospital.” During a review of the facility’s policy titled, “Format and Content of the Record,” dated 7/2024, the policy indicated that, “15. DISCHARGE SUMMARY: The record of each discharged patient must include a discharge summary of the patient’s hospitalization and recommendations concerning follow-up or aftercare, as well as a brief summary of the patient’s condition on discharge. A competent designated agent, approved by the facility and the Medical Executive Committee, may perform summation of information and dictation of the Discharge Summary. All discharge summaries must be authenticated by the attending physician as detailed within the Rules & Regulations of the hospital. All discharge summaries shall be completed within 30 days following the patient’s discharge. Incomplete discharge summaries exceeding 30 days following discharge will be considered delinquent.””

“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: 46333 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for governing body (GB, the leadership group responsible for oversight of the facility operations and patient safety) was met, when the facility’s governing body failed to fulfill its responsibilities to ensure that all patients received care in accordance with the facility’s policies and procedures, and nationally recognized standards of practice as evidenced by: 1. The Governing Body failed to ensure its nursing staff adhered to its internal policies and procedures “Code Blue (emergency call for cardiac [heart] or respiratory arrest [stop breathing]) and Transferring Patients to the Emergency Room,” and did not follow current American Heart Association (AHA) Basic Life Support (BLS) guidelines (nationally procedures for emergency resuscitation [emergency effort to restore breathing or heartbeat], including chest compressions [pressing on the chest to pump], airway support [keeping breathing passages open], and use of a defibrillator [a device that delivers an electric shock to restart or correct the heart’s rhythm] during a cardiac arrest [heart stop] or other life-threatening conditions) for one (1) of 43 sampled patients (Patient 1). This deficient practice resulted in the lack of timely and effective emergency response for a patient (Patient 1) who was found unresponsive (not responding to verbal command, touch, or pain). This deficient practice also increased the likelihood of poor patient outcomes or death during medical emergencies. (Refer to A-0063) 2. The Governing Body failed to ensure oversight in maintaining a safe environment for de-escalation (is a method to prevent potential violence), in accordance with the facility’s policy on “Patient Precautions,” for one (1) of 43 sampled patients (Patient 6), who had a known history of violent and unpredictable behavior and was brought into an unsecured and hazardous area (South Cafeteria). The cafeteria was not designed for patients for de-escalation and the cafeteria contained furniture and items that could be used as weapons (metal-legged chairs, hard plastic objects). This deficient practice resulted in patient care areas not being assessed for safety prior to use, which contributed to an actual physical injury (laceration to the head) to the Director of Admission (DOA). The lack of oversight also had the potential to cause further harm to patients and staff if unsafe areas continue to be used for behavioral crisis (a situation where an individual’s mental or emotional state becomes so severe that it poses a threat to their own safety or the safety of others) interventions. (Refer to A-0063) 3. The Governing Body failed to ensure oversight on the Nursing Services Department to ensure accurate 15-minute Patient rounding (a regular, systematic process where healthcare professionals assess patients) and documentation of the patient rounding were completed, in accordance with the facility’s policy on supervision of patients/patient rounds, for 20 of 43 sampled patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43). This deficient practice resulted in the inability to ensure accurate monitoring of patients with behavioral health needs, increasing the risk of undetected self-harm (hurting themselves), aggression (behavior aimed at harming others physically), or medical deterioration. Inaccurate rounding may also result in delayed or missed interventions with potentially severe consequences. (Refer to A-0063) 4. The Governing Body failed to ensure timely authentication of restraint (any physical restraint that is a mechanical or personal restriction that immobilizes or reduces the ability of an individual to move his or her arms, legs, or head freely) orders, in accordance with the facility’s policy on restraints, for one (1) of 43 sampled patients (Patient 29). This deficient practice resulted in the inability to ensure that restraints were used under proper medical authority. The absence of physician verification may lead to unauthorized restraint use, which poses a risk to patient rights and dignity. (Refer to A-0063) 5. The Governing Body failed to ensure that the legal admission status (the circumstances under which a patient was admitted and treated. It essentially determines whether the patient is voluntarily seeking help or is being admitted involuntarily) was documented and honored, for two (2) of 43 sampled patients (Patient 23 and Patient 30), in accordance with the facility’s guidelines on “Rights for Individuals in Mental Health Facilities.” This deficient practice resulted in the inability to ensure patients’ legal rights were upheld. Detaining a patient without proper documentation violates patient autonomy (their right to make decisions about their care). (Refer to A-0063) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment. In addition, the cumulative effect of these systemic failures placed patients at risk for physical harm, psychological trauma (a deeply distressing or overwhelming experience that can have significant and lasting negative effects on a person’s mental health and well-being), violation of rights, and preventable medical emergencies. These deficient practices demonstrated that the facility leadership did not provide effective oversight or ensure that appropriate care practices were implemented and followed.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46333 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 provide a certification review hearing (also known as probable cause hearing, a legal proceeding with a specific purpose related to involuntary psychiatric holds to determine if there is sufficient legal justification [probable cause] to continue holding an individual involuntarily for intensive treatment due to a mental disorder), in a timely manner, for three of 43 sampled patients (Patients 23, 24 and 28), in accordance with facility’s policy and procedures regarding certification review hearing as well as state regulations when: 1.a. The facility failed to provide proof of signed voluntary admission for Patient 23. This deficient practice resulted in Patient 23 not receiving a certification review hearing on 5/23/2025 and had a potential to result in detaining Patient 23 unnecessarily. (Refer to A-0129) 1.b. The social services staff did not request and arrange a certification review hearing for Patient 24 after a 5250-hold (14 Days Involuntary Intensive Treatment) was placed on 1/7/2025. This deficient practice resulted in Patient 24 not receiving a certification review hearing and had a potential to result in detaining Patient 24 unnecessarily. (Refer to A-0129) 1.c. The social services staff was delayed in requesting a certification review hearing for Patient 28 after a 5250-hold was placed on 7/18/2025. This deficient practice delayed Patient 28 in receiving a certification review hearing and had potential to result in detaining Patient 28 unnecessarily. (Refer to A-0129) 2. The facility failed to provide a safe environment of care in accordance with the facility’s policy titled “Patient Precautions,” and the facility’s Governing Body (GB, responsible for setting policies, ensuring quality of care, and managing the hospital’s financial health. Essentially, they act as the legal and ethical guardians of the institution and its mission) bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization pertaining to the GB’s accountability for the safety and quality of care, treatment, and services provided), when one (1) of 43 sampled patients (Patient 6), who had a known history of violent and unpredictable behavior, was brought into an unsecured and hazardous area (South Cafeteria). The cafeteria was not designed for patients for de-escalation (is a method to prevent potential violence) and the cafeteria contained furniture and items that could be used as weapons (metal-legged chairs, hard plastic objects). This deficient practice resulted in Patient 6 accessing and picking up a chair with metal legs and throwing the chair at the Director of Admission (DOA), causing a head laceration (a pattern of injury in which blunt forces tear the skin and underlying tissues). As a result, staff-initiated Code 10 (a call for all trained personnel to respond to a dangerous situation) for Patient 6 and a Code Blue (hospital announcement means that an individual is having a medical emergency) for the Director of Admission who suffered a head laceration. Following this event, Patient 6 engaged in another violent episode, during which he (Patient 6) assaulted a second staff member (MHT, Mental Health Technician 5), resulting in a broken nose. (Refer to A-0144) 3. The facility failed to monitor 20 of 43 sampled patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43) in the Psychiatric Intensive Care (relating to acute mental or behavior illness) Unit, every 15 minutes, in accordance with the facility’s policy and procedure regarding supervision of patients and patient rounds, who are admitted to the behavior or mental health unit. This deficient practice placed 20 patients’ safety at risk, such as self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done) and violence. (Refer to A-0144) 4. The facility failed to ensure the physician authenticated a telephone 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) order within 24 hours for one of 43 sampled patients (Patient 29), in accordance with the facility’s policy and procedure regarding restraints use, when Patient 29 was placed on physical restraint (type of physical restraint, a manual or physical method of holding the patient against patient’s will that restricts freedom of movement or normal access to one’s body) on 7/16/2025. This deficient practice resulted in a lack of physician verification of physical restraints use on Patient 29 and had the potential to result in unnecessary restraint use for Patient 29. (Refer to A-0168) 5. The facility failed to ensure its nursing staff notified physician, within 30 minutes, after a face-to-face evaluation (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) was performed for one of 43 sampled patients (Patient 6) on 7/14/2025 and 7/22/2025, in accordance with the facility’s policy and procedure regarding 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). This deficient practice had the potential to result in Patient 6’s physician not knowing Patient 6’s response to restraint and had the potential to lead to Patient 6 not receiving additional treatment or care as needed. (Refer to A-0182) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare 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: 46333 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 ensure nursing staff assessed and documented the blood sugar level for one of 43 sampled patients (Patient 1), in accordance with the facility’s policy regarding Nursing Assessment and Reassessment of Patients, when Patient 1’s blood sugar (body’s source of energy) was not assessed and when Patient 1 received Metformin (medication used to control blood sugar) without a corresponding blood sugar level checked. This deficient practice had the potential for Patient 1 to not receive the appropriate monitoring and interventions and may contribute to Patient 1’s change of condition such as hypoglycemia (low blood sugar) and/or death. (Refer to A-0395) 2. The facility failed to ensure for one of 43 sampled patients (Patient 13), nursing staff supervised care and adhered to the facility’s policy titled, “Supervision of Patients/Patient Rounds (a regular, systematic process where healthcare professionals assess patients),” when Patient 13’s “Round Sheet” did not have the Registered Nurse’s (RN) signature to validate that a patient rounding was completed. This deficient practice had the potential for Patient 13’s care to not have the proper oversight by an RN, which may result in patient harm if the rounding was not accurately performed. (Refer to A-0398) 3. The facility failed to conduct a suicide (thoughts of taking one’s own life) screening (a procedure that uses a standardized instrument or protocol, like a set of questions, to quickly identify individuals who may be at risk for suicide), daily, for one of 43 sampled patients (Patient 15), in accordance with the facility’s policy and procedure regarding suicide screening. This deficient practice resulted in two missed suicide screenings and had the potential for suicide risk to be unidentified for Patient 15, which may result in patient harm and/or death. (Refer to A-0398) 4. The facility failed to ensure its nursing staff adhered to its internal policies and procedures “Code Blue (Emergency overhead announcement for medical resuscitation) and Transferring Patients to the Emergency Room,” and did not follow current American Heart Association (AHA) Basic Life Support (BLS) guidelines (nationally procedures for emergency resuscitation [emergency effort to restore breathing or heartbeat], including chest compressions [pressing on the chest to pump], airway support [keeping breathing passages open], and use of a defibrillator [a device that delivers an electric shock to restart or correct the heart’s rhythm] during cardiac arrest [heart stop] or other life-threatening conditions) for one (1) of 43 sampled patients (Patient 1). This deficient practice resulted in the failure to provide timely and appropriate resuscitation (emergency efforts to restore breathing or heartbeat) for Patient 1 and placed other patients at risk for delayed or inadequate emergencies during future medical emergencies. (Refer to A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 46333 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Medical Record Services was met, as evidenced by: 1. The facility failed to ensure that medical records for 20 of 43 sampled patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43), were accurately written or documented, in accordance with the facility’s policy regarding “Supervision of Patients / Patient Rounds.” The patient rounds (a systematic process where a healthcare team member checks on a patient regularly) conducted, every 15 minutes, in the Intensive Treatment Unit, were inaccurately documented in the medical record for 20 of 43 sampled patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43). This deficient practice led to the inaccurate documentation on 12/20/2025 at 9:45 p.m., that 20 patients had been visualized by a staff, when in fact, the round was not conducted at that time. This deficient practice also placed 20 patients’ safety at risk for self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done) and violence. (Refer to A-0438) 2. The facility failed to ensure staff completed and retained a record of voluntary admission for one of 43 sampled patients (Patient 23), when staff claimed Patient 23 had signed voluntary admission on 5/23/2025 to justify admission and continued hospitalization. This deficient practice resulted in confusion regarding Patient 23’s legal status (the circumstances under which the patient was admitted and/or is being treated - voluntary or involuntary, committed by court, evaluation and recertification are in accordance with state requirements) including an incomplete medical record to reflect Patient 23’s proper legal status for the admission, which had the potential to violate patient’s right regarding voluntary treatment. (Refer to A-0449) 3. The facility failed to ensure all physician orders were dated, timed and authenticated by the ordering physician, in a timely manner (within 24 hours), for one of 43 sampled patients (Patient 29), in accordance with the facility’s policy and procedure regarding 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)/seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving). This deficient practice resulted in a lack of physician verification of order and incomplete medical records. (Refer to A-0454) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“Special Medical Record Requirements CFR(s): Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals The medical records maintained by a psychiatric hospital must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution. This Condition is not met as evidenced by: 46333 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Special Medical Record Requirements, was met, as evidenced by: 1. The facility failed to ensure a patient’s legal status (the circumstances under which the patient was admitted and/or is being treated - voluntary or involuntary, committed by court, evaluation and recertification are in accordance with state requirements) was correctly reflected on one of 43 sampled patient’s (Patient 30) medical record, after Patient 30 signed a voluntary admission on 7/7/2025. This deficient practice resulted in confusion on Patient 30’s legal status and led to unnecessary hold placement (putting a patient in an involuntary admission) on 7/15/2025, which violated Patient 30’s right regarding voluntary treatment. (Refer to A-1622) 2. The facility failed to ensure to develop an individualized treatment plan (a document that outlines an individual’s assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided) for one of 43 sampled patients (Patient 24) to address Patient 24’s past trauma as sexual abuse victim, in accordance with the facility’s policy regarding “Interdisciplinary Patient-Centered Care Planning.” This deficient practice resulted in Patient 24 feeling anxious around male staff conducting patient rounding (a regular, systematic process where healthcare professionals assess patients) at nighttime during Patient 24’s course of hospitalization. (Refer to A-1640) 3. The facility failed to ensure its multidisciplinary team (a group of professionals including physicians, nurses, social workers and therapists who collaborate to provide comprehensive and coordinated patient care) set a long-term goal when developing a treatment plan (a document that outlines an individual’s assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided) for two of 43 sampled patients (Patients 24, and 25), in accordance with the facility’s policy regarding treatment plans. This deficient practice had the potential to result in failure in evaluating patient’s care progress and response to treatment, which may lead to a premature or a delayed discharge. (Refer to A-1642) 4. The facility failed to ensure the medication consent record for one (1) of 43 sampled patients (Patient 5), was completed, in such a way to assure that all active therapeutic efforts were included, in accordance with the facility’s policy titled “Informed Consent For Psychotropic Medications (medications that affect the brain and can alter mood, awareness, thoughts, feelings, or behavior).” Specifically, the facility failed to ensure that the medication consent form for a sedation-hypnotic medication (Ambien, a medication used to treat insomnia [difficulty falling or staying asleep]) included: the dosing range, name and signature of the treating practitioner, the diagnosis, the intended benefits and outcomes of the medication, and documentation of the possibility that the medication may require adjustment. This deficient practice resulted in a medication being administered to Patient 5 without a fully completed and physician signed medication consent form. The medical record did not contain documentation that the physician explained the medication’s risks, benefits, or purpose to Patient 5. This lack of documentation may interfere with the treatment team’s ability to assess informed consent, track treatment planning, and ensure proper authorization. This deficient practice also had the potential to affect other patients if medications were administered without a complete and accurately documented consent process. (Refer to A-1650) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare 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: 46333 Based on observation, interview, and record review, the facility’s Governing Body (the legal responsible leadership group for hospital operations and patient safety) failed to ensure oversight in compliance with the facility’s own policies and procedures for the care of patients as follows: 1. The Governing Body failed to ensure its nursing staff adhered to its internal policies and procedures “Code Blue (emergency call for cardiac [heart] or respiratory arrest [stop breathing]) and Transferring Patients to the Emergency Room,” and did not follow current American Heart Association (AHA) Basic Life Support (BLS) guidelines (nationally procedures for emergency resuscitation [emergency effort to restore breathing or heartbeat], including chest compressions [pressing on the chest to pump], airway support [keeping breathing passages open], and use of a defibrillator [a device that delivers an electric shock to restart or correct the heart’s rhythm] during a cardiac arrest [heart stop] or other life-threatening conditions) for one (1) of 43 sampled patients (Patient 1). This deficient practice resulted in the lack of timely and effective emergency response for a patient (Patient 1) who was found unresponsive (not responding to verbal command, touch, or pain). This deficient practice also increased the likelihood of poor patient outcomes or death during medical emergencies. 2. The Governing Body failed to ensure oversight in maintaining a safe environment for de-escalation (is a method to prevent potential violence), in accordance with the facility’s policy on “Patient Precautions,” for one (1) of 43 sampled patients (Patient 6), who had a known history of violent and unpredictable behavior and was brought into an unsecured and hazardous area (South Cafeteria). The cafeteria was not designed for patients for de-escalation and the cafeteria contained furniture and items that could be used as weapons (metal-legged chairs, hard plastic objects). This deficient practice resulted in patient care areas not being assessed for safety prior to use, which contributed to an actual physical injury (laceration to the head) to the Director of Admission (DOA). The lack of oversight also had the potential to cause further harm to patients and staff if unsafe areas continue to be used for behavioral crisis (a situation where an individual’s mental or emotional state becomes so severe that it poses a threat to their own safety or the safety of others) interventions. 3. The Governing Body failed to ensure oversight on the Nursing Services Department to ensure accurate 15-minute Patient rounding (a regular, systematic process where healthcare professionals assess patients) and Documentation of the patient rounding completed, in accordance with the facility’s policy on supervision of patients/patient rounds, for 20 of 43 sampled patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43). This deficient practice resulted in the inability to ensure accurate monitoring of patients with behavioral health needs, increasing the risk of undetected self-harm (hurting themselves), aggression (behavior aimed at harming others physically), or medical deterioration. Inaccurate rounding may also result in delayed or missed interventions with potentially severe consequences. 4. The Governing Body failed to ensure timely authentication of restraint (any physical restraint that is a mechanical or personal restriction that immobilizes or reduces the ability of an individual to move his or her arms, legs, or head freely) orders, in accordance with the facility’s policy on restraints, for one (1) of 43 sampled patients (Patient 29). This deficient practice resulted in the inability to ensure that restraints were used under proper medical authority. The absence of physician verification may lead to unauthorized restraint use, which poses a risk to patient rights and dignity. 5. The Governing Body failed to ensure that the legal admission status (the circumstances under which a patient was admitted and treated. It essentially determines whether the patient is voluntarily seeking help or is being admitted involuntarily) was documented and honored, for two (2) of 43 sampled patients (Patient 23 and Patient 30), in accordance with the facility’s guidelines on “Rights for Individuals in Mental Health Facilities.” This deficient practice resulted in the inability to ensure patients’ legal rights were upheld. Detaining a patient without proper documentation violates patient autonomy (their right to make decisions about their care). Findings: 1. During a review of Patient 1’s “Daily Progress Note,” dated 12/20/2024, the note indicated, Patient 1 had medical history including: Diabetes (a chronic condition that leads to elevated blood sugar) with diagnoses of schizoaffective (a mental health condition that combines symptoms of both schizophrenia [a mental health condition combining symptoms of schizophrenia [characterized by significant disturbances in thought, perception, emotion, and behavior] and a mood disorder like), and bipolar (a mental illness marked by extreme mood swings from highs [mania] to lows [depression]) disorder. During a review of Patient 1’s medical record document titled, “Code Blue (emergency call for cardiac [heart] or respiratory arrest [stop breathing])/Medical Emergency Documentation,” dated 12/20/2024, the record indicated the following: -Code Blue (Emergency overhead announcement for medical resuscitation) was called at 10:03 p.m. -No AED (Automated External Defibrillator, a portable electronic device that analyzes heart rhythms and delivers an electrical shock to help restore a normal heartbeat in cases of sudden cardiac arrest [heart stops beating]) was applied. -No Blood glucose (Blood sugar) check, despite Patient 1’s diabetes diagnosis. -Documentation indicated “mouth sweep (inserting fingers into the mouth to remove a blockage- should only be done if the object is visible), Heimlich maneuver (abdominal thrusts to relieve choking-should only be used when there are signs of choking), with no documented evidence that the patient was choking or had a visible obstruction. During an interview on 7/22/2025 at 3:41 p.m. with RN 11, RN 11stated they were unsure whether to apply the AED if the patient was unresponsive but had a pulse. During a concurrent observation and interview on 7/22/2025 at 12:13 p.m. with the Assistant Chief Nursing Officer/ Clinical Educator (ACNO), in Unit ABC, the crash cart (a mobile cart containing emergency resuscitation equipment) was found lacking a suction machine (device used in hospitals to remove fluids and secretions from a patient’s body, primarily the airway). The ACNO confirmed the facility did not have suction equipment available for use during a Code Blue. During a concurrent interview and surveillance video observation and review on 7/24/2025 at 10:08 a.m. with the Director of Risk Management (DRM), the video footage, dated 12/20/2024, showed the following: -At 10:01:00 p.m., Registered Nurse (RN) 9 and Certified Nurse Assistant (CNA, Certified nursing assistants provide basic care to patients) 1 entered Patient 1’s room. -At 10:02:00 p.m., RN 9 and CNA 1 exited the room. -At 10:02:36 p.m., CNA 1 re-entered Patient 1’s room -At 10:03:00 p.m., RN 9 returned, and Code Blue was called. During the same interview on 7/24/2025 at 10:08 a.m. with the Director of Risk Management (DRM), the DRM confirmed there was a two -minute delay between discovery of the unresponsive patient (Patient 1) and the initiation of emergency procedures (such as calling a code blue). During an interview on 7/25/2025 at 5:58 p.m. with Registered Nurse (RN) 1, RN 1 stated the facility did not have a suction equipment installed on the unit (Unit ABC). RN 1 stated there was a training conducted on suction machines a month prior, but confirmed the equipment was still unavailable during medical emergencies, leaving staff without a method to clear a patient’s airway when needed. During an interview with the Chief Executive Officer (CEO, is the top administrator of a hospital or a network of hospitals. They are responsible for the overall management and strategic direction of the organization, including its operations, finances, and quality of care) on 7/25/2025 at 6:30 p.m., the CEO stated that the Governing Body was responsible for oversight of patient safety, financial matters, regulatory compliance, environmental safety, policy approval, and credentialing of medical providers. During a review of the facility’s policy and procedure (P&P) titled, “Code Blue and Transferring Patients to the Emergency Room,” dated June 2025, the P&P indicated, “The staff member who finds/witnesses the medical emergency will immediately call for help and have a Code Blue paged overhead. The Code Blue will be paged overhead three times, including the location. The staff member will not leave the patient alone. The staff from the unit housing the patient will bring the vital signs machine, accu-check machine (used to check blood sugar), AED, oxygen tank, emergency crash carts, and any other pertinent equipment/supplies, based on the situation ...” During a review of the facility’s policy and procedure (P&P) titled, “Medical Emergencies and Acute Change in Condition,” dated May 2025, the P&P indicated, “An RN may initiate a 911 call prior to calling the physician and House Supervisor ... Airway Problems: If the patient is coughing or can speak, stay with the patient and encourage continued coughing ... If the patient continues to cough ineffectively and appears to be in increasing distress, the object may be totally obstructing the airway. Call 911 and initiate a Code Blue. If the patient cannot speak or breathe, perform abdominal thrusts, call 911, and initiate a Code Blue.” During a review of the American Heart Association (AHA) 2020 Guidelines for CPR and Emergency Cardiovascular Care, Part 3 - Part 8: Adult Basic and Advance Life Support,” indicated the following: -“Initiate CPR immediately; do not leave the victim unattended.” -“Apply AED to all unresponsive patients regardless of the presence of a pulse, to analyze heart rhythm and guide next steps.” -“Suction equipment should be readily available in hospital settings where cardiac arrest may occur.” -“The Heimlich maneuver (abdominal thrusts) and finger sweeps should only be used when a foreign body airway obstruction is clearly present.” During review of the facility’s Bylaws (provide a framework for the hospital’s operations, ensuring accountability, quality of care, and adherence to legal and ethical standards) of the Board of Governors, dated 4/1/2020, indicated, “The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital. The primary purposes of the Hospital are to own and operate a behavioral health care facility and to perform such other activities for such other purposes as authorized by the Corporate Entity’s governing corporate documents and as authorized by the Corporate Governing Body.” 2. During a review of Patient 6’s “Daily Progress Note,” dated 7/18/2025, the note indicated Patient 6’s diagnoses included psychosis (a mental health condition where a person loses touch with reality), schizophrenia (a mental illness affecting thought, emotion, and behavior), and documented high risk for “self-harm or harm to others.” The note also indicated Patient 6 had a history of assaultive behavior (refers to actions or behaviors that involve physical aggression, threats, or actions intended to cause physical harm or injury to another person). During a surveillance video review of the South Cafeteria, on 7/23/2025 at 11:30 a.m. (video dated 7/22/2025 at 2:42 p.m.), in the presence of the Director of Quality and DQPI), the following events were observed: -Nurse Manager (NM) escorted Patient 6 to the South Cafeteria and provided a soda as part of a calming strategy. - Patient 6 approached the soda machine, served himself, and sat with NM 1. - A second Staff member (Staff 1) entered the cafeteria and sat at the opposite end of the room. -Patient 6 suddenly stood up and chased Staff 1 around the table. - Patient 6 then picked up a metal chair with metal legs and threw it at the Director of Admission (DOA), striking him (DOA) in the forehead and causing a head laceration (a deep cut or tear in the skin). - The DOA clutched his (DOA) head, and staff-initiated Code 10 (call for emergency trained responders) for Patient 6, and a Code Blue (medical emergency alert) for DOA (due to head laceration). During an interview on 7/23/2025 at 4:20 p.m. with the Director of Plant Operation and Safety officer (DPO), DPO stated the cafeteria chairs were made of metal and it was not appropriate to bring an agitated patient to that environment. During a concurrent interview and record review on 7/25/2025 at 8:45 p.m. with the Director of Plant Operations and Safety Officer (DPO, the staff member in charge of facility safety and maintenance), the facility’s “Environmental Rounds,” checklist was reviewed and there was no checklist for the facility’s cafeterias. The DPO stated that monthly EOC rounds were conducted to identify safety hazards. However, DPO confirmed that the South Cafeteria, which contained chairs with metal legs (items that could be used as weapons), was not included in the routine EOC rounding. The DPO stated that EOC rounds were conducted monthly to identify safety hazards. However, the South Cafeteria which contained chairs with metal legs was not included because it was considered a “non-patient care area.” The DPO also confirmed that patients routinely used the cafeteria for meals and, in some cases, for de-escalation (a behavioral intervention used to calm agitated (feeling worried, uneasy, or disturbed, and showing this through restlessness or physical behavior) patients without using physical restraint or medication). The DPO stated the cafeteria would now be added to future EOC rounds. During an interview with the Chief Executive Officer (CEO, is the top administrator of a hospital or a network of hospitals. They are responsible for the overall management and strategic direction of the organization, including its operations, finances, and quality of care) on 7/25/2025 at 6:30 p.m., the CEO stated that the Governing Body was responsible for oversight of patient safety, financial matters, regulatory compliance, environmental safety, policy approval, and credentialing of medical providers. During a review of the facility’s policy and procedure (P&P) titled, “Patient Precautions,” dated 7/2025, the P&P indicated, “All patients are assessed for risks of suicide (thoughts of taking one’s own life)/self-harm, assault (refers to actions or behaviors that involve physical aggression, threats, or actions intended to cause physical harm or injury to another person), fall (an unexpected event where a patient unintentionally comes to rest on the ground or a lower level, like a bed or chair, during their hospital stay) ...and elopement (when a patient leaves the healthcare facility without authorization or notice) upon admission. All patients are also re-assessed for the same risk factors on a daily basis throughout their hospitalization to determine if there are any changes in their level of risk. Patients will also be re¿assessed for risk whenever there is an abrupt change in their behavior or mental status. Once risk factors are identified, the physician will determine appropriate precautions for each patient ... All patients identified to be on Assault Precautions will have the following measure initiated: May be restricted to the unit ... Monitor closely and ensure that vulnerable patients are monitored for safety ...Monitor and assess for environmental risks, including contraband, property damage, and items that could be used as weapons ... If an assault occurs: RN will assess and consult with attending psychiatrist for additional interventions including but not limited to: Change in observation level ... 1 :1 therapy ...” During a review of the facility’s Bylaws (provide a framework for the hospital’s operations, ensuring accountability, quality of care, and adherence to legal and ethical standards) of the Board of Governors, dated 4/1/2020, indicated, “The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital. The primary purposes of the Hospital are to own and operate a behavioral health care facility and to perform such other activities for such other purposes as authorized by the Corporate Entity’s governing corporate documents and as authorized by the Corporate Governing Body.” 3. During a video surveillance observation and review on 7/24/2025 at 10:08 a.m. with the Chief Nursing Officer (CNO) and the Director of Risk Management (DRM), a video footage of the Intensive Treatment Unit, dated 12/20/2024, was reviewed. The video footage on 12/20/2024 starting at 9 p.m. and ending at 11 p.m. indicated patient rounds (a systematic process where a healthcare team member checks on a patient regularly) were not performed for 20 Patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43), at 9:45 p.m. This video footage was in contrast with what staff documented that the 20 patients in the Intensive Treatment Unit (ITU) were checked during the required 15-minute safety rounds on 12/20/2024. During an interview on 7/24/2025 at 1:53 a.m., with the Chief Executive Officer (CEO), the CEO stated he (CEO) was aware that patient rounds had not been conducted on 12/20/2025 at 9:45 p.m., and verified that the Rounding Sheets for Patient 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43) had been “falsification” of a document. During a review of “Round Sheet,” dated 12/20/2024, for Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43, the Round Sheets indicated that rounds had been conducted at 9:45 p.m. The CNO and the CEO verified that the documentation was inaccurate. During an interview with the Chief Executive Officer (CEO, is the top administrator of a hospital or a network of hospitals. They are responsible for the overall management and strategic direction of the organization, including its operations, finances, and quality of care) on 7/25/2025 at 6:30 p.m., the CEO stated that the Governing Body was responsible for oversight of patient safety, financial matters, regulatory compliance, environmental safety, policy approval, and credentialing of medical providers. During a review of the facility’s policy and procedure (P&P) titled, “Supervision of Patients/Patient Rounds,” dated 7/2025, the P&P indicated the following: All patients who require supervision and rounds, are conducted continuously with each patient’s location and behavior documented every 15 minutes. The staff assigned to the initial rounds will ensure that the Round Sheets for all patients on every 15-minute rounding are completed thoroughly and accurately. During review of the facility’s Bylaws (provide a framework for the hospital’s operations, ensuring accountability, quality of care, and adherence to legal and ethical standards) of the Board of Governors, dated 4/1/2020, indicated, “The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital. The primary purposes of the Hospital are to own and operate a behavioral health care facility and to perform such other activities for such other purposes as authorized by the Corporate Entity’s governing corporate documents and as authorized by the Corporate Governing Body.” 4. During a review of Patient 29’s face sheet (face sheet, document provides patient’s demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance) titled, “Patient Demographic Profile,” dated 7/14/2025, the face sheet indicated Patient 29 was an involuntary admission with admitting diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During a concurrent interview and record review on 7/25/2025 at 4:41 p.m. with the Director of Risk Management (DRM), Patient 29’s physical 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) order titled, “Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving)/Restraint/Chemical Restraint (use of medications to control a patient’s behavior or restrict freedom of movement) Order,” dated 7/16/2025, was reviewed. The physician restraint order indicated a telephone order was obtained for use of Physical Restraint on Patient 29 on 7/16/2025 at 2:12 p.m. The physician restraint order also indicated physician did not sign off on the order. DRM stated the order was missing a physician’s signature. During an interview on 7/25/2025 at 7:10 p.m. with the Chief Nursing Officer (CNO), CNO stated the following: a physician order was required when putting a patient on restraint. The physician was required to authenticate the order within 24 hours. It would be considered as restraining patient without physician order because the physician did not sign off on the order (telephone order). During an interview with the Chief Executive Officer (CEO, is the top administrator of a hospital or a network of hospitals. They are responsible for the overall management and strategic direction of the organization, including its operations, finances, and quality of care) on 7/25/2025 at 6:30 p.m., the CEO stated that the Governing Body was responsible for oversight of patient safety, financial matters, regulatory compliance, environmental safety, policy approval, and credentialing of medical providers. During a review of the facility’s policy and procedure (P&P) titled, “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion,” dated 7/2025, the P&P indicated, “Restraints or seclusion shall be used in emergency situations only and requires an order from a physician ... the physician shall authenticate the telephone/verbal order within 24 hours.” During review of the facility’s Bylaws (provide a framework for the hospital’s operations, ensuring accountability, quality of care, and adherence to legal and ethical standards) of the Board of Governors, dated 4/1/2020, indicated, “The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital. The primary purposes of the Hospital are to own and operate a behavioral health care facility and to perform such other activities for such other purposes as authorized by the Corporate Entity’s governing corporate documents and as authorized by the Corporate Governing Body.” 5.a. During a review of Patient 23’s “Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 5/17/2025, the Psych Eval indicated, Patient 23 was admitted to the facility with diagnoses including but not limited to bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration). During a concurrent interview and record review on 7/25/2025 at 2:45 p.m. with the Director of Clinical Services (DCS), Patient 23’s “Certification Review Hearing (also known as probable cause hearing, a legal proceeding with a specific purpose related to involuntary psychiatric holds to determine if there is sufficient legal justification [probable cause] to continue holding an individual involuntarily for intensive treatment due to a mental disorder) Record,” dated 5/23/2025, was reviewed. The “Certification Review Hearing Record” indicated, “the hearing was not held. Reason: patient (Patient 23) has signed VOL (voluntary admission) per [staff].” DCS stated the hearing was not held because Patient 23 signed for voluntary admission. During an interview on 7/25/2025 at 2:46 p.m. with DCS, DCS stated the following: there was no voluntary admission form found in Patient 23’s medical record. A patient would sign the voluntary admission form when changing legal status (the circumstances under which the patient was admitted and/or is being treated - voluntary or involuntary, committed by court, evaluation and recertification are in accordance with state requirements) from involuntary to voluntary. The Psychiatrist (physician specializes in mental health) would then sign the voluntary admission form to confirm the voluntary admission. Patient 23 remained as involuntary admission during the hospital stay and did not receive a certification review hearing. DCS also stated it was important to have accurate medical record to reflect patient’s legal status. Without the proof of voluntary admission form, there would be confusion on patient’s legal status. During an interview with the Chief Executive Officer (CEO, is the top administrator of a hospital or a network of hospitals. They are responsible for the overall management and strategic direction of the organization, including its operations, finances, and quality of care) on 7/25/2025 at 6:30 p.m., the CEO stated that the Governing Body was responsible for oversight of patient safety, financial matters, regulatory compliance, environmental safety, policy approval, and credentialing of medical providers. During a review of the facility’s patient handbook titled, “Rights for Individuals in Mental Health Facilities,” dated 7/2018, the patient handbook indicated, “If you are held beyond 72 hours, you have the right to remain in the hospital for voluntary treatment. If you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four (4) days of the end of your 72-hour hold. You may be represented at this hearing by a patient’s rights advocate or another person of your choice. You can also request to have family members to help explain your circumstances.” During review of the facility’s Bylaws (provide a framework for the hospital’s operations, ensuring accountability, quality of care, and adherence to legal and ethical standards) of the Board of Governors, dated 4/1/2020, indicated, “The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital. The primary purposes of the Hospital are to own and operate a behavioral health care facility and to perform such other activities for such other purposes as authorized by the Corporate Entity’s governing corporate documents and as authorized by the Corporate Governing Body.” 5.b. During a review of Patient 30’s “Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 6/30/2025, the Psych Eval indicated, Patient 30 was admitted to the facility with diagnoses including but not limited to major depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), severe, recurrent (repeat), with psychosis (a severe mental disorder with hallucinations [an experience involving the apparent perception of something not present]) and post-traumatic stress disorder (PTSD, an anxiety disorder that develops after experiencing stressful, frightening or distressing events). During a concurrent interview and record review on 7/25/2025 at 3:11 p.m. with DCS, Patient 30’s involuntary hold notice titled, “Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment) of the Welfare and Institutions Code,” dated 7/15/2025, the involuntary hold notice indicated, Patient 30 was placed on a 30-day hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 30 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for gravely disability due to being “irritable, labile (a tendency to be unpredictable), still working on a viable safety plan for discharge.” DSC stated this hold was unnecessary because Patient 30 was already on voluntary status since 7/7/2025. During a review of the facility’s patient handbook titled, “Rights for Individuals in Mental Health Facilities,” dated 7/2018, the patient handbook indicated, “If you are held beyond 72 hours, you have the right to remain in the hospital for voluntary treatment. If you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four (4) days of the end of your 72-hour hold.” During an interview with the Chief Executive Officer (CEO, is the top administrator of a hospital or a network of hospitals. They are responsible for the overall management and strategic direction of the organization, including its operations, finances, and quality of care) on 7/25/2025 at 6:30 p.m., the CEO stated that the Governing Body was responsible for oversight of patient safety, financial matters, regulatory compliance, environmental safety, policy approval, and credentialing of medical providers. During review of the facility’s Bylaws (provide a framework for the hospital’s operations, ensuring accountability, quality of care, and adherence to legal and ethical standards) of the Board of Governors, dated 4/1/2020, indicated, “The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital. The primary purposes of the Hospital are to own and operate a behavioral health care facility and to perform such other activities for such other purposes as authorized by the Corporate Entity’s governing corporate documents and as authorized by the Corporate Governing Body.””

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to provide a certification review hearing (also known as probable cause hearing, a legal proceeding with a specific purpose related to involuntary psychiatric holds to determine if there is sufficient legal justification [probable cause] to continue holding an individual involuntarily for intensive treatment due to a mental disorder), in a timely manner, for three of 43 sampled patients (Patients 23, 24 and 28), in accordance with facility’s policy and procedures regarding certification review hearing as well as state regulations when: 1. The facility failed to provide proof of signed voluntary admission for Patient 23. This deficient practice resulted in Patient 23 not receiving a certification review hearing on 5/23/2025 and had a potential to result in detaining Patient 23 unnecessarily. 2. The social services staff did not request and arrange a certification review hearing for Patient 24 after a 5250-hold (14 Days Involuntary Intensive Treatment) was placed on 1/7/2025. This deficient practice resulted in Patient 24 not receiving a certification review hearing and had potential to result in detaining Patient 24 unnecessarily. 3. The social services staff was delayed in requesting a certification review hearing for Patient 28 after a 5250-hold was placed on 7/18/2025. This deficient practice delayed Patient 28 in receiving a certification review hearing and had potential to result in detaining Patient 28 unnecessarily. Findings: 1. During a review of Patient 23’s “Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 5/17/2025, the Psych Eval indicated, Patient 23 was admitted to the facility with diagnoses including but not limited to bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 23’s face sheet (face sheet, document provides patient’s demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance) titled, “Patient Demographic Profile,” dated 5/25/2025, the face sheet indicated Patient 23 was an involuntary admission from 5/17/2025 to 5/24/2025. During an interview on 7/25/2025 at 11:22 a.m. with the Director of Clinical Services (DCS), DCS stated the following: social services staff would file a request for certification review hearing the next business day with court after a patient was placed on 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment). The hearing would be scheduled by the court within four (4) days. The court would then determine whether there was probable cause (sufficient legal justification) existing to detain the patient for involuntary detainment for psychiatric treatment. During a review of Patient 23’s involuntary hold notice titled, “Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment) of the Welfare and Institutions Code,” dated 5/19/2025, the involuntary hold notice indicated Patient 23 was placed on 14-day hold due to danger to himself or herself on 5/19/2025. During a concurrent interview and record review on 7/25/2025 at 2:45 p.m. with DCS, Patient 23’s “Certification Review Hearing Record,” dated 5/23/2025, was reviewed. The “Certification Review Hearing Record” indicated, “the hearing was not held. Reason: patient (Patient 23) has signed VOL (voluntary admission) per [staff].” DCS stated the hearing was not held because Patient 23 signed for voluntary admission. During an interview on 7/25/2025 at 2:46 p.m. with DCS, DCS stated the following: there was no voluntary admission form found in Patient 23’s medical record. A patient would sign the voluntary admission form when changing legal status (the circumstances under which the patient was admitted and/or is being treated - voluntary or involuntary, committed by court, evaluation and recertification are in accordance with state requirements) from involuntary to voluntary. The Psychiatrist (physician specializes in mental health) would then sign the voluntary admission form to confirm the voluntary admission. Patient 23 remained as involuntary admission during the hospital stay and did not receive a certification review hearing. During a review of the facility’s policy and procedure (P&P) titled, “Certification Review Hearings,” dated 5/2025, the P&P indicated, “In accordance with [state] Welfare and Institution Code (WIC) 5256.4 and 5276, every patient detained under these articles shall have a certification hearing within 4 days of the initiation of that certification ... Procedure ... The process of Probable Cause Hearings is as follows: A. All patients on a 5250 or a 5270.15 must be provided a copy of the completed Notice of Certification on the date it is issued by the physician who executes the Certification. The Physician or designee must inform the patients that: 1. He or she will have a certification review hearing within four (4) days to determine whether or not there is “probable cause” to detain him or her ... the social worker must ... 3. Complete “Mental Health Court Notification of Holds” form (CLIN-078) notifying the Superior Court Department 95 of the initiation of the certification and patient’s request to have family member or support person present. A. This form is to be completed within 24 hours (excluding weekends, holidays and court furlough days) of the initiation of the certification.” During a review of the facility’s patient handbook titled, “Rights for Individuals in Mental Health Facilities,” dated 7/2018, the patient handbook indicated, “If you are held beyond 72 hours, you have the right to remain in the hospital for voluntary treatment. If you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four (4) days of the end of your 72-hour hold. You may be represented at this hearing by a patients’ rights advocate or another person of your choice. You can also request to have family members present to help explain your circumstances.” 2. During a review of Patient 24’s “Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 1/5/2025, the Psych Eval indicated, Patient 24 was admitted to the facility on 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 and treatment) with diagnoses including but not limited to bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), depressed (mood disorder that causes a persistent feeling of sadness and loss of interest in life) type, without psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality), posttraumatic stress disorder (PTSD, an anxiety disorder that develops after experiencing stressful, frightening or distressing events) and diabetes (high blood sugar). During an interview on 7/25/2025 at 11:22 a.m. with the Director of Clinical Services (DCS), DCS stated the following: social services staff would file a request for certification review hearing the next business day with court after a patient was placed on 5250-hold. The hearing would be scheduled by the court within four (4) days. The court would then determine whether there was probable cause (sufficient legal justification) existing to detain the patient for involuntary detainment for psychiatric treatment. During a review of Patient 24’s involuntary hold notice titled, “Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment) of the Welfare and Institutions Code,” dated 1/7/2025, the involuntary hold notice indicated, Patient 24 was placed on 14-day hold due to danger to himself or herself and gravely disabled (inability to care for one’s self) on 1/7/2025. During an interview on 7/25/2025 at 3:12 p.m. with DCS, DCS stated social services staff did not send a request of certification review hearing for Patient 24. Patient 24 did not receive a certification review hearing during the hospitalization. During a review of the facility’s policy and procedure (P&P) titled, “Certification Review Hearings,” dated 5/2025, the P&P indicated, “In accordance with [state] Welfare and Institution Code (WIC) 5256.4 and 5276, every patient detained under these articles shall have a certification hearing within 4 days of the initiation of that certification ... Procedure ... The process of Probable Cause Hearings is as follows: A. All patients on a 5250 or a 5270.15 must be provided a copy of the completed Notice of Certification on the date it is issued by the physician who executes the Certification. The Physician or designee must inform the patients that: 1. He or she will have a certification review hearing within four (4) days to determine whether or not there is “probable cause” to detain him or her ... the social worker must ... 3. Complete “Mental Health Court Notification of Holds” form (CLIN-078) notifying the Superior Court Department 95 of the initiation of the certification and patient’s request to have family member or support person present. A. This form is to be completed within 24 hours (excluding weekends, holidays and court furlough days) of the initiation of the certification.” During a review of the facility’s patient handbook titled, “Rights for Individuals in Mental Health Facilities,” dated 7/2018, the patient handbook indicated, “If you are held beyond 72 hours, you have the right to remain in the hospital for voluntary treatment. If you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four (4) days of the end of your 72-hour hold. You may be represented at this hearing by a patients’ rights advocate or another person of your choice. You can also request to have family members present to help explain your circumstances.” 3. During a review of Patient 28’s “Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 7/18/2025, the Psych Eval indicated, Patient 28 was admitted to the facility with diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), chronic, paranoid type (having excessive or irrational distrust and suspicion of others, often believing that they are plotting against you or trying to harm you), with acute (new onset) exacerbation (worsening). During an interview on 7/25/2025 at 11:22 a.m. with the Director of Clinical Services (DCS), DCS stated the following: social services staff would file a request for certification review hearing the next business day with court after a patient was placed on 5250-hold. The hearing would be scheduled by the court within four (4) days. The court would then determine whether there was probable cause (sufficient legal justification) existing to detain the patient for involuntary detainment for psychiatric treatment. During a review of Patient 28’s involuntary hold notice titled, “Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment) of the Welfare and Institutions Code,” dated 7/18/2025, the involuntary hold notice indicated, Patient 28 was placed on 14-day hold due to danger to himself or herself and gravely disabled, on 7/18/2025. During an interview on 7/25/2025 at 5:13 p.m. with DCS, DCS stated social service staff submitted a request for certification review hearing for Patient 28 on 7/23/2025. DCS stated it was two (2) days late (should be on 7/21/2025). DCS stated it could cause delay in scheduling certification review hearing for Patient 28. During a review of the facility’s policy and procedure (P&P) titled, “Certification Review Hearings,” dated 5/2025, the P&P indicated, “In accordance with [state] Welfare and Institution Code (WIC) 5256.4 and 5276, every patient detained under these articles shall have a certification hearing within 4 days of the initiation of that certification ... Procedure ... The process of Probable Cause Hearings is as follows: A. All patients on a 5250 or a 5270.15 must be provided a copy of the completed Notice of Certification on the date it is issued by the physician who executes the Certification. The Physician or designee must inform the patients that: 1. He or she will have a certification review hearing within four (4) days to determine whether or not there is “probable cause” to detain him or her ... the social worker must ... 3. Complete “Mental Health Court Notification of Holds” form (CLIN-078) notifying the Superior Court Department 95 of the initiation of the certification and patient’s request to have family member or support person present. A. This form is to be completed within 24 hours (excluding weekends, holidays and court furlough days) of the initiation of the certification.” During a review of the facility’s patient handbook titled, “Rights for Individuals in Mental Health Facilities,” dated 7/2018, the patient handbook indicated, “If you are held beyond 72 hours, you have the right to remain in the hospital for voluntary treatment. If you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four (4) days of the end of your 72-hour hold. You may be represented at this hearing by a patients’ rights advocate or another person of your choice. You can also request to have family members present to help explain your circumstances.””

“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: 46333 Based on observation, interview, and record review, the facility failed to: 1. Provide a safe environment of care in accordance with the facility’s policy titled, “Patient Precautions” and the facility’s Governing Body (GB, responsible for setting policies, ensuring quality of care, and managing the hospital’s financial health. Essentially, they act as the legal and ethical guardians of the institution and its mission) bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization pertaining to the GB’s accountability for the safety and quality of care, treatment, and services provided), when one (1) of 43 sampled patients (Patient 6), who had a known history of violent and unpredictable behavior, was brought into an unsecured and hazardous area (South Cafeteria). The cafeteria was not designed for patients for de-escalation (is a method to prevent potential violence) and the cafeteria contained furniture and items that could be used as weapons (metal-legged chairs, hard plastic objects). This deficient practice resulted in Patient 6 accessing and picking up a chair with metal legs and throwing the chair at the Director of Admission (DOA), causing a head laceration (a pattern of injury in which blunt forces tear the skin and underlying tissues). As a result, staff-initiated Code 10 (a call for all trained personnel to respond to a dangerous situation) for Patient 6 and a Code Blue (hospital announcement means that an individual is having a medical emergency) for the Director of Admission who suffered a head laceration. Following this event, Patient 6 engaged in another violent episode, during which he (Patient 6) assaulted a second staff member (MHT, Mental Health Technician 5), resulting in a broken nose. 2. Monitor twenty (20) of 43 sampled patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43) in the Psychiatric Intensive Care (relating to acute mental or behavior illness) Unit, every 15 minutes, in accordance with the facility’s policy and procedure regarding supervision of patients and patient rounds, who are admitted to the behavior or mental health unit. This deficient practice placed 20 patients’ safety at risk, such as self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done) and violence. On 7/24/2025 at 5:47 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 Executive Officer (CEO), Chief Nursing Officer (CNO), Regional Vice President (RVP), and the Director of Quality and Performance Improvement Compliance Officer (DQPI). The facility failed to provide a safe environment by not providing appropriate safety measures by bringing Patient 6 who was in an aggressive (ready or likely to attack or confront) state, who had known history of violent and unpredictable behavior into an unsecured area (South cafeteria) not designed for de-escalation (the process of reducing the intensity of a conflict or crisis, typically through communication and strategic actions, to prevent or minimize harm to all parties involved), with access to potential weapons (chairs, metal legs, and hard plastic objects). The facility lacked adequate risk assessment and failed to implement a safe intervention plan, appropriate use of seclusion, and observation. This deficient practice resulted in a staff injury (head laceration to the Director of Admission) and a subsequent violent episode causing a broken nose to another staff member (MHT, Mental Health Technician) 5. This deficient practice created an ongoing and immediate threat of harm not only to staff, but to all patients in the facility. During a review of Patient 6’ “Daily Progress Note,” dated 7/18/2025, the note indicated Patient 6 diagnoses included psychosis (a mental health condition where a person loses touch with reality), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), capacity for self-harm or harm to others was high, and had prior aggression behavior (violent or threatening actions toward others). On 7/22/2025, at 2:42 p.m., surveillance video showed that staff brought Patient 6 into the South cafeteria to calm Patient 6 down (a process called de-escalation). However, the cafeteria was not a secure area and contained removable wooden chairs with metal legs and other hard objects (such as hard food trays) that could be used as weapons. While in the cafeteria, Patient 6 became physically aggressive. The video showed Patient 6 chasing a staff member (DOA, Director of Admission) and throwing a chair at the DOA, hitting the DOA in the head and causing a laceration (a deep cut). After the incident, Patient 6 was taken back to a shared room in the unit with other patients, and no additional supervision-such as one-to-one observation (having a staff member assigned to watch one patient closely at all times)- was put in place. Shortly after, Patient 6 assaulted another staff member (MHT, Mental Health Technician) 5, resulting in a nasal fracture (a broken nose). During an Interview on 7/24/225 at 3:34 p.m. with Nurse Manger (NM) 1, NM 1 confirmed that the cafeteria was regularly used to calm down agitated patients, even though it was not a ligature-free area (a space that does not contain items that could be used for self-harm or harm others). NM 1 also confirmed that the chairs and furniture in the cafeteria were unsafe for this purpose. On 7/25/2025 at 9:06 p.m., the IJ was removed in the presence of the RVP via phone, CNO, CEO, DQPI, Chief Operating Officer (COO), Division of Director of Clinical Services (DDCS) via phone, Director of Pharmacy (DP), Director of Clinical Services/ licensed marriage family therapist (DCS), and Director of Plant Operation (DPO). The elements of the IJ Removal Plan (interventions to correct the deficient practice) were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated: 1. All metal chairs in the cafeteria were immediately removed and replaced with blunt-edged plastic chairs. The cafeteria will no longer be used for patient de-escalation. 2. The “Patient Precautions” policy was modified to include that any patient in an agitated state will be assessed by unit RN or House Supervisor to determine adequate risk and a safe intervention plan that may include not being allowed to go to cafeteria. 3. Risk assessment (existing nursing re-assessment when change in behavior or condition) will be reviewed with the treatment team, consisting of physician, nurse and social worker for implementation of an alternative plan that will assist in de-escalation of patients demonstrating increased aggression. 4. De-escalation efforts with agitated/aggressive patients will be implemented on the unit in an area without plastic chairs or in the courtyard that is secured by being devoid of sharp objects, objects that can be lifted and thrown, and peripheral doors closed, restricting access back on to the unit and affording the patient with less stimulation. The patient will return to the unit when assessed to be in a calm and safe state. 5. Alternative treatment plans that address de-escalation of an aggressive patient may include removing the patient from the milieu to decrease stimulation accompanied by two clinical staff members trained in Handle with Care, and preferably those with the most rapport with patient, onto an area without plastic chairs or in the courtyard that is secured by being devoid of sharp objects, objects that can be lifted and thrown, and peripheral doors closed, restricting access back on to the unit and affording the patient with less stimulation. The patient will return to the unit when assessed to be in a calm and safe state. 6. The Patient Precautions policy was reviewed and revised to include restriction of agitated and assaultive patients to the Unit when not responding to de-escalation techniques. For the safety of other patients and staff, the agitated/assaultive patient may require seclusion to decrease danger to others. 7. All RNs, LVNs, LPNs and Mental Health Workers were trained in the revised Patient Precautions policy. Training was initiated on 7/24/25 to include all scheduled nursing staff on the night shift and conducted by the CNO, ACNO, or designee. Training will continue on 7/25/25 with day shift nursing staff and on all shifts until training is completed. Staff that do not attend this training will not be scheduled to work until training is completed. Findings: 1. During a review of Patient 6’s “Daily Progress Note,” dated 7/18/2025, the note indicated Patient 6’s diagnoses included psychosis (a mental health condition where a person loses touch with reality), schizophrenia (a mental illness affecting thought, emotion, and behavior), and documented high risk for “self-harm or harm to others.” The note also indicated Patient 6 had a history of assaultive behavior (refers to actions or behaviors that involve physical aggression, threats, or actions intended to cause physical harm or injury to another person). During a surveillance video review of the South Cafeteria on 7/23/2025 at 11:30 a.m. (video dated 7/22/2025 at 2:42 p.m.), in the presence of the Director of Quality and DQPI), the following events were observed: -Nurse Manager (NM) escorted Patient 6 to the South Cafeteria and provided a soda as part of a calming strategy. - Patient 6 approached the soda machine, served himself, and sat with NM 1. - A second Staff member (Staff 1) entered the cafeteria and sat at the opposite end of the room. -Patient 6 suddenly stood up and chased Staff 1 around the table. - Patient 6 then picked up a metal chair with metal legs and threw it at the Director of Admission (DOA), striking him (DOA) in the forehead and causing a head laceration (a deep cut or tear in the skin). - The DOA clutched his (DOA) head, and staff-initiated Code 10 (call for emergency trained responders) and a Code Blue (medical emergency alert). During an observation on 7/22/2025 at 5:30 p.m., with the Chief Executive Officer (CEO) at the South cafeteria. The cafeteria contained 12 dining tables, each with multiple removable chairs that had metal legs. Additionally, a stack of approximately 30 large plastic trays was observed on an open shelf that was accessible to anyone present in the cafeteria, including patients. During an interview on 7/22/2025 at 3:12 p.m. with Registered Nurse (RN) 6, RN 6 stated that staff commonly used the cafeteria, courtyard, or dayroom to calm agitated (feeling worried, uneasy, or disturbed, and showing this through restlessness or physical behavior) patients. During an interview on 7/23/2025 at 3:34 p.m. with Nurse Manger (NM)1, NM 1 stated Patient 6 was upset with a staff on the unit and was getting agitated. NM 1 stated she (NM 1) offered to take Patient 6 to the cafeteria to get a soda to de-escalate the situation. NM 1 stated that during the middle of the conversation with her (NM 1), Patient 6 got up and went toward Staff 1. NM 1 stated Patient 6 had a history of aggression and especially toward male staff and was unpredictable. NM1 stated designated areas to take patients for de-escalation were the two courtyards, the 2-day rooms, and the South Cafeteria. NM 1 also confirmed that Patient 6 hit DOA on the head with the chair. NM 1 stated the chairs in the cafeteria were of concern regarding safety. During the same interview on 7/23/2025 at 3:34 p.m. with Nurse Manager (NM) 1, NM1 stated after the incident, Patient 6 was taken back to the room where other patients were housed. Additionally, Patient 6 was aggressive towards another staff member (MHT 5), assaulted the staff (MHT 5), and broke his (MHT 5’s) nose. Patient 6 was not isolated from others and was not assigned a sitter (caregiver who provides continuous supervision to a patient) or a line-of-sight monitoring (staff to have continuous visual of the patient). NM1 stated Patient 6 was on “Assault Precaution (monitor and assess for environmental risks, including contraband (anything that can be used as a weapon such as lighters, razors, and knives), property damaged, and items that could be used as a weapons). NM 1 stated the reason a sitter was not assigned to Patient 6 was because Patient 6 may hit the sitter. NM 1 confirmed that Patient 1’s monitoring situation did not change after Patient 6 assaulted the DOA in the cafeteria, such as placing Patient 6 into an observation room or obtaining an order for a line-of-sight observation. During an interview on 7/23/2025 at 4:20 p.m. with the Director of Plant Operation (DPO), DPO stated the cafeteria chairs were made of metal and it was not appropriate to bring an agitated patient to that environment. During a review of the facility’s policy and procedure (P&P) titled, “Patient Precautions,” dated 7/2025, the P&P indicated, “It is the policy of (name of the facility) to identify and assess risk factors of all patients in order to provide care in a safe and therapeutic milieu. All patients are assessed for risks for suicide (thoughts of taking one’s own life)/self-harm, assault (refers to actions or behaviors that involve physical aggression, threats, or actions intended to cause physical harm or injury to another person), fall (an unexpected event where a patient unintentionally comes to rest on the ground or a lower level, like a bed or chair, during their hospital stay), seizures (a sudden, uncontrolled electrical disturbance in the brain, which can cause changes in behavior, movements, or consciousness), sexual aggression, sexual victimization (any unwanted or non-consensual sexual experiences), medical issues, detoxification (a set of interventions aimed at managing acute intoxication and withdrawal), and elopement (when a patient leaves the healthcare facility without authorization or notice) upon admission. All patients are also re-assessed for the same risk factors on a daily basis throughout their hospitalization to determine if there are any changes in their level of risk. Patients will also be re¿assessed for risk whenever there is an abrupt change in their behavior or mental status. Once risk factors are identified, the physician will determine appropriate precautions for each patient ... All patients identified to be on Assault Precautions will have the following measure initiated: May be restricted to the unit ... Monitor closely and ensure that vulnerable patients are monitored for safety ... Be aware of potentially escalating situations and will assume the patient will not be in control of his/her behavior. Staff will pay attention to phone calls or meetings with the physician where upsetting news may be communicated. Assess the patient every shift for signs of aggression or agitation, such as verbal and physical outbursts, including punching walls, slamming doors, throwing things, and pacing with clenched fists or jaw. Staff will promptly notify the Charge Nurse of any such behavior. Aim to separate the patient from others in the milieu if the agitation/aggression is directed at a specific person(s) ... Monitor and assess for environmental risks, including contraband, property damage, and items that could be used as weapons ... If an assault occurs: RN will assess and consult with attending psychiatrist for additional interventions including but not limited to: Change in observation level ... 1 :1 therapy ...” During a review of the facility’s GB (Governing Body, responsible for setting policies, ensuring quality of care, and managing the hospital’s financial health. Essentially, they act as the legal and ethical guardians of the institution and its mission.) bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization), approved by the GB on 4/1/2020, the bylaws indicated, “ The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital ...” During a review of the facility’s policy and procedure (P&P) titled, “Environmental of Care Committee, dated 1/2024, the P&P indicated, “The administration and senior leadership of the facility are responsible for safety and security of (name of the facility) ... The Environment of Care Committee shall have full authority to intervene in any matter affecting the immediate safety or security of the facility, and ensure a safe environment for patients, visitors, or staff ... Seven key activities of the EOC Committee: Hazard Identification - Identifying hazards and unsafe practices in the healthcare environment ...” 2. During a concurrent interview and record review on 7/24/2025 at 10:08 a.m., with the Chief Nursing Officer (CNO) and the Director of Risk Management (DRM), a Video footage of the Intensive Treatment Unit, dated 12/20/2024, was reviewed. The video footage on 12/20/2025 starting at 9 p.m. and ending at 11 p.m. indicated patient rounds (a systematic process where a healthcare team member checks on a patient regularly) were not performed for 20 Patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43), at 9:45 p.m. The CNO and the DRM verified that patient rounds had not been completed. During an interview on 7/24/2025 at 10:35 a.m. with the Chief Nursing Officer (CNO), the CNO stated patient rounds should be done every 15 minutes for all patients. Staff should enter patients and document patients’ location and behavior and ensure the patients were safe. If patients were sleeping, staff should enter patients’ rooms and observe for rise and fall of the chest. During a review of Patient 17’s Initial Psychiatric History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/16/2025, the H&P indicated the following: Patient was admitted to the facility due to increased bizarre behavior, delusions (fixed, false beliefs that conflict with reality) of paranoia (a mental state characterized by excessive distrust and suspicion of others, often without reason), believed that she (Patient 17) was being followed. Problem areas: Poor coping skills and danger to self. During a review of Patient 17’s “Round Sheet,” dated 12/20/2024, the Round Sheet (indicates the patient’s location and behavior and completed every 15 minutes monitoring by staff) indicated Patient 17 was being monitored for safety, every 15 minutes. There was no documentation for rounding at 10 p.m. During a review of Patient 18’s Initial Psychiatric History and Physical, dated 7/09/2024, the H&P indicated the following: Patient (Patient 18) was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for Grave Disability (a person who is unable to care for their basic needs due to a mental health disorder). Patient 18 had schizophrenia (a disorder that affects a person’s ability to think, feel, and behave clearly). During a review of Patient 18’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 18 was being monitored for assault (refers to actions or behaviors that involve physical aggression, threats, or actions intended to cause physical harm or injury to another person)/aggression, and safety, every 15 minutes. There was no documentation for rounding at 10 p.m. During a review of Patient 19’s Initial Psychiatric History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 9/24/2024, the H&P indicated the following: Patient19 was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for Grave Disability. Patient 19 had a seizure disorder (uncontrolled jerking, loss of consciousness, blank stares caused by electrical activity in the brain). During a review of Patient 19’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 19 was being monitored for falls (an unexpected event where a patient unintentionally comes to rest on the ground or a lower level, like a bed or chair, during their hospital stay), seizures, and safety, every 15 minutes. There was no documentation for rounding at 10 p.m. During a review of Patient 20’s Psychiatric Initial History and Physical, dated 9/24/2024, the H&P indicated the following: Patient 20 was admitted to the facility on a 5150 Hold due to increasing bizarre and disorganized behavior, and hearing voices telling him (Patient 20) to hurt himself. During a review of Patient 20’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 20 was being monitored for suicide (killing self), every 15 minutes. There was no documentation for rounding at 10 p.m. During a review of Patient 21’s Initial Psychiatric History and Physical, dated 8/09/2024, the H&P indicated the following: Patient 21 was admitted to the facility on a 5150 Hold for danger to self and grave disability. During a review of Patient 21’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 21 was being monitored for suicide, sexual aggression, and elopement (when a patient leaves the healthcare facility without authorization or notice), every 15 minutes. There was no documentation for rounding at 10 p.m. During a review of Patient 22’s Initial Psychiatric History and Physical, dated 12/16/2024, the H&P indicated the following: Patient 22 was admitted to the facility on a 5150 Hold for danger to others. Patient 22 came in agitated and aggressive towards grandparents. During a review of Patient 22’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 22 was being monitored for assault/aggression, every 15 minutes. There was no documentation for rounding at 10 p.m. During a review of Patient 26’s Initial Psychiatric History and Physical, dated 7/10/2024, the H&P indicated the following: Patient 21 was admitted to the facility under conservatorship (a legal process where a court appoints someone to manage the affairs of an individual who is unable to care for themselves) under the Surge Program (a program intended for former inmates who are too dangerous to be released into the community). During a review of Patient 26’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 26 was being monitored, every 15 minutes, for assault/aggression and sexual aggression. There was no documentation for rounding at 10 p.m. During a review of Patient 31’s Initial Psychiatric History and Physical, dated 12/18/2024, the H&P indicated the following: Patient 31 was admitted to the facility on a 5150 Hold due to increasing agitation (feeling worried, uneasy, or disturbed, and showing this through restlessness or physical behavior) and threatening behavior. During a review of Patient 31’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 31 was being monitored, every 15 minutes, for assault/aggression, and elopement. There was no documentation for rounding at 10 p.m. During a review of Patient 32’s Initial Psychiatric History and Physical, dated 12/11/2024, the H&P indicated the following: Patient 32 was admitted to the facility on a 5150 Hold for grave disability. During a review of Patient 32’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 32 was being monitored for assault/aggression, every 15 minutes. There was no documentation for rounding at 10 p.m. During a review of Patient 33’s Initial Psychiatric History and Physical, dated 12/19/2024, the H&P indicated the following: Patient 33 was admitted to the facility on a 5150 Hold after making threats to hurt herself and others. During a review of Patient 33’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 33 was being monitored, every 15 minutes, for suicide, and assault/aggression. There was no documentation for rounding at 10 p.m. During a review of Patient 34’s Initial Psychiatric History and Physical, dated 12/15/2024, the H&P indicated the following: Patient 34 was admitted to the facility on a 5150 Hold due to increased agitation and threatening behavior. During a review of Patient 34’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 34 was being for monitored, every 15 minutes, for assault/-aggression, and safety. There was no documentation for rounding at 10 p.m. During a review of Patient 35’s Initial Psychiatric History and Physical, dated 12/09/2024, the H&P indicated the following: Patient 35 was admitted to the facility on a 5150 Hold because he endorsed active suicidal ideations (thought of killing self), homicidal ideation (thoughts of hurting or killing others) with no plan. During a review of Patient 35’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 35 was being monitored, every 15 minutes. for suicide, and assault/ aggression. There was no documentation for rounding at 10 p.m. During a review of Patient 36’s Initial Psychiatric History and Physical, dated 12/16/2024, the H&P indicated the following: Patient 36 was admitted to the facility on a 5150 Hold for being gravely disabled. During a review of Patient 36’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 36 was being monitored, every 15 minutes, for sexual aggression and safety. There was no documentation for rounding at 10 p.m. During a review of Patient 37’s Initial Psychiatric History and Physical, dated 12/17/2024, the H&P indicated the following: Patient 37 had a history of schizophrenia and was admitted to the facility with increased confusion, delusions (false beliefs) of paranoia (fear and distrust in others). During a review of Patient 37’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 37 was being monitored, every 15 minutes, for suicide and assault/aggression. There was no documentation for rounding at 10 p.m. During a review of Patient 38’s Initial Psychiatric History and Physical, dated 12/20/2024, the H&P indicated the following: Patient 38 was admitted to the facility on a 5150 Hold because he (Patient 38) endorsed auditory hallucinations (hearing voices that are not present). During a review of Patient 38’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 38 was being monitored, every 15 minutes, for assault/aggression. There was no documentation for rounding at 10 p.m. During a review of Patient 39’s Initial Psychiatric History and Physical, dated 12/20/2024, the H&P indicated the following: Patient 39 had schizophrenia and presented to the facility due to increased agitation, and aggressive behavior. During a review of Patient 39’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 39 was being monitored, every 15 minutes, for suicide, assault/aggression and safety. There was no documentation for rounding at 10 p.m. During a review of Patient 40’s Initial Psychiatric History and Physical, dated 12/20/2024, the H&P indicated the following: Patient 40 was admitted to the facility due to increased bizarre and disorganized behavior. Patient 40 was on a 5150 Hold for danger to self, danger to others, and grave disability. During a review of Patient 40’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 40 was being monitored, every 15 minutes, for suicide, assault/ aggression and safety. There was no documentation for rounding at 10 p.m. During a review of Patient 41’s Initial Psychiatric History and Physical, dated 12/19/2024, the H&P indicated the following: Patient 41 was on a 5150 Hold due to increasing disorganized behavior and agitation. During a review of Patient 41’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 41 was being monitored, every 15 minutes, for assault/aggression, falls, and safety. There was no documentation for rounding at 10 p.m. During a review of Patient 42’s Initial Psychiatric History and Physical, dated 12/18/2024, the H&P indicated the following: Patient 42 was admitted on a 5150 Hold for danger to self. During a review of Patient 42’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 42 was being monitored, every 15 minutes, for suicide. There was no documentation for rounding at 10 p.m. During a review of Patient 43’s Initial Psychiatric History and Physical, dated 12/18/2024, the H&P indicated the following: Patient 43 was admitted on a 5150 Hold for danger to self and others. During a review of Patient 43’s “Round Sheet,” dated 12/20/2024, the Round Sheet indicated Patient 43 was being monitored, 15 minutes, for suicide, assault/aggression. There was no documentation for rounding at 10 p.m. During a review of the facility’s policy and procedure (P&P) titled, “Supervision of Patients/ Patient Rounds,” dated 7/2025, the P&P indicated the following: It is the policy of the Hospital that patients be supervised to diminish the risk of harm and/or injury. All patients require supervision and rounds are conducted continuously with each patient’s location and behavior documented every 15 minutes ...Observe each patient, a minimum of every 15 minutes and document observation (location and behavior) on the patient Rounds Sheet at time of observation ...Observe patients in bed or sleeping by: Looking for the rise of the chest; Making sure that the patient has moved from his/her previous sleeping position. Visually observe patients when behind closed doors by: Knocking on bedroom and bathroom doors; Announce that they are stepping into the room for rounds; Open the door and visually observe the safety of the patient.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure the physician authenticated a telephone 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) order within 24 hours for one of 43 sampled patients (Patient 29), in accordance with the facility’s policy and procedure regarding restraints use, when Patient 29 was placed on physical restraint (type of physical restraint, a manual or physical method of holding the patient against patient’s will that restricts freedom of movement or normal access to one’s body) on 7/16/2025. This deficient practice resulted in the lack of physician verification of physical restraints use on Patient 29 and had the potential to result in unnecessary restraint use for Patient 29. Findings: During a review of Patient 29’s face sheet (face sheet, document provides patient’s demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance) titled, “Patient Demographic Profile,” dated 7/14/2025, the face sheet indicated Patient 29 was an involuntary admission with admitting diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During a concurrent interview and record review on 7/25/2025 at 4:41 p.m. with the Director of Risk Management (DRM), Patient 29’s physical 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) order titled, “Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving)/Restraint/Chemical Restraint (use of medications to control a patient’s behavior or restrict freedom of movement) Order,” dated 7/16/2025, was reviewed. The physician restraint order indicated a telephone order was obtained for use of Physical Restraint on Patient 29 on 7/16/2025 at 2:12 p.m. The physician restraint telephone order also indicated physician did not sign off on the order. DRM stated the order was missing a physician’s signature. During an interview on 7/25/2025 at 7:10 p.m. with the Chief Nursing Officer (CNO), CNO stated the following: a physician order was required when putting a patient on restraint. The physician was required to authenticate the order within 24 hours. It would be considered as restraining patient without physician order because the physician did not sign off on the order (telephone order). During a review of the facility’s policy and procedure (P&P) titled, “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion,” dated 7/2025, the P&P indicated, “Restraints or seclusion shall be used in emergency situations only and requires an order from a physician ... the physician shall authenticate the telephone/verbal order within 24 hours.””

“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: 48212 Based on interview and record review, the facility failed to ensure its nursing staff notified physician, within 30 minutes, after a face-to-face evaluation (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) was performed for one of 43 sampled patients (Patient 6) on 7/14/2025 and 7/22/2025, in accordance with the facility’s policy and procedure regarding 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). This deficient practice had the potential to result in Patient 6’s physician not knowing Patient 6’s response to restraint and had the potential to lead to Patient 6 not receiving additional treatment or care as needed. Findings: During a review of Patient 6’s “Daily Progress Note,” dated 7/18/2025, the note indicated Patient 6’s diagnoses included psychosis (a mental health condition where a person loses touch with reality), schizophrenia (a mental illness affecting thought, emotion, and behavior), and documented high risk for “self-harm or harm to others.” The note also indicated Patient 6 had a history of assaultive behavior (refers to actions or behaviors that involve physical aggression, threats, or actions intended to cause physical harm or injury to another person). During an interview on 7/24/2025 at 3:53 p.m. with Registered Nurse (RN) 2, RN 2 stated the RN would perform face-to-face evaluation (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) after applying physical hold (type of physical restraint, a manual or physical method of holding the patient against patient’s will that restricts freedom of movement or normal access to one’s body) on patient to assess patient’s response to restraints and intervention. RN 2 further stated, normally the RN would only call physician back if something abnormal was identified during the face-to-face evaluation for further orders. During a review of Patient 6’s physician order titled, “Seclusion/Restraint/Chemical Restraint (use of medications to control a patient’s behavior or restrict freedom of movement) Order,” dated 7/14/2025, the physician order indicated a physician order was obtained on 7/14/2025 at 8 p.m. when Patient 26 was placed on physical restraint on 7/14/2025 at 7:50 p.m. During a concurrent interview and record review on 7/25/2025 at 5:35 p.m. with the Director of Risk Management (DRM), Patient 26’s “Post Intervention Face to Face Evaluation (face-to-face evaluation)” form, dated 7/14/2025, was reviewed. The face-to-face evaluation indicated Registered Nurse (RN) 13 completed the face-to-face evaluation on 7/14/2025 at 8:45 p.m. and notified physician on 7/14/2025 at 8 p.m. DRM stated the physician notification time was incorrect. DRM stated the time did not reflect RN 13 had called the physician after performing face-to-face evaluation for Patient 26. RN 13 called the physician before completing the face-to-face evaluation of the restraint use. During a review of Patient 6’s physician order titled, “Seclusion/Restraint/Chemical Restraint Order,” dated 7/22/2025, the physician order indicated a physician order was obtained on 7/22/2025 at 3:30 p.m. when Patient 26 was placed on physical restraint on 7/22/2025 at 3:08 p.m. During an interview on 7/25/2025 at 11:34 a.m. with Registered Nurse (RN 1), RN 1 stated nurse would need to call the physician after face-to-face evaluation to let physician know about the patient and if interventions were effective or not. During a concurrent interview and record review on 7/25/2025 at 5:37 p.m. with the Director of Risk Management (DRM), Patient 26’s “Post Intervention Face to Face Evaluation (face-to-face evaluation)” form, dated 7/22/2025, was reviewed. The face-to-face evaluation indicated RN 2 completed the face-to-face evaluation on 7/22/2025 at 3:45 p.m. and notified physician on 7/22/2025 at 3:18 p.m. DRM stated the physician notification time was inaccurate. DRM stated based on document, RN 2 did not call the physician after performing face-to-face evaluation for Patient 26. RN 2 called the physician before the face-to-face evaluation of restraint use was completed. During a review of the facility’s policy and procedure (P&P) titled, “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion,” dated 7/2025, the P&P indicated, “Face to Face Evaluation by the physician, licensed independent practitioner, or trained RN: within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician, authorized LIP (Nurse Practitioner), or trained RN ... The evaluation will be documented in the medical record to include the following: 1. The date and time of the evaluation 2. An assessment of the patient’s immediate situation 3. An evaluation of the patient’s reaction to the intervention 4. An assessment of the patient’s medical and behavioral condition ... 5. An assessment of the need to continue or terminate the restraint/seclusion ... If the evaluation is conducted by a trained RN, he/she must consult with the attending physician or other LIP responsible for the patient’s care as soon as possible (within 30 minutes) after the evaluation. This consultation should include a discussion of the findings of the 1-hour evaluation, the need for other interventions or treatments, and the need continue or discontinue the use of restraint/seclusion.””

“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: 46333 Based on interview and record review, the facility failed to ensure its Quality Assessment and Performance Improvement (QAPI) program (a hospital-wide quality improvement system designed to monitor and improve safety and care) addressed environmental safety hazards (unsafe physical conditions that may cause injury or harm) in areas regularly accessed by patients. This deficient practice affected one (1) of the 43 sampled patients (Patient 6), when Patient 6 picked up a metal-legged chair in the cafeteria and threw it at the Director of Admission (DOA), causing a head injury. This deficient practice resulted in head injury for DOA and resulted in a lack of structured safety oversight in patient-used areas, particularly for patients with known behavioral risks. The absence of proper monitoring and environmental risk assessments contributed to unsafe conditions and had the potential to affect the health and safety of other patients and staff throughout the facility. Findings: During a concurrent interview and record review on 7/25/2025 at 5:25 p.m. with the Director of Quality and Performance Improvement (DQPI, a hospital leader responsible for quality and safety monitoring), the facility performance improvement project (PI, a structured, ongoing effort to enhance the quality and efficiency of healthcare services), was reviewed. The DQPI confirmed that monthly QAPI meetings were held. The facility had active PI projects (targeted safety initiatives) including fall prevention, medication safety, and infection control. However, the DQPI stated there were no PI projects addressing environmental safety in areas such as cafeterias. The DQPI stated that reports were collected from monthly Environmental of Care (EOC) rounds (routine facility safety inspections), but confirmed that there were no incident reports related to movable furniture. DQPI could not confirm that the South Cafeteria was included in the EOC rounds, nor was it monitored through QAPI activities or included in adverse event (an undesirable outcome or occurrence that results from medical care) tracking or improvement efforts related to behavioral or environmental risks. During a concurrent interview and record review on 7/25/2025 at 8:45 p.m. with the Director of Plant Operations and Safety Officer (DPO, the staff member in charge of facility safety and maintenance), the facility’s “Environmental Rounds,” checklist was reviewed and there was no checklist for the facility’s cafeterias. The DPO stated that monthly EOC rounds were conducted to identify safety hazards. However, DPO confirmed that the South Cafeteria, which contained chairs with metal legs (items that could be used as weapons), was not included in the routine EOC rounding. The DPO stated that EOC rounds were conducted monthly to identify safety hazards. However, the South Cafeteria which contained chairs with metal legs was not included because it was considered a “non-patient care area.” The DPO also confirmed that patients routinely used the cafeteria for meals and, in some cases, for de-escalation (a behavioral intervention used to calm agitated (feeling worried, uneasy, or disturbed, and showing this through restlessness or physical behavior) patients without using physical restraint or medication). The DPO stated the cafeteria would now be added to future EOC rounds. During a surveillance video review of the South Cafeteria, on 7/23/2025 at 11:30 a.m. (video dated 7/22/2025 at 2:42 p.m.), it was observed that Patient 6, who had a documented history of violent and unpredictable behavior was brought into the South Cafeteria for de-escalation, despite the area not being assessed for safety or designed to manage behavioral emergencies. During a surveillance video review of the South Cafeteria, on 7/23/2025 at 11:30 a.m. (video dated 7/22/2025 at 2:42 p.m.), in the presence of the Director of Quality and DQPI), the following events were observed: -Nurse Manager (NM) 1 escorted Patient 6 to the South Cafeteria and provided a soda as part of a calming strategy. - Patient 6 approached the soda machine, served himself, and sat with NM 1. - A second Staff member (Staff 1) entered the cafeteria and sat at the opposite end of the room. -Patient 6 suddenly stood up and chased Staff 1 around the table. - Patient 6 then picked up a metal chair with metal legs and threw it at the Director of Admission (DOA), striking him (DOA) in the forehead and causing a head laceration (a deep cut or tear in the skin). - The DOA clutched his (DOA) head, and staff initiated Code 10 (call for emergency trained responders) for Patient 6 and a Code Blue (medical emergency alert) for DOA (due to a head laceration). During a review of the facility’s policy and procedure (P&P) titled, “Quality Assurance & Performance Improvement (QAPI) 2025,” dated 2/27/2025, the P&P indicated, “The plan is used as a guide to design, measure, assess and improve organizational performance; identify, minimize, and prevent organizational risks and ensure delivery of safe patient care ... The 2025 Plan addresses patient-focused and organization-wide processes and functions that have the greatest potential to improve patient safety and outcomes ... To enhance, maintain and continually improve the quality and safety of patient care through departmental/service measurement and assessment of patient care, resolution of problems and on-going pursuit of opportunities to improve patient care ... To promote safety and prevent untoward occurrences through systematic monitoring of the treatment environment to reduce facility and medical liability. The Environment of Care (EOC) Committee serves to assess and mitigate risks to safety in the physical environment. EOC Rounds are conducted to gather data on the environment and remedy any issues. The Committee monitors performance by identifying metrics for safety, handling hazardous waste materials, fire safety, equipment inspections and utilities.””

“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: 50516 Based on interview and record review, the facility failed to ensure nursing staff assessed and documented the blood sugar level for one of 43 sampled patients (Patient 1), in accordance with the facility’s policy regarding Nursing Assessment and Reassessment of Patients when Patient 1’s blood sugar (body’s source of energy) was not assessed and when Patient 1 received Metformin (medication used to control blood sugar) without a corresponding blood sugar level checked. This deficient practice had the potential for Patient 1 to not receive the appropriate monitoring and interventions and may contribute to Patient 1’s change of condition such as hypoglycemia (low blood sugar) and/or death. Findings: During a review of Patient 1’s “Discharge Summary,” dated 12/26/2024, the Discharge Summary indicated Patient 1 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 [focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for grave disability (unable to take care of basic needs). Patient 1’s medical history included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia (an abnormally high concentration of fat particles in the blood), alcohol abuse (alcohol use that can negatively affect how someone thinks and acts) and polysubstance (more than one drug use and/or alcohol or tobacco use) abuse. The record further indicated Patient 1 expired (died) on 12/20/2024. During a review of Patient 1’s “Progress Note,” dated 12/20/2024, the Progress Note did not indicate Patient 1 refused blood sugar checks and any notification to other nurses and Patient 1’s physician. The record further indicated at 10:00 p.m., “Patient (Patient 1) was found unresponsive (not responding to verbal command, touch, or pain) ...” During a concurrent interview and record review on 7/23/2025 at 3:40 p.m. with the Assistant Chief Nursing Officer (ACNO), Patient 1’s “Electronic Health Record (EHR, digital version of paper chart),” undated, was reviewed. The record indicated on 11/11/2024, Patient 1 had an order for Insulin (injectable medication used to control diabetes) sliding scale (blood sugar level determines how much medication should be given) to be given as needed. The record further indicated on 12/12/2024, Patient 1 had an order for Metformin (medication used to control diabetes) 500 milligrams [mg, a unit of measure]) twice a day to be taken by mouth. During a concurrent interview and record review on 7/23/2025 at 3:40 p.m. with the Assistant Chief Nursing Officer (ACNO), Patient 1’s “Electronic Health Record,” undated, was reviewed. The EHR indicated on 10/12/2024, Patient 1 had an order for blood glucose (sugar levels and the body’s primary source of energy from food) monitoring four times a day, at 7:30 a.m., 11:30 a.m., 4:30 p.m., and at 9:00 p.m. for hypoglycemic (low blood sugar) checks. During a concurrent interview and record review on 7/23/2025 at 3:40 p.m. with the ACNO, Patient 1’s “EHR,” undated, was reviewed. The record indicated the following: -On 12/19/2024 at 4:30 p.m. and 9:00 p.m., Patient 1’s blood sugar check was marked as not completed. ACNO stated Patient 1’s blood sugar was not checked. -On 12/20/2024 at 12:20 p.m., Patient 1’s medication response after receiving 4 units (amount, a unit of measure for insulin based on the blood sugar level) of Humalog (type of injectable insulin given to given control blood sugar) was documented as “effective.” ACNO stated there was not another blood sugar recheck at that time. -On 12/20/2024 at 4:30 p.m., Patient 1’s blood sugar level was marked as “complete” and did not show a value. The ACNO stated this was the last blood sugar check because Patient 1 refused the 9:00 p.m. check. During a concurrent interview and record review on 7/23/2025 at 3:40 p.m. with the ACNO, Patient 1’s “EHR,” undated, indicated the following: -On 12/19/2024 at 9:00 a.m. and 4:47 p.m., Patient 1 received Metformin 500 mg. -On 12/20/2024 at 9:25 a.m. and 4:46 p.m., Patient 1 received Metformin 500 mg. -On 12/20/2024 at 11:48 a.m., Patient 1 received 4 units (amount, a unit of measure for insulin based on the blood sugar level) of Humalog (type of injectable insulin given). -On 12/20/2024 at 12:20 p.m., Patient 1’s medication response was documented as “effective.” ACNO stated there was not another blood sugar recheck at that time. -On 12/20/2024 at 4:46 p.m., Patient 1 received Metformin 500 mg. During an interview on 7/24/2025 at 3:43 p.m. with the Licensed Practical Technician (LPT), LPT stated patients should not get Metformin if they refused their blood sugar check. LPT stated if a patient was given Metformin (medication used to control diabetes) 500 milligrams [mg, a unit of measure]) without a blood sugar check, the blood sugar can go too low and cause problems. During an interview on 7/24/2025 at 3:33 p.m. with the LPT, LPT stated if patient refused to have a blood sugar check using a glucometer (machine used to check blood sugar), the reason why it was needed to be monitored, should be explained to the patient. LPT stated if the patient still refused, another nurse who had a better rapport (friendly relationship) with the patient should try and explain the purpose to them. LPT further stated if the patient still refused, the issue should be brought to the charge nurse to let them know what happened. During a review of the facility’s policy and procedure (P&P) titled, “Nursing Assessment and Reassessment of Patients,” dated 7/2025, indicated, “The assessment includes the collection and analysis of data about the patient to determine the need for any additional information, the patient’s care needs, and the care to be provided ...Reassessment is done to determine the patient’s response to treatment and need for further interventions.””

“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: 50516 Based on observation, interview and record review, the facility failed to: 1. Ensure for one of 43 sampled patients (Patient 13), nursing staff supervised care and adhered to the facility’s policy titled, “Supervision of Patients/Patient Rounds (a regular, systematic process where healthcare professionals assess patients),” when Patient 13’s “Round Sheet” did not have the Registered Nurse’s (RN) signature to validate that a patient rounding was completed. This deficient practice had the potential for Patient 13’s care to not have the proper oversight by an RN, which may result in patient harm if the rounding was not accurately performed. 2. Conduct a suicide (thoughts of taking one’s own life) screening (a procedure that uses a standardized instrument or protocol, like a set of questions, to quickly identify individuals who may be at risk for suicide), daily, for one of 43 sampled patients (Patient 15), in accordance with the facility’s policy and procedure regarding suicide screening. This deficient practice resulted in two missed suicide screenings and had the potential for suicide risk to be unidentified for Patient 15, which may result in patient harm and/or death. 3. Ensure its nursing staff adhered to its internal policies and procedures “Code Blue (Emergency overhead announcement for medical resuscitation) and Transferring Patients to the Emergency Room,” and did not follow current American Heart Association (AHA) Basic Life Support (BLS) guidelines (nationally procedures for emergency resuscitation [emergency effort to restore breathing or heartbeat], including chest compressions [pressing on the chest to pump], airway support [keeping breathing passages open], and use of a defibrillator [a device that delivers an electric shock to restart or correct the heart’s rhythm] during cardiac arrest [heart stop] or other life-threatening conditions) for one (1) of 43 sampled patients (Patient 1). This deficient practice resulted in the failure to provide timely and appropriate resuscitation (emergency efforts to restore breathing or heartbeat) for Patient 1 and placed other patients at risk for delayed or inadequate emergencies during future medical emergencies. Findings: 1. During a review of Patient 13’s “Initial Psychiatric (focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation,” dated 7/18/2025, the record indicated Patient 13 was admitted to the facility for depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life), anxiety (a group of mental disorders characterized by significant feelings of fear), and had a history of self-harm. During an interview on 7/24/2025 at 11:59 a.m. with the Director of Risk Management (DRM), the DRM stated the “Number one thing for safety is patient rounding (checking for patient’s behavior and location every 15 minutes).” During a concurrent interview and record review on 7/25/2025 at 5:48 p.m. with the DRM, Patient 13’s “Round Sheet (indicates the patient’s location and behavior and completed every 15 minutes monitoring by staff),” dated 7/20/2025 to 7/21/2025, was reviewed. The Round Sheet contained several areas for staff to mark what the patient was doing and where; the position the patient was sleeping in; precautions to take if the patient was aggressive, tried to harm themselves, and other behaviors; observation level (every 15 minutes or 1:1 [someone is with the patient at all times]). The record also indicated two areas for staff to sign: the “Registered Nurse (RN) Oversight” section and another area for staff to write their initial, name, and title. During the same concurrent interview and record review on 7/25/2025 at 5:48 p.m. with the DRM, Patient 13’s “Round Sheet (indicates the patient’s location and behavior and completed every 15 minutes by staff),” dated 7/20/2025 to 7/21/2025, was reviewed. The Round Sheet further indicated, there was only one signature from 2300 (11:00 p.m.) to 0300 (3:00 a.m.) in the “Registered Nurse (RN) Oversight” section. The sections with the timeframes of 0300-0700 (7:00 a.m.), 0700-1100 (11:00 a.m.), 1100-1500 (11:00 a.m. to 3:00 p.m.), 1500-1900 (3:00 p.m. to 7:00 p.m.), and 1900-2300 (7 p.m. to 11 p.m.), were left blank. DRM stated, the nurse should round twice a shift, and the RNs should initial next to the staff’s signature who was assigned to do rounds at a specific time. DRM acknowledged the RNs should have identified themselves in the “RN Oversight” section. During a review of the facility’s policy and procedure (P&P) titled, “Supervision of Patients/Patient Rounds,” dated 7/2025, indicated, “The Charge Nurse will also provide oversight of the Rounds process at least one more time each shift. He/she will complete another set of Rounds or initial next to the time at which oversight was provided. He/she will be monitoring to ensure the Rounds Sheet information (name, precautions, etc.) is complete and accurate, as well as ensuring the staff are completing it properly and in a timely manner.” 2. During a concurrent interview and record review on 7/25/2025 at 2:45 p.m. with the Chief Nursing Officer (CNO), the CNO reviewed Patient 15’s CSSRS (Columbia-Suicide Severity Rating Scale, a suicide risk assessment tool) assessments. The CNO stated CSSRS assessments should be completed upon admission and every day in order to implement interventions, if necessary. The CNO verified that Patient 15’s CSSRS assessment was not completed on 6/24/2025 and on 6/27/2025. During a review of Patient 15’s Face Sheet (document provides patient’s demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance), the Face Sheet indicated Patient 15 was admitted to the facility on 6/22/2025 at 11:30 a.m., and discharged on 6/27/2025 at 1:51 p.m. During a review of Patient 15’s Initial Psychiatric Evaluation, dated 3/21/2025, the psychiatric evaluation indicated Patient 15 presented to the hospital 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 and treatment) because she (Patient 15) was throwing things at staff, yelling, kicking, fighting, and being agitated (feeling worried, uneasy, or disturbed, and showing this through restlessness or physical behavior). During a review of Patient 15’s Daily Nursing Progress Notes, the Daily Nursing Progress Notes indicated the CSSRS screen was not completed on 6/24/2025 and 6/27/2025. During a review of the facility’s policy and procedure (P&P) titled, “Assessment for Suicide Risk Potential,” dated 5/2025, the P&P indicated the following: It is the policy of the Hospital to create an environment of care that will foster the accurate identification and successful management of patients who are at an increased risk for suicide or self-destructive behaviors ...Nursing staff will screen all patients with an evidence-based tool who are admitted to the hospital that identify patient characteristics that may indicate an increased risk of suicide. As indicated by the screening tool, the identified intervention will be enacted ...Reassessment of suicidality will occur daily. 3. During a review of Patient 1’s “Daily Progress Note,” dated12/20/2024, the note indicated, Patient 1 had medical history including: Diabetes (a chronic condition that leads to elevated blood sugar) with diagnoses of schizoaffective (a mental health condition that combines symptoms of both schizophrenia [a mental health condition combining symptoms of schizophrenia [characterized by significant disturbances in thought, perception, emotion, and behavior] and a mood disorder like), and bipolar (a mental illness marked by extreme mood swings from highs [mania] to lows [depression]) disorder. During a review of Patient 1’s medical record document titled, “Code Blue (Emergency overhead announcement for medical resuscitation)/Medical Emergency Documentation,” dated 12/20/2024, the document indicated the following: -Code Blue (Emergency overhead announcement for medical resuscitation) was called at 10:03 p.m. -No AED (Automated External Defibrillator, a portable electronic device that analyzes heart rhythms and delivers an electrical shock to help restore a normal heartbeat in cases of sudden cardiac arrest [heart stops beating]) was applied on Patient 1. -No Blood glucose (blood sugar) check, despite Patient 1’s diabetes diagnosis. -Documentation indicated “mouth sweep (inserting fingers into the mouth to remove a blockage- should only be done if the object is visible), Heimlich maneuver (abdominal thrusts to relieve choking-should only be used when there are signs of choking), with no documented evidence that the patient was choking or had a visible obstruction. During a concurrent observation and interview on 7/22/2025 at 12:13 p.m. with the Assistant Chief Nursing Officer/Clinical Educator (ACNO), in Unit ABC, the crash cart (a mobile cart containing emergency resuscitation equipment) was found lacking a suction machine (device used in hospitals to remove fluids and secretions from a patient’s body, primarily the airway). The ACNO confirmed the facility did not have suction equipment available for use during a Code Blue. During an interview on 7/22/2025 at 12:51 p.m. with charge nurse (Registered Nurse, a nurse who has graduated from a college’s nursing program or from a school of nursing and has passed a national licensing exam) 10, RN 10 stated: -staff were required to call a Code Blue immediately upon finding an unresponsive patient. -Do not leave the patient -Begin CPR (cardiopulmonary resuscitation, an emergency procedure that combines chest compressions, and rescue breathing to keep blood flowing). The AED should always be applied, even if the patient had a pulse, to allow the device to analyze the heart rhythm. -Check the blood sugar to rule out hypoglycemia (low blood sugar), which can be treated with Glucagon (a hormone that raises blood sugar). -Perform Heimlich maneuver (abdominal thrusts used to relieve choking) only if obvious choking signs were present -Never perform a blind finger sweep (inserting a finger into the mouth without visualizing the obstruction) During a concurrent interview and surveillance video review on 7/24/2025 at 10:08 a.m. with the Director of Risk Management (DRM), the video footage dated 12/20/2024 showed the following: -At 10:01:00 p.m., Registered Nurse (RN) 9 and Certified Nurse Assistant (CNA, Certified nursing assistants provide basic care to patients) 1 entered Patient 1’s room. -At 10:02:00 p.m., RN 9 and CNA 1 exited the room. -At 10:02:36 p.m., CNA 1 reentered Patient’s room -At 10:03:00 p.m., RN 9 returned, and Code Blue was called. During the same interview on 7/24/2025 at 10:08 a.m. with the Director of Risk Management (DRM), the DRM confirmed there was a two -minute delay between discovery of the unresponsive patient and initiation of emergency procedures (such as calling a code blue). During an interview on 7/22/2025 at 3:41 p.m. with RN 11, RN 11stated they were unsure whether to apply the AED if the patient was unresponsive but had a pulse. During a concurrent observation and interview on 7/23/2025 at 2:47 p.m., with RN 12, in Unit CDE, the crash cart was again found to be missing a suction machine. RN 12 also stated uncertainty about AED use in an unresponsive patient with pulse but stated the AED “helps analyze heart rhythm.” During an interview with on 7/25/2025 at 5:58 p.m. with RN 1, RN 1 stated the facility did not have suction equipment installed on the unit. RN 1 stated training on suction machines a month prior was conducted but confirmed the equipment was still unavailable during medical emergencies, leaving staff without a method to clear a patient’s airway when needed. During a review of the facility’s policy and procedure (P&P) titled, “Code Blue and Transferring Patients to the Emergency Room,” dated June 2025, the P&P indicated, “The staff member who finds/witnesses the medical emergency will immediately call for help and have a Code Blue paged overhead. The Code Blue will be paged overhead three times, including the lo cation. The staff member will not leave the patient alone. The staff from the unit housing the patient will bring the vital signs machine, accu-check machine, AED, oxygen tank, emergency crash carts, and any other pertinent equipment/supplies, based on the situation ...” During a review of the facility’s policy and procedure (P&P) titled, “Medical Emergencies and Acute Change in Condition,” dated May 2025, the P&P indicated, “An RN may initiate a 911 call prior to calling the physician and House Supervisor ... Airway Problems: If the patient is coughing or can speak, stay with the patient and encourage continued coughing ... If the patient continues to cough ineffectively and appears to be in increasing distress, the object may be totally obstructing the airway. Call 911 and initiate a Code Blue. If the patient cannot speak or breathe, perform abdominal thrusts, call 911, and initiate a Code Blue.” During a review of the American Heart Association (AHA) 2020 Guidelines for CPR and Emergency Cardiovascular Care, Part 3 - Part 8: Adult Basic and Advance Life Support,” indicated the following: -“Initiate CPR immediately; do not leave the victim unattended.” -“Apply AED to all unresponsive patients regardless of the presence of a pulse, to analyze heart rhythm and guide next steps.” -“Suction equipment should be readily available in hospital settings where cardiac arrest may occur.” -“The Heimlich maneuver (abdominal thrusts) and finger sweeps should only be used when a foreign body airway obstruction is clearly present.””

“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 that medical records for 20 of 43 sampled patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43) were accurately written or documented, in accordance with the facility’s policy regarding “Supervision of Patients / Patient Rounds.” The patient rounds (a systematic process where a healthcare team member checks on a patient regularly) conducted, every 15 minutes, in the Intensive Treatment Unit, were inaccurately documented in the medical record for 20 of 43 sampled patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43). This deficient practice led to the inaccurate documentation on 12/20/2025 at 9:45 p.m., that 20 patients had been visualized by a staff, when in fact, the round was not conducted at that time. This deficient practice also placed 20 patients’ safety at risk for self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done) and violence. Findings: During an interview and record review on 7/24/2025 at 10:08 a.m., a Video footage, dated 12/20/2024 of the Intensive Treatment Unit, was reviewed. The following was observed on video surveillance with the Chief Nursing Officer (CNO) and the Director of Risk Management (DRM). The video footage on 12/20/2025 starting at 9 p.m. and ending at 11 p.m. indicated patient rounds (a systematic process where a healthcare team member checks on a patient regularly) were not performed for 20 Patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43), at 9:45 p.m. The CNO and the DRM verified that patient rounds had not been completed. The CNO stated that the documentation for the rounds on 12/20/2025 at 9:45 p.m., was inaccurate, and did not reflect what was seen on video footage. During an interview on 7/24/2025 at 1:53 a.m., with the Chief Executive Officer (CEO), the CEO stated he (CEO) was aware that patient rounds had not been conducted on 12/20/2025 at 9:45 p.m., and verified that the Rounding Sheets for Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43) had been “falsification” of a document. During a review of “Round Sheet (indicates the patient’s location and behavior and completed every 15 minutes by staff),” dated 12/20/2024, for Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43, the Round Sheets indicated that rounds had been conducted at 9:45 p.m. The CNO and the CEO verified that the documentation was inaccurate. During a review of the facility’s policy and procedure (P&P) titled, “Supervision of Patients / Patient Rounds,” dated 7/2025, the P&P indicated the following: All patients require supervision and rounds are conducted continuously with each patient’s location and behavior documented every 15 minutes. The staff assigned to the initial rounds will ensure that the Round Sheets for all patients on every 15 precaution(s) are completed thoroughly and accurately.”

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure staff completed and retained a record of voluntary admission for one of 43 sampled patients (Patient 23), when staff claimed Patient 23 had signed voluntary admission on 5/23/2025 to justify admission and continued hospitalization. This deficient practice resulted in confusion regarding Patient 23’s legal status (the circumstances under which the patient was admitted and/or is being treated - voluntary or involuntary, committed by court, evaluation and recertification are in accordance with state requirements) including an incomplete medical record to reflect Patient 23’s proper legal status for the admission, which had the potential to violate patient’s right regarding voluntary treatment. Findings: During a review of Patient 23’s “Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 5/17/2025, the Psych Eval indicated, Patient 23 was admitted to the facility with diagnoses including but not limited to bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 23’s face sheet (face sheet, document provides patient’s demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance) titled, “Patient Demographic Profile,” dated 5/25/2025, the face sheet indicated Patient 23 was an involuntary admission from 5/17/2025 to 5/24/2025. During a review of Patient 23’s involuntary hold notice titled, “Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment) of the Welfare and Institutions Code,” dated 5/19/2025, the involuntary hold notice indicated Patient 23 was placed on 14-day hold (14 days involuntary intensive treatment) due to danger to himself or herself on 5/19/2025. During a concurrent interview and record review on 7/25/2025 at 2:45 p.m. with the Director of Clinical Services (DCS), Patient 23’s “Certification Review Hearing (also known as probable cause hearing, a legal proceeding with a specific purpose related to involuntary psychiatric holds to determine if there is sufficient legal justification [probable cause] to continue holding an individual involuntarily for intensive treatment due to a mental disorder) Record,” dated 5/23/2025, was reviewed. The “Certification Review Hearing Record” indicated, “the hearing was not held. Reason: patient (Patient 23) has signed VOL (voluntary admission) per [staff].” DCS stated the hearing was not held because Patient 23 signed for voluntary admission. During an interview on 7/25/2025 at 2:46 p.m. with DCS, DCS stated the following: there was no voluntary admission form found in Patient 23’s medical record. A patient would sign the voluntary admission form when changing legal status (the circumstances under which the patient was admitted and/or is being treated - voluntary or involuntary, committed by court, evaluation and recertification are in accordance with state requirements) from involuntary to voluntary. The Psychiatrist (physician specializes in mental health) would then sign the voluntary admission form to confirm the voluntary admission. Patient 23 remained as involuntary admission during the hospital stay and did not receive a certification review hearing. DCS also stated it was important to have accurate medical record to reflect patient’s legal status. Without the proof of voluntary admission form, there would be confusion on patient’s legal status. During an interview on 7/25/2025 at 6:15 p.m. with the Chief Operating Officer (COO), the COO stated patients could sign a voluntary admission during an involuntary hospitalization. COO further stated the facility did not have a policy and procedure that speaks to the process of voluntary admission. During a review of the facility’s patient handbook titled, “Rights for Individuals in Mental Health Facilities,” dated 7/2018, the patient handbook indicated, “If you are held beyond 72 hours, you have the right to remain in the hospital for voluntary treatment. If you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four (4) days of the end of your 72-hour hold. You may be represented at this hearing by a patients’ rights advocate or another person of your choice. You can also request to have family members present to help explain your circumstances.””

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure all physician orders were dated, timed and authenticated by the ordering physician, in a timely manner (within 24 hours), for one of 43 sampled patients (Patient 29), in accordance with the facility’s policy and procedure regarding 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)/seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving). This deficient practice resulted in a lack of physician verification of order and incomplete medical records. Findings: During a review of Patient 29’s face sheet (face sheet, document provides patient’s demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance) titled, “Patient Demographic Profile,” dated 7/14/2025, the face sheet indicated Patient 29 was an involuntary admission with admitting diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During a concurrent interview and record review on 7/25/2025 at 4:41 p.m. with the Director of Risk Management (DRM), Patient 29’s physician 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) order titled, “Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving)/Restraint/Chemical Restraint (use of medications to control a patient’s behavior or restrict freedom of movement) Order,” dated 7/16/2025, was reviewed. The physician restraint order indicated a telephone order was obtained for use of Physical Restraint on Patient 29 on 7/16/2025 at 2:12 p.m. The physician restraint order also indicated physician did not sign off the telephone order. DRM stated the order was missing physician’s signature. During an interview on 7/25/2025 at 7:10 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following: a physician order was required when putting a patient on restraint. The physician was required to authenticate the order within 24 hours. It would be considered as restraining patient without a physician order because the physician did not sign off on the order. During a review of the facility’s policy and procedure (P&P) titled, “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion,” dated 7/2025, the P&P indicated, “Restraints or seclusion shall be used in emergency situations only and requires an order from a physician ... the physician shall authenticate the telephone/verbal order within 24 hours.””

“Patient Legal Status CFR(s): The identification data must include the patient’s legal status. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure a patient’s legal status (the circumstances under which the patient was admitted and/or is being treated - voluntary or involuntary, committed by court, evaluation and recertification are in accordance with state requirements) was correctly reflected on one of 43 sampled patient’s (Patient 30) medical record, after Patient 30 signed a voluntary admission on 7/7/2025. This deficient practice resulted in confusion on Patient 30’s legal status and led to unnecessary hold placement (putting a patient in an involuntary admission) on 7/15/2025, which violated Patient 30’s right regarding voluntary treatment. Findings: During a review of Patient 30’s “Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 6/30/2025, the Psych Eval indicated, Patient 30 was admitted to the facility with diagnoses including but not limited to major depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), severe, recurrent (repeat), with psychosis (a severe mental disorder with hallucinations [an experience involving the apparent perception of something not present]) and post-traumatic stress disorder (PTSD, an anxiety disorder that develops after experiencing stressful, frightening or distressing events). During a review of Patient 30’s involuntary hold notice titled, “Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment) of the Welfare and Institutions Code,” dated 7/1/2025, the involuntary hold notice indicated Patient 30 was placed on a 14-day hold (5250-hold, allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to danger to others, danger to himself or herself, and gravely disabled (inability to care for oneself). During a concurrent interview and record review on 7/25/2025 at 3:07 p.m. with the Director of Clinical Services (DCS), Patient 30’s “Request for Voluntary Admission (a patient consent form for voluntary admission),” dated 7/7/2025, was reviewed. The “Request for Voluntary Admission” indicated, Patient 30 signed for voluntary admission on 7/7/2025 and signed off by physician on 7/7/2025. DCS stated Patient 30’s legal status should be “voluntary” starting 7/7/2025. During a review of Patient 30’s “Daily Progress Note,” dated 7/14/2025, the “Daily Progress Note” indicated Patient 30’s legal status as 5250 (5250-hold, allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment). During a concurrent interview and record review on 7/25/2025 at 3:09 p.m. with DCS, Patient 30’s face sheet (face sheet, document provides patient’s demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance) titled, “Patient Demographic Profile,” dated 7/15/2025, was reviewed. The face sheet indicated Patient 30’s admission as involuntary status. DCS stated the face sheet was not updated. Patient 30 should be on voluntary status. During a concurrent interview and record review on 7/25/2025 at 3:11 p.m. with DCS, Patient 30’s involuntary hold notice titled, “Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment) of the Welfare and Institutions Code,” dated 7/15/2025, the involuntary hold notice indicated, Patient 30 was placed on a 30-day hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 30 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for grave disability due to being “irritable, labile (a tendency to be unpredictable), still working on a viable safety plan for discharge.” DSC stated this hold was unnecessary because Patient 30 was already on voluntary status since 7/7/2025. During an interview on 7/25/2025 at 6:15 p.m. with the Chief Operating Officer (COO), COO stated patients could sign a voluntary admission during an involuntary hospitalization. COO further stated the facility did not have a policy and procedure that speaks to the process of voluntary admission. During a review of the facility’s patient handbook titled, “Rights for Individuals in Mental Health Facilities,” dated 7/2018, the patient handbook indicated, “If you are held beyond 72 hours, you have the right to remain in the hospital for voluntary treatment. If you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four (4) days of the end of your 72-hour hold.””

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure to develop an individualized treatment plan (a document that outlines an individual’s assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided) for one of 43 sampled patients (Patient 24) to address Patient 24’s past trauma as sexual abuse victim, in accordance with the facility’s policy regarding “Interdisciplinary Patient-Centered Care Planning.” This deficient practice resulted in Patient 24 feeling anxious around male staff conducting patient rounding (a regular, systematic process where healthcare professionals assess patients) at nighttime during Patient 24’s course of hospitalization. Findings: During a review of Patient 24’s “Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 1/5/2025, the Psych Eval indicated, Patient 24 was admitted to the facility on 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 and treatment) with diagnoses including but not limited to bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), depressed (mood disorder that causes a persistent feeling of sadness and loss of interest in life) type, without psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality), posttraumatic stress disorder (PTSD, an anxiety disorder that develops after experiencing stressful, frightening or distressing events) and diabetes (high blood sugar). The Psych Eval also indicated, “Her (Patient 24’s) father sexually abused her (Patient 24) when she (Patient 24) was a child ... Patient (Patient 24) complains of high anxiety (a feeling of fear and uneasiness), racing thoughts, insomnia (inability to sleep), labile (tendency to be unpredictable) mood, lack of motivation, feelings of hopelessness and worthlessness.” During a concurrent interview and record review on 7/25/2025 at 11:57 a.m. with the Registered Nurse (RN) 1, Patient 24’s nursing admission assessment titled, “Nursing Admission Assessment - ADULTS (age 18+),” dated 1/5/2025, was reviewed. The nursing admission assessment indicated Patient 24 was a victim of sexual abuse and with history of psychological trauma due to sexual abuse. The nursing admission assessment also indicated Patient 24 was depressed for 30 years after this trauma. RN 1 stated this would trigger the primary nurse to develop a treatment plan (a document that outlines an individual’s assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided) with problem of “sexually acting out - victim” to address Patient 24’s trauma related to sexual abuse. RN 1 further stated it was important to identify past trauma because it would shape the interventions of the treatment plan. During a concurrent interview and record review on 7/25/2025 at 12:01 p.m. with RN 1, Patient 24’s treatment plan titled, “Initial and Master Treatment Plan,” dated 1/5/2025, was reviewed. The treatment plan indicated, “depressed mood with suicidality (thoughts of taking one’s own life)” and “mood swings” as Patient 24’s active problems. RN 1 stated the treatment plan to address the problem of “sexually acting out - victim” was missing. RN 1 stated this could result in staff being unaware of what interventions and adjustments in patient care that are needed to be provided to Patient 24 to avoid triggering the trauma. During a concurrent interview and record review on 7/25/2025 at 12:17 p.m. with RN 1, Patient 24’s group progress notes titled, “[unit] Adult Group Note Friday (group note),” dated 1/10/2025, was reviewed. The group note indicated, “Patient (Patient 24) stated she is not happy with tall male nurses coming into her (Patient 24’s) room at night, makes her anxious.” RN 1 stated this could be avoided by providing proper interventions such as avoiding male staff assignment rounding for Patient 24 at night and alert male staff to stay from a distance with Patient 24 in order to avoid triggering her stress and making her (Patient 24) anxious. During a concurrent interview and record review on 7/25/2025 at 2:47 p.m. with the Director of Clinical Services (DCS), Patient 24’s “Psychosocial Assessment (assessment completed by social service staff),” dated 1/6/2025, was reviewed. The “Psychosocial Assessment” indicated, Patient 24 had history of trauma as a sexual abuse victim. The “Psychosocial Assessment” also indicated, “severe and chronic depression, and history of trauma” as the high-risk psychosocial issues requiring early treatment planning and interventions. DCS stated there should be a treatment plan developed to address Patient 24’s past sexual abuse trauma to provide proper intervention to aid Patient 24’s mental health healing process. DCS further stated Patient 24’s treatment plan did not address Patient 24’s past trauma. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Patient-Centered Care Planning,” dated 5/2025, the P&P indicated, “It is the policy of [the facility] to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient’s assessed needs to be addressed during treatment and develop appropriate goals and interventions ... Each discipline completing their individual assessments will begin to identify the patient’s problems to be treated and the focus of their treatment interventions which will be included in the MTP (master treatment plan).” During a review of the facility’s policy and procedure (P&P) titled, “ Active and Individualized Treatment,” dated 5/2024, the P&P indicated, “Active treatment is substantive engagement with the patient in their care through the course of a day which occurs in the therapeutic milieu where our patients are surrounded by a safe, structured community through which their activities of daily living are a means of encouraging healthier ways of thinking and behaving ... It is the policy of [the facility] to provide care and a model of active treatment for all patients hospitalized at the facility. Active treatment services provided must be ... provided under an individualized treatment plan.””

“Treatment Plan - Goals CFR(s): [The written plan must include] Short-term and long range goals; This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its multidisciplinary team (a group of professionals including physicians, nurses, social workers and therapists who collaborate to provide comprehensive and coordinated patient care) set a long-term goal when developing a treatment plan (a document that outlines an individual’s assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided) for two of 43 sampled patients (Patients 24, and 25), in accordance with the facility’s policy regarding treatment plans. This deficient practice had the potential to result in failure in evaluating a patient’s care progress and response to treatment, which may lead to a premature or a delayed discharge. Findings: 1. During a review of Patient 24’s “Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 1/5/2025, the Psych Eval indicated, Patient 24 was admitted to the facility on 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 and treatment) with diagnoses including but not limited to bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), depressed (mood disorder that causes a persistent feeling of sadness and loss of interest in life) type, without psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality), posttraumatic stress disorder (PTSD, an anxiety disorder that develops after experiencing stressful, frightening or distressing events), and diabetes (high blood sugar). During an interview on 7/25/2025 at 11:48 a.m. with the Registered Nurse (RN) 1, RN 1 stated each patient would have a treatment plan (a document that outlines an individual’s assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided) developed with short term and long-term goals set to each problem identified by the multi-disciplinary team (a group of professionals including physicians, nurses, social workers and therapists who collaborate to provide comprehensive and coordinated patient care). RN 1 further stated there must be set goals for a patient to meet before discharge. During a concurrent interview and record review on 7/25/2025 at 12:01 p.m. with RN 1, Patient 24’s treatment plan titled, “Multidisciplinary Treatment Plan - Mood Swing/Labile (tendency to be unpredictable) Mood,” dated 1/8/2025, was reviewed. The treatment plan indicated, “Problem Name: Mood Swings/Labile Mood with behavioral manifestations/observations: patient (Patient 24) mood fluctuates from calm to easily agitated.” The treatment plan also indicated there was no long-term goal/discharge criteria listed. RN 1 stated the long-term goal was missing. RN 1 further stated, without the long-term goal, the treatment team could not measure if Patient 24’s mood improved or not. During an interview on 7/25/2025 at 2:56 p.m. with the Director of Clinical Services (DCS), DCS stated the following: there should be at least one long-term goal and one short-term goal set for each problem identified for patient in the treatment plan. Every patient should have a measurable set goal, otherwise the treatment team would not be able to measure a patient’s progress and adjust interventions as needed to meet the set goals. Once the patient had met the goals, the patient would be ready for discharge. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Patient-Centered Care Planning,” dated 5/2025, the P&P indicated, “It is the policy of [the facility] to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient’s assessed needs to be addressed during treatment and develop appropriate goals and interventions ... Each patient’s written Treatment Plan must include ... short-term and long-term goals for each active problem, developed with patient input ... Procedures: Developing the Treatment Plan ... 4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan ... the treatment team will complete the MTP (Master Treatment Plan) including ... b. completion of an individual problem sheet for each active psychiatric or medical problem. The problem sheets will include the problem, specific patient behavioral manifestations, long and short-term goals with target dates, and interventions for each appropriate discipline ... the following would be cause of conducting a review of the plan and developing a revision... the patient has successfully completed treatment goals ... the patient fails to reach treatment goals despite reasonable clinical care.” 2. During a review of Patient 25’s face sheet (face sheet, document provides patient’s demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance) titled, “Patient Demographic Profile,” dated 7/16/2025, the face sheet indicated, Patient 25 was admitted to the facility with diagnosis of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), recurrent (repeat). During an interview on 7/25/2025 at 11:48 a.m. with the Registered Nurse (RN) 1, RN 1 stated each patient would have a treatment plan developed with short term and long-term goals set to each problem identified by the multi-disciplinary team. RN 1 further stated there must be set goals for a patient to meet before discharge. During an interview on 7/25/2025 at 2:56 p.m. with the Director of Clinical Services (DCS), the DCS stated the following: there should be at least one long-term goal and one short-term goal set for each problem identified for a patient in the treatment plan. Every patient should have a measurable set goal, otherwise the treatment team would not be able to measure a patient’s care progress and adjust interventions as needed to meet the set goals. Once the patient had met the goals, the patient would be ready for discharge. During a concurrent interview and record review on 7/25/2025 at 3:02 p.m. with the DCS, Patient 25’s treatment plan titled, “Multidisciplinary Treatment Plan - Depressed Mood with Suicidality (ending one’s own life),” dated 7/16/2025, was reviewed. The treatment plan indicated, “Problem Name: Depressed Mood with Suicidality with behavioral manifestations/observations: endorsed suicidal ideation with a plan to overdose (an excessive and dangerous dose of a drug).” The treatment plan also indicated there was no long-term goals/discharge criteria listed. DCS stated the following: the long-term goal was missing. It was the multidisciplinary team’s responsibility to make sure there was at least one long-term goal listed on the active problem. There was nothing to measure and evaluate Patient 25’s progress because there was no long-term goal. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Patient-Centered Care Planning,” dated 5/2025, the P&P indicated, “It is the policy of [the facility] to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient’s assessed needs to be addressed during treatment and develop appropriate goals and interventions ... Each patient’s written Treatment Plan must include ... short-term and long-term goals for each active problem, developed with patient input ... Procedures: Developing the Treatment Plan ... 4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan ... the treatment team will complete the MTP (Master Treatment Plan) including ... b. completion of an individual problem sheet for each active psychiatric or medical problem. The problem sheets will include the problem, specific patient behavioral manifestations, long and short-term goals with target dates, and interventions for each appropriate discipline ... the following would be cause of conducting a review of the plan and developing a revision... the patient has successfully completed treatment goals ... the patient fails to reach treatment goals despite reasonable clinical care.””

“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: 46333 Based on observation, interview and record review, the facility failed to ensure the medication consent record for one (1) of 43 sampled patients (Patient 5), was completed, in such a way to assure that all active therapeutic efforts were included, in accordance with the facility’s policy titled “Informed Consent For Psychotropic Medications (medications that affect the brain and can alter mood, awareness, thoughts, feelings, or behavior).” Specifically, the facility failed to ensure that the medication consent form for a sedation-hypnotic medication (Ambien, a medication used to treat insomnia [difficulty falling or staying asleep]) included: the dosing range, name and signature of the treating practitioner, the diagnosis, the intended benefits and outcomes of the medication, and documentation of the possibility that the medication may require adjustment. This deficient practice resulted in a medication being administered to Patient 5 without a fully completed and physician signed medication consent form. The medical record did not contain documentation that the physician explained the medication’s risks, benefits, or purpose to Patient 5. This lack of documentation may interfere with the treatment team’s ability to assess informed consent, track treatment planning, and ensure proper authorization. This deficient practice also had the potential to affect other patients if medications were administered without a complete and accurately documented consent process. Findings: During a review of Patient 5’s “Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation,” dated 7/14/2025, indicated that Patient 5 was admitted for complaints of anxiety (a persistent feeling of worry or nervousness), depression (a mood disorder causing a persistent feeling of sadness or loss of interest), and thoughts of suicide (intending to take one’s own life) through overdose (when you take more than the recommended amount of something, often a medicine or drug). Patient 5’s psychiatric diagnosis included bipolar disorder (a mental health condition causing extreme mood swings including manic highs and depressive lows). During a review of Patient 5’s form titled, “Medication Consent For: Sedation (produce a state of calm or sleep), Hypnotics (used to induce and maintain sleep), and Anti-Anxiety Agents,” dated 7/16/2025, the medication Ambien (a sedative-hypnotic used to treat insomnia [difficulty falling or staying asleep]) was listed. However, the consent form was missing the following required elements: Physician signature attesting that the risks, benefits, alternatives of hypnotics and anxiety agents, had been explained to Patient 5, dosing range, diagnosis, and Documentation that the medication might need adjustment. During a review of Patient 5’s Medication Administration Record, dated from 7/16/2025 through 7/22/2025, the record indicated, Ambien 10 milligrams (mg, a unit of measurement) oral tablet was documented as administered on the following dates: o 7/16/2025 at 11:45 p.m. o 7/17/2025 at 8:44 p.m. o 7/18/2025 at 11:47 p.m. o 7/20/2025 at 12:49 a.m. o 7/21/2025 at 2:13 a.m. o 7/22/2025 at 1:33 a.m. o 7/23/2025 at 12:50 a.m. o 7/24/2025 at 12:01 a.m. During a concurrent interview and record review on 7/25/2025 at 8:05 p.m. with the Director of Quality and Performance Improvement Compliance Officer (DQPI), Patient 5’s “Medication Consent For: Sedation, Hypnotics, and Anti-Anxiety Agents,” dated 7/16/2025, was reviewed. The DQPI confirmed that the form lacked all required documentation including: -the dosing range, -the name and signature of the prescribing practitioner, -the psychiatric diagnosis, -the potential need for medication adjustment. During a concurrent interview and record review on 7/25/2025 at 8:05 p.m. with the Chief Executive Officer (CEO), Patient 1’s medication consent form, was reviewed. The CEO confirmed that the physician had not signed the consent form and that the witness signature was illegible. During a review of the facility’s Policy and Procedure (P&P) titled, “Informed Consent for Psychotropic Medication (medications that affect the brain and can alter mood, awareness, thoughts, feelings, or behavior),” dated June 2024, was reviewed. The P&P indicated: “Each medication ordered by the physician must have a distinct and separate medication consent form filled out by the physician or his designee in black ink. Dosing range must be documented, name and signature of the treating practitioner, the diagnosis, the benefits and intended outcomes, and the possibility that the medication would need to be adjusted.” During a review of the facility’s Medical Staff Bylaws (a set of rules and regulations that govern the internal management of an organization), Rules, and Regulations, dated 1/23/2025, the bylaws indicated: “Required consents for any and all treatments should be obtained ...All orders for treatment and/or medications shall be in writing ...The responsible practitioner shall sign such orders with date and time at the next visit, within 48 hours.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42937 Based on 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 one of 30 sampled patients (Patient 28), was provided information regarding the Condition of Admission (COA, a contract that outlines the patient’s obligations to the hospital, such as paying for services, providing informed consent [A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment], and understanding the hospital’s arrangements). This deficient practice had the potential for Patient 28 not being able to fully understand and exercise rights as a patient, which may lead to Patient 28’s inability to effectively make decisions regarding own care and treatment in the facility. (Refer to A-0117) 2. The facility failed to ensure patient safety, in accordance with the facility’s policy regarding patient supervision, for one of 30 sampled patients (Patient 1), when Patient 1 was involved in two separate physical altercations (a confrontation or fight involving physical contact or force, potentially resulting in injury) with Patients 2 and 3 within a 30-minute time period. Patient 1 was physically attacked by Patients 2 and 3. This deficient practice resulted in Patient 1 suffering a hematoma (a collection of blood that pools outside of a blood vessel, often forming a lump or bruise-like area, due to a broken blood vessel) to the forehead and required a transfer to the acute care hospital for further evaluation and treatment. (Refer to A-0144) 3. The facility failed to ensure that one of 30 sampled patients (Patient 1), was free from all forms of abuse (any action or failure to act which causes unreasonable suffering, misery, or harm to the patient. Includes physical abuse, neglect, sexual abuse, emotional and financial abuse), when preventive mechanisms/methods to prevent the re-occurrence of abuse were not implemented, in accordance with the facility’s policy regarding patient rights in mental health facilities and patient supervision. Patient 1 was involved in two separate incidents of altercations (physical and verbal) within a 30-minute time span. This deficient practice resulted in Patient 1 suffering a hematoma (a collection of blood that pools outside of a blood vessel, often forming a lump or bruise-like area, due to a broken blood vessel) to the forehead, which required a transfer to the acute care hospital for further evaluation and treatment. This deficient practice also had the potential for other patients not to feel safe and secure in the healthcare environment. (Refer to A-0145) 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: 42937 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 ensure for two of 30 sampled patients (Patient 11 and Patient 21), the following: 1.a. Patient’s 11 treatment plan/care plan (a document that outlines a patient’s healthcare needs, goals, and the interventions and treatments planned to achieve those goals, serving as a roadmap for their care and facilitating communication among the healthcare team) regarding Hepatitis B (a viral infection that causes inflammation of the liver), was developed and implemented within (8) hours of admission, in accordance with the facility’s policy regarding care planning. This deficient practice had the potential for Patient 11’s condition to remain unmonitored and untreated and also had the potential for proper infection protocol not to be implemented which can result in the spread of infection among patients, staff and visitors. (Refer to A-0396) 1.b. Patient 21’s treatment plan/care plan regarding suicide (thoughts of taking one’s own life) and major depression (a common and serious mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life), was reviewed, re-assessed, and updated to determine if the treatment goal was met or if there was a need to modify the treatment plan, in accordance with the facility’s policy regarding care planning. This deficient practice had the potential for Patient 21’s patient care needs and progress to not be identified and monitored which can lead to a delay in modifying the treatment plan and implementation of necessary interventions resulting in poor patient outcomes (Example: increased risk of suicide and worsened mood disorders). (Refer to A-0396) 2. The facility failed to report a physical abuse (deliberately aggressive or violent behavior by one person toward another that results in bodily injury) incident in a timely manner (within five days), for one of 30 sampled patients (Patient 1), in accordance with the facility’s policy and procedure titled, “Serious Event Notification.” This deficient practice had the potential to result in a delay in investigation, potentially placing patients at risk of not receiving necessary care and treatment. (Refer to A-0398) 3. The facility failed to ensure one of 30 sampled patients (Patient 21), was appropriately assessed and monitored for Detoxification (a set of interventions aimed at managing acute intoxication [a potentially life-threatening condition resulting from consuming a large amount of alcohol in a short period, leading to impaired bodily functions and potentially coma or death] and withdrawal)/Withdrawal symptoms (include cravings, sleep problems, headaches, nausea [an urge to vomit] and feeling restless or agitated), in accordance with the facility’s policy regarding “Management of Detox Patients.” This deficient practice had the potential for Patient 21’s care needs not to be addressed in a timely manner, which may result in Patient 21’s worsening withdrawal symptoms leading to complications such as seizures (sudden, temporary disruptions in brain electrical activity that can cause changes in behavior, movement, sensation, and awareness) or even death. (Refer to A-0398) 4. The facility failed to ensure one of one sampled crash cart (Crash Cart #1, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) located in the Del Sol Unit and the CTC Unit (Crisis Treatment Center, Adult Psychiatric Unit), was equipped with a full oxygen tank (used to provide oxygen support when performing cardiopulmonary resuscitation [CPR, an emergency life?saving procedure performed when the heart stops beating]) to be used for 36 of 36 sampled patients during an emergency situation requiring oxygen support, in accordance with the facility’s “Emergency Medical Equipment Daily Checklist.” This deficient practice had the potential for oxygen supplies to not be readily available in case of an emergency and had the potential to result in a delayed emergency care needed by patients, which may lead to 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.”

“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: 42976 Based on interview, and record review, the facility failed to ensure one of 30 sampled patients (Patient 28), was provided information regarding the Condition of Admission (COA, a contract that outlines the patient’s obligations to the hospital, such as paying for services, providing informed consent [A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment], and understanding the hospital’s arrangements). This deficient practice had the potential for Patient 28 not being able to fully understand and exercise rights as a patient, which may lead to Patient 28’s inability to effectively make decisions regarding own care and treatment in the facility. Findings: During a review of Patient 28’s “Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation (first interview between physician and patient to help identify disorders and help the treatment team develop a treatment plan),” dated 03/04/2025, the document indicated that Patient 28 was a 57 years old male who was admitted on 03/04/2025 for danger to self and grave disability (a severe mental health condition that renders an individual unable to provide for their basic needs, such as food, clothing, and shelter) hold. The psychiatric evaluation also indicated Patient 28 was previously diagnosed with a history of mood disorder (a mental health condition that primarily affects a person’s emotional state, characterized by persistent and intense changes in mood, energy levels, and behavior, often including periods of extreme sadness [depression] or excessive happiness [mania]). Patient 28’s psychiatric evaluation also indicated Patient 28’s mental status was alert and oriented to person, place, time and situation. During a concurrent interview and record review on 3/14/2025 at 11:09 a.m. with the Intake Director (ID 1), Patient 28’s medical record titled, “Condition of Admission (COA- a contract that outlines the patient’s obligations to the hospital, such as paying for services, providing informed consent [A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment], and understanding the hospital’s arrangements),” dated 3/04/2025, was reviewed. Patient 1’s COA record indicated “Refused, Sleeping.” ID 1 stated the following: confirmed documentation done by staff was inappropriate and staff should have followed up with patient (Patient 28) to ensure patient (Patient 28) understood his (Patient 28) COA and affirm understanding by signing the COA form. During the same interview on 3/14/2025 at 11:09 a.m. with the Intake Director (ID 1), ID 1 stated the facility did not have a policy on Condition of Admission and the facility will start developing a policy for it. ID 1 also said that it was the responsibility of the intake staff to obtain the signature of the patients for the COA to ensure that the patient understood what the COA was for and provide the patient the opportunity to ask questions. During an interview on 3/14/2025 at 2:45 p.m. with the Director of Performance Improvement (DPI 1), DPI 1 stated and confirmed that the facility had no policy for Condition of Admission.”

“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 interview and record review, the facility failed to ensure patient safety, in accordance with the facility’s policy regarding patient supervision, for one of 30 sampled patients (Patient 1), when Patient 1 was involved in two separate physical altercations (a confrontation or fight involving physical contact or force, potentially resulting in injury) with Patients 2 and 3 within a 30-minute time period., Patient 1 was physically attacked by Patients 2 and 3. This deficient practice resulted in Patient 1 suffering a hematoma (a collection of blood that pools outside of a blood vessel, often forming a lump or bruise-like area, due to a broken blood vessel) to the forehead and required a transfer to the acute care hospital for further evaluation and treatment. Findings: During a review of Patient 1’s Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation (first interview between physician and patient to help identify disorders and help the treatment team develop a treatment plan), dated 8/28/2023, the psychiatric evaluation indicated that Patient 1 was admitted to the facility on 8/27/2023 on a 5150 (an involuntary 72-hour hold for the treatment of a psychiatric condition) for danger to self and others and a diagnosis of disruptive mood dysregulation disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts). The psychiatric evaluation also indicated that Patient 1 was to be discharged to an outpatient facility on 8/28/2023. During a review of Patient 1’s Progress notes, dated 8/28/2023 and timed at 13:13 (1:13 p.m.), Patient 1’s Progress Notes indicated that Patient 1 was transferred to an acute hospital for evaluation and that Patient 1 complained of left shoulder pain and loss of consciousness (neither awake nor aware of the external environment). During a review of Patient 1’s document titled, “Out of Hospital Consultation Report,” dated 8/28/2023, the report indicated Patient 1 was sent to the acute care hospital for hematoma (a collection of blood that pools outside of a blood vessel, often forming a lump or bruise-like area, due to a broken blood vessel) on the forehead due to altercation (physical altercation- a confrontation or fight involving physical contact or force, potentially resulting in injury) and to rule out (to eliminate or exclude something from consideration) head trauma (a tissue injury that occurs more or less suddenly due to violence or an accident). During a review of Patient 2’s Initial Psychiatric Evaluation, dated 8/23/2023, Patient 2 was admitted to the facility on 8/22/2023 on a 5585 (a minor [anyone under the age of 18] who is put on an involuntary 72-hour hold [for psychiatric treatment and evaluation]) and diagnosis of disruptive mood dysregulation disorder and attention deficit hyperactivity disorder (a condition that makes it hard to focus, sit still, and control impulses, often causing difficulties in daily life). During a review of Patient 2’s Progress notes, dated 8/28/2023 and timed at 1430 (2:30 p.m.), the progress notes indicated that Patient 2 became verbally aggressive and attempted to throw a chair at Patient 1 which was blocked by a facility staff. Patient 1 was then put in a physical restraint technique (PRT-technique used to hold an aggressive patient. Example: holding a patient’s arms or legs) for 10 seconds and then was released. Patient 2 physically attacked Patient 1 again while lining up to exit the facility’s cafeteria. Patient 3 (who was also in the line) intervened and began to attack Patient 1 as well. Patient 2 was placed in a PRT and then released. During a review of Patient 3’s Initial Psychiatric Evaluation, dated 8/18/2023, Patient 3’s psychiatric evaluation indicated Patient 3 was admitted to the facility with the diagnosis of unspecified schizophrenic (chronic mental disorder characterized by a combination of positive [like hallucinations and delusions] and negative symptoms, and disorganized thinking and behavior) spectrum and substance-induced psychosis (state where someone experiences a significant disconnect from reality, often involving hallucinations [seeing or hearing things that aren’t there] and delusions [holding false beliefs]). During a review of Patient 3’s Progress note, dated 8/28/2023 and timed at 1400 (2:00 p.m.), Patient 3’s Progress note indicated that Patient 3 tried to intervene in the altercation between Patient 1 and Patient 2 but was pushed in the process. Patient 3 then pushed Patient 1 to the floor and began to hit Patient 1 repeatedly. Patient 3 was placed in PRT and redirected outside to the courtyard. During an interview on 3/10/2025 at 2:10 p.m. with Mental Health Technician 1 (MHT 1), MHT 1 stated that safety of the patients is a priority. MHT 1 also said “When an altercation (either physical or verbal) occurs between two patients, we separate the individuals and if needed we will call a Code 10. Code 10 is where staff from other units come and help with the situation.” During a concurrent interview and record review on 3/11/2025 at 2:42 p.m. with Registered Nurse (RN) 1, Patient 1’s Progress note dated 8/23/2023, timed at 1430 (2:30 p.m.), was reviewed. The Progress note indicated that Patient 1 was involved in two separate altercations with Patient 2 and Patient 3 in the facility’s cafeteria. The progress note indicated that Patient 1 and Patient 2 were involved in a verbal altercation that resulted in Patient 2 attempting to throw a chair at Patient 1 (First altercation). The second altercation between Patient 1 and Patient 2 occurred while lining up in the facility’s cafeteria, where Patient 3 was also involved with the kicking and punching of Patient 1. The Patients (Patients 1, 2 and 3) involved were separated, and a “Code 10 (all trained staff needed to assist in handling an acutely agitated or assaultive patient),” was called. RN 1 stated that the MHT should have called a “Code 10” during the first altercation (which was not done. The Code 10 was only called after the second altercation occurred). During an interview on 3/13/2025 at 10:27 a.m. with Mental Health Technician (MHT) 2, MHT 2 stated that a RN should have been notified of the first incident between Patient 1 and Patient 2 (referring to the verbal altercation) and that either the aggressor or victim needed to be pulled from the environment to prevent another incident from happening. MHT 2 stated she (MHT 2) remembered the incident vaguely and just remembered protecting Patient 1 from the altercation. During an interview on 3/13/2025 at 11:58 a.m. with Nurse Manager (NM) 1, NM 1 stated that if a PRT was initiated by a staff member, a RN needed to assess the situation and be the one to end the PRT. NM1 stated that if a RN was involved with the first incident (verbal altercation between Patient 1 and Patient 2) or notified about the first incident, incident 2 (when Patient 1 was kicked and punched) might not have occurred. During a review of the facility’s document titled, “Mental Health Technician 1 (MHT 1), dated 7/2020, the document indicated MHT must ensure safety of patient at all times and consistently provide supervision for assigned patients. The document also indicated that to notify charge/staff nurses of patients with potential risk of injury due to falls, self-destructive, or assaultive behaviors. During a review of the facility’s policy and procedure (P&P) titled, “Supervision of Patients/Patient Rounds,” revised 01/2025, the P&P indicated “when staff are observing patients during mealtimes in the off-unit cafeterias, observe for possible elopement, removal of contraband (any item that is prohibited within the facility. Example: knives, razors, illegal drugs) and/or sharp items (intended to cut or penetrate the skin- Example: needles, lancets, etc.), and any unsafe behavior.””

“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 ensure that one of 30 sampled patients (Patient 1) was free from all forms of abuse (any action or failure to act which causes unreasonable suffering, misery, or harm to the patient. Includes physical abuse, neglect, sexual abuse, emotional and financial abuse), when preventive mechanisms/methods to prevent the re-occurrence of abuse were not implemented, in accordance with the facility’s policy regarding patient rights in mental health facilities and patient supervision. Patient 1 was involved in two separate incidents of altercations (physical and verbal) within a 30-minute time span. This deficient practice resulted in Patient 1 suffering a hematoma (a collection of blood that pools outside of a blood vessel, often forming a lump or bruise-like area, due to a broken blood vessel) to the forehead which required a transfer to the acute care hospital for further evaluation and treatment. This deficient practice also had the potential for other patients not to feel safe and secure in the healthcare environment. Findings: During a review of Patient 1’s Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation (first interview between physician and patient to help identify disorders and help to the treatment team develop a treatment plan), dated 8/28/2023, the evaluation indicated that Patient 1 was admitted to the facility on 8/27/2023 on a 5150 (an involuntary 72-hour hold for the treatment of a psychiatric condition) for danger to self and others and a diagnosis of disruptive mood dysregulation disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts). The psychiatric evaluation also indicated that Patient 1 was to be discharged to an outpatient facility on 8/28/2023. During a review of Patient 1’s Progress notes dated 8/28/2023 and timed at 13:13 (1:13 p.m.), Patient 1’s Progress notes indicated that Patient 1 was transferred to an acute hospital for evaluation (following the second physical altercation involving Patients 2 and 3) and that Patient 1 complained of left shoulder pain and loss of consciousness (neither awake nor aware of the external environment). During a review of Patient 1’s document titled, “Out of Hospital Consultation Report,” dated 8/28/2023, the document indicated Patient 1 was sent to the acute care hospital for hematoma (a collection of blood that pools outside of a blood vessel, often forming a lump or bruise-like area, due to a broken blood vessel) on the forehead due to altercation (referring to the physical altercation [a confrontation or fight involving physical contact or force, potentially resulting in injury] involving Patients 1, 2 and 3) and to rule out (to eliminate or exclude something from consideration) head trauma (a tissue injury that occurs more or less suddenly due to violence or an accident). During a review of Patient 2’s Initial Psychiatric Evaluation, dated 8/23/2023, Patient 2’s psychiatric evaluation indicated Patient 2 was admitted to the facility on 8/22/2023 on a 5585 (a minor [anyone under the age of 18] who is put on an involuntary 72-hour hold [for psychiatric treatment and evaluation]) and a diagnosis of disruptive mood dysregulation disorder and attention deficit hyperactivity disorder (a condition that makes it hard to focus, sit still, and control impulses, often causing difficulties in daily life). During a review of Patient 2’s Progress notes, dated 8/28/2023 and timed at 1430 (2:30 p.m.), the progress notes indicated that Patient 2 became verbally aggressive and attempted to throw a chair at Patient 1 which was blocked by facility staff. Patient 2 was then put in a physical restraint technique (PRT-technique used to hold an aggressive patient. Example: holding a patient’s arms or legs) for 10 seconds and then was released. Patient 2 physically attacked Patient 1 again while lining up to exit the facility’s cafeteria. Patient 3 intervened and began to attack Patient 1. Patient 2 was then placed in a PRT and released. During a review of Patient 3’s Initial Psychiatric Evaluation, dated 8/18/2023, Patient 3’s psychiatric evaluation indicated Patient 3 was admitted to the facility with a diagnosis of unspecified schizophrenic (chronic mental disorder characterized by a combination of positive [like hallucinations and delusions] and negative symptoms, and disorganized thinking and behavior) spectrum and substance-induced psychosis (state where someone experiences a significant disconnect from reality, often involving hallucinations [seeing or hearing things that aren’t there] and delusions [holding false beliefs]). During a review of Patient 3’s Progress note, dated 8/28/2023 and timed at 1400 (2:00 p.m.), Patient 3’s Progress note indicated that Patient 3 tried to intervene in the altercation between Patient 1 and Patient 2 but was pushed in the process. Patient 3 then pushed Patient 1 to the floor and began to hit Patient 1 repeatedly. Patient 3 was placed in PRT and redirected outside to the courtyard. During a concurrent interview and record review on 3/14/2025 at 10:44 a.m. with the Director of Risk Management (DRM), the facility’s policy and procedure (P&P) titled, “Assessment and Reporting Abuse (any action or failure to act which causes unreasonable suffering, misery, or harm to the patient. Includes physical abuse, neglect, sexual abuse, emotional and financial abuse),” dated 10/2001, was reviewed. The DRM stated the abuse can be any physical contact between patient to patient or patient to staff. The DRM then stated that according to the facility’s P&P physical abuse includes any non-accidental physical trauma cause by the caretaker, spouse or cohabitant and that it may include burning, beating, branding, punching, etc. During a review of the facility’s handbook titled, “Rights for Individuals in Mental Health Facilities,” revised July 2018, the handbook (page 22) indicated that patients have the right to be free from abuse, neglect, or harm, including unnecessary or excessive restraint (devices that limit a patient’s movement), isolation (supervised confinement of a patient away from other patients) or medication. The handbook also indicated that patients have the right to be free from potentially harmful situations or conditions. During a review of the facility’s policy and procedure (P&P) titled, “Supervision of Patients/Patient Rounds,” revised 01/2025, the P&P indicated when staff are observing patients during mealtimes in the off-unit cafeterias, observe for possible elopement, removal of contraband (any item that is prohibited within the facility. Example: knives, razors, illegal drugs) and/or sharp items (intended to cut or penetrate the skin- Example: needles, lancets, etc.), and any unsafe behavior.”

“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: 42976 Based on interview, and record review, the facility failed to ensure for two of 30 sampled patients (Patient 11 and Patient 21), the following: 1. Patient’s 11 treatment plan/care plan (a document that outlines a patient’s healthcare needs, goals, and the interventions and treatments planned to achieve those goals, serving as a roadmap for their care and facilitating communication among the healthcare team) regarding Hepatitis B (a viral infection that causes inflammation of the liver) was developed and implemented within (8) hours of admission, in accordance with the facility’s policy regarding care planning. This deficient practice had the potential for Patient 11’s condition to remain unmonitored and untreated and also had the potential for proper infection protocol not to be implemented which can result in the spread of infection among patients, staff and visitors. 2. Patient 21’s treatment plan/care plan regarding suicide (thoughts of taking one’s own life) and major depression (a common and serious mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life), was reviewed, re-assessed, and updated to determine if the treatment goal was met or if there was a need to modify the treatment plan, in accordance with the facility’s policy regarding care planning. This deficient practice had the potential for Patient 21’s patient care needs and progress to not be identified and monitored which can lead to a delay in modifying the treatment plan and implementation of necessary interventions resulting in poor patient outcomes (Example: increased risk of suicide and worsened mood disorders). Findings: 1. During a review of Patient 11’s “Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation (first interview between physician and patient to help identify disorders and help to the treatment team develop a treatment plan),” dated 03/03/2025, the document indicated that Patient 11 was a 39 years old male who was admitted on 03/01/2025 for Schizophrenia (a chronic [persists for a long time] mental illness characterized by disruptions in thought, perception, emotion, and behavior). Patient 11’s psychiatric evaluation also indicated that Patient 11 had a past medical problem of Hepatitis B (a viral infection that causes inflammation of the liver). During a concurrent interview and record review on 3/10/2025 at 2:40 p.m. with Registered Nurse (RN) 3, Patient 11’s medical record titled, “Chronic/Stable Psychiatric & Medical Problem List,” undated, was reviewed. Patient 11’s record did not indicate Hepatitis B was on the problem list. RN 3 stated that Patient 11 was admitted with Hepatitis B as one of his (Patient 11) past medical problems. RN 3 said the admitting nurse failed to note and include Hepatitis B in the treatment plan problem list, so that it can be discussed in the patient’s weekly treatment rounds. RN 3 also stated the weekly treatment rounds was when members of multidisciplinary teams (comprises professionals from various disciplines who collaborate to provide comprehensive care and support for patients or clients, focusing on coordinated, patient-centered care) meet to review a patient progress, develop personalized care plans (a document that outlines a patient’s healthcare needs, goals, and the interventions and treatments planned to achieve those goals, serving as a roadmap for their care and facilitating communication among the healthcare team. ), and address potential risks to improve patient outcomes. During a review of the facility’s Policy and Procedure (P&P) titled, “Interdisciplinary Patient - Centered Care Planning,” (Policy No.: PC-13), with revised date of May 2024, the P&P indicated the following: Policy: It is policy to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient’s assessed needs to be addressed during treatment and develop appropriate goals and interventions. All therapeutic services that are beyond routine tasks to be provided to the patient are included in the plan and the treatment plans are routinely reviewed to assess the patient’s progress and determine if any modifications are needed. Each patient’s written Treatment Plan must include: -Substantiated diagnosis(es) -Identification of problems to be treated and the specific behavioral manifestations of those problems in the patient -Short-term and long-term goals for each active problem, developed with patient input -The specific treatment modalities with individualized patient focus -The responsibilities of each member of the treatment team Procedure: Developing the Treatment Plan 1. The Nurse completing the Nursing Assessment or designee shall develop the Initial Treatment Plan within eight (8) hours of admission. The nurse will utilize the problems and specific behavioral manifestations identified in the initial assessment and nursing assessment to develop clinically appropriate and individualized goals and interventions which will be included in the Initial Treatment Plan. a. Any medical problems or diagnoses that are not receiving treatment will be listed on the Treatment Plan cover sheet/problem list as deferred with justification provided. If the medical problem requires active treatment, it will either be included in the plan as a “Chronic/Stable” medical problem if only routine care is provided or on a separate problem sheet if more than routine care is indicated. b. At the time of the development of the Interdisciplinary Master Treatment Plan (MTP), the Initial Treatment Plan will be considered resolved, with psychiatric problems either moved to the MTP or fully resolved and medical problems moved to the MTP. 2. During a review of Patient 21’s “Initial Psychiatric Evaluation,” dated 03/10/2025, the document indicated that Patient 21 was a 59 years old female who was admitted on 03/09/2025 for feeling suicidal (thoughts of taking one’s own life). The psychiatric evaluation also indicated Patient 21 was previously diagnosed with major depression (a common and serious mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life). During a concurrent interview and record review on 3/13/2025 at 11:09 a.m. with Nurse Manager (NM) 1, Patient 21’s medical record titled, “Multidisciplinary Treatment Plan,” dated 3/09/2025, was reviewed. Patient 21’s Multidisciplinary Treatment Plan record indicated the staff did not evaluate Patient 21’s care plan goals. NM 1 stated the following: Confirmed achieved dates (completion date of goals indicated in the treatment plan that helps indicate if the identified problem was resolved or if there was a need to revise the treatment plan) were not done for Patient 21’s treatment goals. No documentation from staff that treatment goals were achieved/met/or reviewed. NM 1 also said it was important to complete the achieve dates (dates the treatment goals were met) for the care plan per policy and NM 1 will educate the staff to make sure they complete the care plan’s achieved treatment goal dates. During a review of the facility’s Policy and Procedure titled, “Interdisciplinary Patient - Centered Care Planning,” (Policy No.: PC-13), with revised date of May 2024, the P&P indicated the following: Policy: It is policy to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient’s assessed needs to be addressed during treatment and develop appropriate goals and interventions. All therapeutic services that are beyond routine tasks to be provided to the patient are included in the plan and the treatment plans are routinely reviewed to assess the patient’s progress and determine if any modifications are needed. 2. Resolving, Discontinuing or Continuing Goals and Interventions a. During the treatment plan review, the treatment team will evaluate if goals have been met by established target dates. Once a goal has been resolved, the date will be identified on the treatment plan. b. If the goal has not been met, the team needs to either reevaluate the target date and establish a new one or re-evaluate the appropriateness of the goal. c. Staff members, upon discharge, shall either document on remaining goals the date if resolved or “ongoing” meaning that the problem has not yet been resolved.”

“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: 45743 Based on observation, interview and record review, the facility failed to: 1. Report a physical abuse (deliberately aggressive or violent behavior by one person toward another that results in bodily injury) incident in a timely manner (within five days), for one of 30 sampled patients (Patient 1), in accordance with the facility’s policy and procedure titled, “Serious Event Notification.” This deficient practice had the potential to result in a delay in investigation, potentially placing patients at risk of not receiving necessary care and treatment. 2. Ensure one of 30 sampled patients (Patient 21), was appropriately assessed and monitored for Detoxification (a set of interventions aimed at managing acute intoxication [a potentially life-threatening condition resulting from consuming a large amount of alcohol in a short period, leading to impaired bodily functions and potentially coma or death] and withdrawal)/Withdrawal symptoms (include cravings, sleep problems, headaches, nausea [an urge to vomit] and feeling restless or agitated), in accordance with the facility’s policy regarding “Management of Detox Patients.” This deficient practice had the potential for Patient 21’s care needs not to be addressed in a timely manner, which may result in Patient 21’s worsening withdrawal symptoms leading to complications such as seizures (sudden, temporary disruptions in brain electrical activity that can cause changes in behavior, movement, sensation, and awareness) or even death. 3. Ensure one of one sampled crash cart (Crash Cart #1, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) located in the Del Sol Unit and the CTC Unit (Crisis Treatment Center, Adult Psychiatric Unit), was equipped with a full oxygen tank (used to provide oxygen support when performing cardiopulmonary resuscitation [CPR, an emergency life?saving procedure performed when the heart stops beating]) to be used for 36 of 36 sampled patients during an emergency situation requiring oxygen support, in accordance with the facility’s “Emergency Medical Equipment Daily Checklist.” This deficient practice had the potential for oxygen supplies to not be readily available in case of an emergency and had the potential to result in a delayed emergency care needed by patients, which may lead to patient harm and/or death. Findings: 1. During a review of Patient 1’s Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation (first interview between physician and patient to help identify disorders and help to the treatment team develop a treatment plan), dated 8/28/2023, Patient 1’s psychiatric evaluation indicated that Patient 1 was admitted to the facility on 8/27/2023 on a 5150 (an involuntary 72-hour hold for the treatment of a psychiatric condition) for danger to self and others and a diagnosis of disruptive mood dysregulation disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts). The document also indicated that Patient 1 was to be discharged to an outpatient facility on 8/28/2023. During a review of Patient 1’s Progress notes, dated 8/28/2023 and timed at 13:13 (1:13 p.m.), Patient 1’s Progress notes indicated that Patient 1 was transferred to an acute hospital for evaluation (following the second physical altercation [a confrontation or fight involving physical contact or force, potentially resulting in injury] involving Patients 2 and 3) and that Patient 1 complained of left shoulder pain and loss of consciousness (neither awake nor aware of the external environment). During a review of Patient 2’s Initial Psychiatric Evaluation, dated 8/23/2023, Patient 2’s psychiatric evaluation indicated Patient 2 was admitted to the facility on 8/22/2023 on a 5585 (a minor [anyone below 18 years old] who is put on an involuntary 72-hour hold [for psychiatric treatment and evaluation]) and a diagnosis of disruptive mood dysregulation disorder and attention deficit hyperactivity disorder (a condition that makes it hard to focus, sit still, and control impulses, often causing difficulties in daily life). During a review of Patient 2’s Progress notes, dated 8/28/2023 and timed at 1430 (2:30 p.m.), the progress notes indicated that Patient 2 became verbally aggressive and attempted to throw a chair at Patient 1 which was blocked by facility staff. Patient 1 was then put in a physical restraint technique (PRT-technique used to hold an aggressive patient. Example: holding a patient’s arms or legs) for 10 seconds and then was released from PRT. Patient 2 physically attacked Patient 1 again while lining up to exit the facility’s cafeteria. Patient 3 intervened and began to attack Patient 1 as well. Patient 2 was placed in a PRT and then released from PRT. During a review of Patient 3’s Initial Psychiatric Evaluation, dated 8/18/2023, Patient 3’s psychiatric evaluation indicated Patient 3 was admitted to the facility with a diagnosis of unspecified schizophrenic (chronic mental disorder characterized by a combination of positive [like hallucinations and delusions] and negative symptoms, and disorganized thinking and behavior) spectrum and substance-induced psychosis (state where someone experiences a significant disconnect from reality, often involving hallucinations [seeing or hearing things that aren’t there] and delusions [holding false beliefs]). During a review of Patient 3’s Progress note, dated 8/28/2023 and timed at 1400 (2:00 p.m.), Patient 3’s Progress note indicated that Patient 3 tried to intervene in the altercation (physical) between Patient 1 and Patient 2 but was pushed in the process. Patient 3 then pushed Patient 1 to the floor and began to hit Patient 1 repeatedly. Patient 3 was placed in PRT and redirected outside to the courtyard. During a review of the facility’s fax confirmation sheet, dated 9/12/2023, the fax confirmation sheet indicated that the incident between Patients 1, 2, and 3, was reported to the Department on 9/12/2023 at 4:09 p.m. (The physical altercation happened on 8/28/2023). During a concurrent interview and record review on 3/14/2025 at 9:37 a.m. with the Director of Risk Management (DRM), Patient 1’s Progress Note, dated 8/28/2023 and timed at 1313 (1:13 p.m.,), was reviewed. The progress note indicated that Patient 1 was transferred to the acute care hospital (after the second incident of physical altercation) and the Progress note also indicated that Patient 1 was complaining of left shoulder pain and “loss of consciousness.” The DRM stated that the incident between Patients 1, 2 and 3 was a reportable event due to Patient 1’s loss of consciousness. During an interview on 3/14/2025 at 3:37 p.m., with the Regional Vice President (RVP), the RVP stated that the facility reported the incident between Patients 1, 2, and 3 but the report was “late.” (The incident happened on 8/28/2023 but the facility reported the incident to the Department on 9/12/2023). During a review of the facility’s policy and procedure (P&P) titled, “Serious Event Notifications,” dated 11/17/2022, the P&P indicated it is the policy of the facility to comply with all regulatory reporting requirements and to identify and communicate all serious events to internal and external stakeholders in a standardized manner to improve patient care and to promote safe facility practices. The P&P also indicated that the facility will notify the regulatory agency no later than five days after the adverse event has been detected. 2. During a review of Patient 21’s “Initial Psychiatric Evaluation,” dated 03/10/2025, Patient 21’s psychiatric evaluation indicated that Patient 21 was a 59 years old female who was admitted on 03/09/2025 for feeling suicidal (thoughts of taking one’s own life). The psychiatric evaluation also indicated Patient 21 was previously diagnosed with major depression (a common and serious mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life). During a review of Patient 21’s “Multidisciplinary Treatment Plan Substance Abuse (The use of illegal drugs or the use of prescription or over-the-counter drugs or alcohol for purposes other than those for which they are meant to be used, or in excessive amounts)/Detox (a set of interventions aimed at managing acute intoxication and withdrawal),” record, dated 3/09/2025, the record indicated that Patient 21 was on behavioral manifestation/observation for mixed drinks binge for 1 month daily with a goal to identify 3 coping skills to use to prevent relapse (a return to substance use or addictive behaviors after a period of abstinence or improvement). During a review of Patient 21’s “Final Ancillary Orders,” dated 3/13/2025, the document indicated that Patient 21 had a nursing general order to complete the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-AR, a tool used to assess the severity of alcohol withdrawal symptoms) every four hours. During a concurrent interview and record review on 3/13/2025 at 11:13 a.m. with Nurse Manager (NM) 1, Patient 21’s medical record titled, “Detoxification/Withdrawal Assessment,” dated 3/11/2025, was reviewed. The record indicated staff did not fully complete the assessment and documented Detoxification/Withdrawal Assessment symptoms at 0200 (2 a.m.) for Patient 21. NM 1 stated the following: Confirmed assessment was not done by staff and will educate staff on the importance of completing the assessment every fours, per Management of Detox Patients policy. During a review of the facility’s Policy and Procedure (P&P) titled, “Management of Detox Patients” (Policy No.: PC-15), with revised date of March 2022, the P&P indicated the following: PURPOSE: To outline the assessment and care of any patient whose primary diagnosis is substance abuse or any patient who reports regular use of addictive drugs or alcohol. PROCEDURE: I. Pre-Admission Screening: The Intake Department will obtain substance abuse information and notify the unit staff of substance use history. II. Assessment Upon Admission: Upon arrival on the unit, the RN will complete an admission nursing assessment, including collecting information about alcohol/substance use (types, frequency/pattern of use, last use), completing an AUDIT-C tool, tobacco use screening, and assessment of withdrawal symptoms. The RN will assess vital signs, complete a body/skin check (L VN/LPT may complete this task), and perform a mental status examination, including assessing for level of consciousness, orientation, thought process, speech, behavior, and presence of hallucinations. The RN will also collect current and history information for each body system, including cardiovascular, respiratory, neurological, and gastrointestinal. The RN will obtain admission and detoxification orders from the psychiatrist and internist, as appropriate. Within 24 hours of admission, the psychiatrist will complete an admission assessment, and the internist will perform a History and Physical assessment. Ill. Plan of Care: Nursing staff will implement the interventions ordered by the physician, including administering medications routinely/as needed and obtaining vital signs and assessing for withdrawal symptoms Q4hours around the clock, including but not limited to nausea/vomiting, diarrhea, sweats, anxiety, tremors, and headache. The RN will review assessment data and notify the physician of significantly abnormal vital signs (as listed below) and/or emergency situations, including but not limited to, seizure activity, severe chest pain, and deterioration of mental status from baseline. 3. During a concurrent observation and interview on 3/10/2025 at 2:02 p.m. with the Charge Registered Nurse (CRN 1) and the Director of Risk Management (DRM 1), at the area between the Del Sol Unit and the CTC (Crisis Treatment Center) unit, a crash cart (a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency), was observed with an empty oxygen tank. CRN 1 and DRM 1 stated the following: Confirmed oxygen tank was empty. The night shift staff checks the crash cart and day shift staff does not check it. CRN 1 will let plant operator know to replace the empty oxygen tank. The crash cart was shared between two units (Del Sol and the CTC). CRN 1 was observed removing the empty oxygen tank from the crash cart. During an interview on 3/10/2025 at 2:17 p.m. with the Charge Registered Nurse (CRN 1), CRN 1 stated the following: Crash cart was shared between two units. Staff need to immediately let the house supervisor know if the oxygen tank was empty to get it replaced and also let the nurses know from the other unit about the empty tank. During an interview on 3/10/2025 at 3:13 p.m. with House Supervisor (HS 1), HS 1 stated the following: Did not get informed by staff about the empty oxygen tank today (3/10/2025). Will educate the staff to remove empty oxygen tank and replace with full oxygen tank incase there is a code (Code Blue- a medical emergency, specifically a cardiac [when the heart stops beating] or respiratory arrest [when breathing stops], that triggers immediate response from the resuscitation team to provide life-saving interventions) so Staff does not grab empty tank to use (during a code). During an interview on 3/12/2025 at 3:36 p.m. with Nurse Manager (NM 2), NM 2 stated the following: Crash cart should not have empty oxygen tank, not safe for the patients when staff are not aware of using empty tank during a code, will educate staff on it. For an empty oxygen tank, immediately remove tank and replace it so that staff does not use the empty oxygen tank during an emergency. During a review of the facility’s “Emergency Medical Equipment Daily Checklist,” dated March 2025, the Emergency Medical Equipment Daily Checklist indicated the following: Staff are to check the Oxygen Levels of the tank and “If oxygen tank is below 50%, Immediately notify Facilities at ext. 292 and the Nursing/Shift Supervisor.””

“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: 46238 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 provide adequate staffing based on census (number of patients in the unit) and ensure nursing staff consistently performed and documented patient acuity report (defined as evaluations of the severity of a patient’s condition and care needs to determine the appropriate level of nursing care required), in accordance with the facility’s policy and procedure regarding acuity system to determine appropriate nursing staffing levels and align staff assignments with patient care needs on four of four sampled behavioral health units (BHU [inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders] 1, 2, 3 and 5). This deficient practice had the potential to result in the inability to meet patients’ needs in a timely manner, thus compromising patients’ safety and the delivery of quality patient care. (Refer to A-0392) 2. The facility failed to ensure for two of 30 sampled patients (Patients 16 and 18), a proper screening and assessment of risk of self-harm or suicide (death caused by injuring oneself with the intent to die), were completed and appropriate steps to protect the patient were implemented, in accordance with the facility’s policy and procedure regarding “Assessment for Suicide risk Potential.” This deficient practice had the potential result in patient harm and or death when patients are not properly screened to determine risks for suicide. (Refer to A-0395) 3. The facility failed to ensure the nursing staff performed accurate patient assessment to assess and evaluate a patient’s care needs for one of 30 sampled patients (Patient 9), in accordance with the facility’s policy and procedure regarding nutritional screening (a process used to quickly identify individuals who might be at risk of malnutrition [a condition that occurs when the body doesn’t have the right amount of nutrients to function properly] by asking a series of brief questions about their dietary habits, weight changes, and medical history), when nursing staff failed to identify Patient 9’s nutritional risk and need for dietician (a healthcare professional who is specifically trained in nutrition and food science) evaluation. This deficient practice had the potential for Patient 9 not to receive the appropriate therapeutic diet (a meal plan that limits certain foods or nutrients to treat a medical condition) due to lack of dietician evaluation. This deficient practice also had the potential to result in complications such as weight loss, delayed recovery, etc. (Refer to A-0395) 4. The facility failed to ensure one of 30 sampled patients (Patient 18) had a care plan for hyperglycemia (high blood sugar) and dysphagia (difficulty swallowing), initiated upon admission, in accordance with the facility’s policy and procedure regarding patient centered care planning (a detailed document that outlines a patient’s specific healthcare needs, goals, and the interventions required to achieve those goals). Patient 18 was identified with hyperglycemia, was on insulin (medication use to treat high blood sugar levels) and had dysphagia on admission. This deficient practice had the potential to result in Patient 18’s needs and risks not identified and may cause a delay in the delivery of necessary treatment to address hyperglycemia which might result in complications such as coma (a state of prolonged unconsciousness where a person is unresponsive to their surroundings and cannot be awakened), and/or death. This deficient practice may also result in complications such as aspiration (the accidental inhalation of foreign material, such as food, liquid, or vomit, into the lungs), weight loss, malnutrition (a condition that occurs when the body doesn’t have the right amount of nutrients to function properly), etc. when Patient 18’s dysphagia problem is not properly addressed. (Refer to A-0396) 5. The facility failed to ensure one of 30 sampled patients (Patient 23) had a comprehensive care plan initiated upon admission including a care plan with interventions to prevent falls (an unintentional event that results in the person coming to rest on the ground or another lower level), in accordance with the facility’s policy and procedure regarding patient centered care planning and fall risk assessment and prevention. Patient 23 fell and hit her head on the floor, ten days after admission. This deficient practice resulted in Patient 23’s needs and risks not identified and may cause a delay in the implementation of preventive measures such as fall precautions to prevent complications from a fall such as concussion (a mild traumatic brain injury [TBI] that occurs when the brain bounces or twists inside the skull due to a blow, bump, or jolt to the head), fracture (break in the bone), etc. (Refer to A-0396) 6. The facility failed to ensure the nursing staff performed medication reconciliation (a process that ensures patients have the correct list of medications they are taking at home, and that any discrepancies are identified and addressed) and communicate with the physician regarding the medication list, in accordance with the facility’s policy and procedure regarding medication reconciliation for five of 30 sampled patients (Patient 8, 17, 18, 19, and 22), when home medications were not evaluated by physician during their hospitalization at the facility. This deficient practice had the potential to compromise patient’s medical condition such as worsening infection, worsened mental or behavioral issues, etc. as their (Patient 8, 17, 18, 19, and 22) routine home medications were not reviewed and resumed by the hospital staff. (Refer to A-0398) 7. The facility failed to complete and document a skin assessment for one of 30 sampled patients (Patient 2), in accordance with the facility’s policy on skin checks. This deficient practice had the potential to result in delayed identification and treatment of skin conditions for Patient 2 including lack of monitoring and follow-up, thus placing Patient 2 at higher risk for skin breakdown (damage to the skin and underlying tissue, usually caused by prolonged pressure on a specific area). (Refer to A-0398) 8. The facility failed to ensure that a medication brought in from home for one of 30 sampled patients (Patient 2) was documented in the Home Medication List section of Patient 2’s chart. This deficient practice had the potential for a patient’s medication, brought in from home, to be unverified by pharmacy and may not be administered to a patient in a timely manner following a physician’s order. (Refer to A-0398) 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.”

“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 interview and record review, the facility’s governing body (GB, defined as the entity legally responsible for the conduct of the hospital, including the provision of safe and effective care and the development of policies and procedures) failed to ensure the following: 1. Policies and procedures with clear guidelines ensuring safety and proper monitoring of patients with specific legal and mental health needs during transportation for external appointments outside the psychiatric care facility (a healthcare institution specializing in diagnosing, treating, and managing mental health conditions, offering services ranging from crisis stabilization to long-term care in a structured and therapeutic environment) were established and implemented to mitigate any potential risks to the patients, transport personnel, or the public. This deficient practice resulted in Patient 1’s elopement (when individuals leave an area they are expected to stay within, for their safety) during transportation to court on 7/24/2024. Additionally, this deficient practice had the potential to result in significant harm, including risks such as injury, or harm to themselves or others, for all facility psychiatric (patients with mental, emotional, and behavioral disorders) patients requiring transportation and monitoring during transportation. 2. A defined and documented policy-making process and mechanism for the development, approval, revision, and review of policies was developed in accordance with federal and local regulatory requirements. This deficient practice had the potential to negatively impact patient outcomes by leading to outdated or lacking policies that could compromise patient safety, reduce the effectiveness of care, and increase the risk of harm due to the lack of alignment with current regulatory standards and best practices. 3. Provide oversight on Nursing Services department to ensure there was adequate staffing based on census (number of census) and patient acuity, and ensure staff consistently performed and documented patient acuity assessments (defined as evaluations of the severity of a patient’s condition and care needs to determine the appropriate level of nursing care required), as required by the facility’s policy and regulatory standards to determine appropriate staffing levels and align staff assignments with patient care needs. This deficient practice had the potential to result in patients’ needs not to be met, compromising patients’ safety and the delivery of quality patient care due to a lack of oversight in implementing and monitoring policies to ensure appropriate staffing levels and assignments were based on patient care needs. Findings: 1. During an interview on 12/3/2024 at 2:19 p.m. with the facility’s Director of Quality Management (DQM) and the Chief Nursing Officer (CNO), regarding Patient 1, who, on 7/24/2024, eloped (leaving a designated area without authorization or supervision, posing a safety risk) from the court, the DQM stated the following: On 7/24/2024, at around 8:45 a.m. at Superior Court in [name of City], Patient 1 eloped from the conservatorship court (a legal proceeding where decisions regarding the care and management of an individual deemed unable to care for themselves are made) where Patient 1 was ordered to appear for a conservatorship hearing (the hearing determines whether the individual requires a permanent conservatorship based on their mental health condition and inability to care for themselves). During the same interview on 12/3/2024 at 2:19 p.m., the CNO stated the following: The conservatorship court hearing was held in person to allow the judge to determine whether the patient (Patient 1) required permanent conservatorship. Prior to the hearing, the facility had called ahead to notify the court of the patient’s (Patient 1) intention to escape. The patient (Patient 1) was on a temporary conservatorship (T-Con) and under a hold (an involuntary detention of a person at a mental health facility, where they are temporarily held against their will to receive a psychiatric evaluation and treatment because they are considered a danger to themselves or others due to a mental health crisis) while awaiting placement (defined as the process of securing a suitable long-term care facility, such as facilities to provide necessary mental health treatment and support). Additionally, the patient (Patient 1) fell under the [Name of] program, which includes individuals referred by the Department of Mental Health (DMH, a government agency responsible for overseeing and providing mental health services, programs, and support to individuals with mental health conditions) after completing their jail sentences. During an interview on 12/3/2024 at 2:27 p.m. with the Director of Quality Management (DQM), DQM explained that the [Name of] program works in collaboration with the Department of Mental Health (DMH) to provide long-term therapeutic support for patients. The program’s goal was to transition these patients to an Institution for Mental Diseases (IMD) for continued care. Patients in the [Name of] program, many of whom have spent months in detention centers, were required to attend court hearings for conservatorship decisions. The judge preferred to see the patient in person to assess their condition, and the patient has the right to challenge the court’s decision. In some cases, the judge may decide not to grant conservatorship. During an interview on 12/3/2024 at 2:31 p.m. with the Director of Clinical Services (DCS), DCS stated the following: The [Name] program, initiated by the Department of Mental Health (DMH) in Los Angeles County, was designed to address the needs of mentally ill individuals, often homeless, who had been incarcerated for minor offenses (defined as non-violent infractions or misdemeanors such as loitering, petty theft, or public disturbances). The program aimed to prevent these individuals from being housed in jails within the area. Many of these patients had been noncompliant with medications and lacked access to necessary resources. Instead of discharging them back to the streets, the court places these individuals on temporary conservatorship (T-con) to ensure oversight and care. The [Name] program was funded by DMH, and the facility collaborates with the department to secure long-term placements for these patients. However, the waitlist for an Institution for Mental Diseases (IMD) placement was currently about one year, presenting a significant challenge in transitioning patients to appropriate care settings. During the same interview on 12/3/2024 at 2:31 p.m., the DCS further stated that upon admission to the facility, patients received care, including appropriate medications, which often resulted in significant improvement in their condition. All patients under the [Name] program were required to be transported to conservatorship court hearings, where judges issued specific orders for their appearances. During a record review of Patient 1’s medical record (MR) titled, “Initial Psychiatric Evaluation,” dated 7/12/2024, the MR indicated that Patient 1 was admitted to the facility on 7/12/2024 on a 5150 hold (a 72-hour involuntary psychiatric hold authorized for individuals who, due to a mental health disorder, pose a danger to themselves, others, or are gravely disabled) for being gravely disabled (GD, defined as the inability to provide for basic personal needs, such as food, clothing, or shelter, due to a mental health condition). The MR also indicated that Patient 1 had been noncompliant with medication treatment in the past, acknowledging that they [Patient 1] only took medications when incarcerated or hospitalized because it was mandated. The MR stated that during an interview on 7/12/2024, Patient 1 showed episodes of angry outbursts, was verbally abusive, and threatening. During further record review of Patient 1’s MR titled, “Initial Psychiatric Evaluation,” dated 7/12/2024, the MR indicated that Patient 1 had a past medical history (PMH, the patient’s prior documented health conditions, including physical and mental health issues) of episodes of aggressive behavior, prior psychiatric hospitalizations, an extensive legal history (refers to a pattern or record of multiple encounters with the legal system, which may include arrests, charges, convictions, or incarcerations over an extended period), and polysubstance use (the use of multiple substances, often simultaneously or in a pattern, including legal or illicit drugs), specifically alcohol and methamphetamine (a powerful and highly addictive stimulant that affects the central nervous system). During a review of Patient 1’s medical record (MR) titled, “The Application for Lanterman-Petris-Short (LPS) Conservatorship (gives legal authority to one adult (called a conservator) to make certain decisions for a seriously mentally ill person (called a conservatee) who is unable to take care of him/ herself)” [for Patient 1], dated 6/26/2024, the MR indicated that temporary conservatorship (T-con, temporary legal authority granted to a conservator to oversee and make decisions for a person deemed gravely disabled due to a mental disorder) for Patient 1 had been granted. The MR further indicated that Patient 1 had to be detained, evaluated, and treated for the mental disorder responsible for the condition of grave disability. Additionally, the MR inidcated that the facility had been informed of the temporary conservatorship prior to Patient 1’s admission (7/12/2024) and that a court date was pending and scheduled for 7/22/2024. During a review of Patient 1’s medical record (MR) titled, “Notice of Certification for Intensive Treatment Pursuant to Section 5250,” dated 7/14/2024, the MR indicated that Patient 1’s hold was extended for an additional 14 days. Section 5250 refers to the California Welfare and Institutions Code, which allows for the extension of an initial 72-hour involuntary psychiatric hold (under Section 5150) by up to 14 days for individuals requiring continued intensive treatment due to a mental health condition that poses a danger to themselves or others or results in grave disability. During an interview on 12/3/2024 at 2:39 p.m. with the Chief Nursing Officer (CNO), the CNO stated that on 7/24/2024, the day of Patient 1’s transportation to court, two staff members, the driver and the program coordinator, accompanied Patient 1. The staff brought breakfast, lunch, and snacks for the patient (Patient 1), anticipating that it would be a long day. The CNO further said that as they (the driver, the program coordinator/specialist, and Patient 1) entered the court building and passed through the metal detector, Patient 1 suddenly ran off. The staff, adhering to policy, did not physically intervene, as restraining (something that limits freedom of movement or action) or tackling individuals off-campus is prohibited. Following the incident, the staff promptly notified the facility’s supervisor and the judge. The CNO said, “We notified everyone.” During an interview on 12/3/2024 at 2:46 p.m. with the Director of Clinical Services (DCS), DCS stated that staff were not permitted to physically intervene when a patient was outside the facility. The DCS explained, “Once the patient is out the door, we do not stop the patient; we call the police.” The DCS further said that staff may only use restraints (methods used to limit a person’s movement or access to their body) if the patient was presenting an imminent danger to themselves or others while inside the facility. The DCS then said, “We would not compromise the safety of staff once the patient is outside the facility and is eloping. We are a psychiatric facility, not a jail. The DMH (Department of Mental Health) or the public guardian (an appointed legal representative responsible for managing the personal and financial affairs of individuals unable to do so themselves) would not question us about why the patient eloped.” During an interview on 12/3/2024 at 2:53 p.m. with the Director of Quality Management (DQM), the DQM stated that the Quality Improvement team conducted a review of the process following the incident involving Patient 1’s elopement on 7/24/2024. As part of the review, the team evaluated the relevant policies and implemented changes to address identified gaps. The DQM stated, “We made it very clear with the transportation,” referencing the updates made to the policy titled “Supervision of Patients/Patient Rounds,” which was revised in August 2024 following the July [2024] adverse event. The updated policy included the following changes: a. A minimum of two staff members must accompany any patient for outside appointments. b. The Chief Nursing Officer (CNO) will assess and determine if additional staff are required for specific situations. c. Staff members with a good rapport with the patient may be assigned to accompany the patient to ensure better communication and cooperation. The DQM further said that, in certain cases, three staff members may be assigned for patient transportation based on the patient’s risk level and specific needs. The DQM said that the incident was formally reported to the governing body in August 2024 as part of the facility’s commitment to process improvement and patient safety. During an interview on 12/3/2024 at 3:12 p.m. with the Director of Clinical Services (DCS) regarding Patient 1’s high risk for elopement during transportation to court, the DCS stated the following: Prior to Patient 1’s transport to court on 7/24/2024, the facility consulted with the public guardian, who shared the same concern about the possibility of the patient running away. This concern was also communicated to the judge. However, the judge maintained the requirement to see the patient in person. During the same interview on 12/3/2024 at 3:12 p.m., the DCS further said the following: WebX (a virtual conferencing platform used for remote meetings and hearings) was utilized during the pandemic (a widespread outbreak of an infectious disease, specifically referring to COVID-19, which necessitated remote interactions to limit physical contact and ensure safety) for court proceedings. Despite this precedent (an established practice or example set in the past), the court now mandates that patients appear in person for hearings. During an interview on 12/3/2024 at 3:12 p.m. with the Chief Nursing Officer (CNO) regarding the [Name] program agreement, the CNO stated, “We made a contract with the Department of Mental Health (DMH), but did we know what we were really getting into? No. It’s a brand-new entity. Then we found out we need to escort the patients to court.” During an interview on 12/3/2024 at 3:17 p.m. with the Director of Quality Management (DQM) regarding the facility’s process for transporting patients on involuntary hold to appointments or court hearings prior to the incident of Patient 1’s elopement on 7/24/2024, the DQM stated, “There was a transportation process before, but it was not as robust, so we created a new process (after the incident with Patient 1 but was not in place when the facility initially entered into a contract with the program).” During an interview on 12/3/2024 at 3:24 p.m. with the Chief Nursing Officer (CNO), the CNO explained that the agreement negotiations for the [Name] program took considerable time due to multiple concerns, stating, “We didn’t know how staff would react to having these patients from the jail.” The CNO further stated that the previous Chief Executive Officer, who was initially the head of the [Name] program, is no longer with the facility. The CEO had been responsible for overseeing the contractual agreement terms and conditions and presenting them to the governing body (GB). During an interview on 12/3/2024 at 3:34 p.m. with the Director of Quality Management (DQM), the DQM stated the following: A Root Cause Analysis (RCA, a structured method used to identify the underlying causes of an issue or adverse event and develop strategies to prevent recurrence) was not conducted. However, the case [Patient 1’s elopement on 7/24/2024] was thoroughly reviewed and discussed among the relevant teams. The DQM further stated that there was no adequate policy in place prior to the incident to provide clear guidelines and procedures for the safe and secure transport of patients. Immediate action was taken to establish and implement clear standards of practice to address the gaps identified during the review process (following the incident with Patient 1 and not prior to the incident). During an interview on 12/4/2024 at 2:14 p.m. with the Program Specialist (PS 1), whose responsibilities included, but were not limited to, transporting patients to court, PS 1 stated the following: “It is my responsibility to ensure that patients get to court safely. Before the transport, I called the court multiple times to inform them of Patient 1’s high elopement risk and history of assault (involves the threat or attempt to physically harm someone). Typically, this is not my responsibility, but I was told the patient still needed to appear in court in front of the judge.” The PSI also stated the following: “On 7/24/2024, I, along with the driver, took the patient (Patient 1) to court. When we arrived at the courthouse, we began walking the patient (Patient 1) inside. As I placed my belongings in the basket at the metal detector, the patient (Patient 1) walked through the metal detector, turned to the right, and fled out of the building.” During the same interview on 12/4/2024 at 2:14 p.m., the PS 1 further said, “As I watched the patient (Patient 1) run past the door, I picked up my belongings and followed her (Patient 1) to the parking garage. However, I did not physically pursue her because our policy prioritizes safety and states that we do not physically pursue patients. Ensuring both my safety and the patient’s safety is paramount. I went up to the court and informed the judge and the public defender (a court-appointed attorney responsible for providing legal representation to individuals who cannot afford to hire private counsel, ensuring their legal rights are upheld), but they said there was nothing we could do.” During an interview on 12/6/2024 at 4:08 p.m. with the Chief Executive Officer (CEO, the highest-ranking executive responsible for the overall management and operations of the facility), the CEO stated the following regarding the facility’s governing body (GB) responsibilities: “The GB reviews all Performance Improvement (PI) metrics. We monitor a range of factors, including safety issues within the hospital, staff turnover, and staff-related controls. We also track all patient-related metrics, focusing on the vast majority of patient care indicators. Additionally, we monitor performance with physicians, allied health professionals, and financial measures. The governing body develops action plans and executes them to address deficiencies, environmental care issues, and monitoring resolutions for any identified problems.” During the same interview on 12/6/2024 at 4:29 p.m. with the Chief Nursing Officer (CNO) and the Chief Executive Officer (CEO), the CEO provided the following information regarding the process for reviewing and approving contracts of this nature, specifically the [Name] program contracted with the Department of Mental Health (DMH): “It is reviewed internally first and then sent to legal. It goes through our corporate office, and legal is our first line. Legal approves it, sends it back for revisions, and then it is sent back to us for finalization.” The CEO also stated that they (CEO) have held the position of CEO for about two months now and will now serve as the new contract manager for this agreement. The facility is currently in the process of updating the contact person for the DMH. In the same interview, on 12/6/2024 at 4:29 p.m., the CNO stated the following regarding how the governing body (GB) assessed the facility’s capacity and capability, including the transportation of patients to external appointments, before entering into the contract with the Department of Mental Health (DMH): “The previous CEO (referred to as CEO 2) was a major spearhead for this contract, serving as the primary contact person (contract manager) for the agreement and initiating this contract.” The CNO also said that the [Name] patients are not different from any other patients in the facility. The CNO said: “We started receiving patients in July 2024,” the CNO stated. “It was the same population that we already had. We do not take predators, and we don’t take pregnant patients. We go through the same screening process as we do for any other patients in the facility.” During the same interview on 12/6/2024 at 4:29 p.m., the Chief Nursing Officer (CNO) stated the following regarding how the facility ensured that patients on involuntary holds were transported safely and securely to off-site appointments, court hearings, or other required commitments: “I don’t know. We don’t know because we were not here,” the CNO said, also referring to the Chief Executive Officer (CEO) and the Director of Quality Management (DQM). During further interview on 12/6/2024 at 4:34 p.m. with the Chief Nursing Officer (CNO), the CNO provided the following information regarding the lack of a formal, written policy for transporting patients on involuntary holds (defined as patients detained under legal authority due to mental health or safety concerns, requiring secure and monitored care) to external appointments such as dental visits or court hearings: “There was no specific transportation policy, or at least not one addressing these situations prior and at the time when the contract was created with the Department of Mental Health (DMH). We have a transportation policy now. Key components include: two staff members accompanying a patient, and if more than one patient is going to court, I send more than one staff member. They have to go in the morning, and oftentimes, they will be there all day. We send them with two meals.” During further interview on 12/6/2024 at 4:54 p.m. with the Chief Executive Officer (CEO), the Chief Nursing Officer (CNO), and the Director of Quality Management (DQM), regarding the revised policy addressing the facility’s safety transportation measures and guidelines, the following information was provided when asked if factors such as patient acuity (defined as the severity of a patient’s condition or the intensity of care required), potential elopement risk, need for restraints, or security presence were considered in the new transportation policy: The CNO stated that staff responsible for transporting patients were not nurses and, therefore, cannot administer medications such as insulin for diabetic patients. In the event of a medical emergency, staff were instructed to call 911 immediately. The CNO further said that staff who accompany patients do not document events during transport, do not record patients’ behaviors, and were not permitted to restrain patients. Additionally, the CNO said that there wass no policy in place that dictates the staff-to-patient ratio during off-site transportation. The CEO and the DQM stated that, in creating and refining the transport policy, the facility relied solely on existing internal policies and analyses. The facility did not consult external entities, such as legal counsel or Department of Mental Health (DMH) representatives, to assess its legal and regulatory obligations for off-site care of patients on holds. During an interview on 12/6/2024 at 4:57 p.m. with the Director of Quality Management (DQM), the DQM stated that the facility measures the effectiveness of the new transportation policy by monitoring incidents of patient elopement during off-site transport. The DQM said that there has been one additional elopement of a patient during transport to court since the initial incident involving Patient 1 [7/24/2024]. The DQM further stated that, at this time, no ongoing improvements or revisions to the current transportation policy have been considered. However, the facility might now evaluate potential changes after identifying certain gaps in the policy. During a review of the facility’s contract for Acute Psychiatric Inpatient Services (APIS, defined as intensive, short-term psychiatric care provided to individuals experiencing severe mental health crises, requiring immediate stabilization in a hospital setting), last amended on 10/11/2023, the contract indicated the following: -The contractor (the facility) shall admit and provide Acute Psychiatric Inpatient Services to all clients referred by the [County] Department of Mental Health. -Scope of APIS Services (Section 2.0): APIS consists of 24/7 intensive services designed to provide psychiatric treatment with the specific intent to address symptoms that pose a danger to self, others, or result in the inability to provide for basic needs such as food, clothing, and shelter due to mental disability, as determined by qualified mental health professional staff of the facility. -The contractor (the facility) assumes total liability and responsibility for the provision of all acute psychiatric services rendered to clients. -Service Requirements (Section 2.1): APIS includes 24 hours a day, seven days a week, 365 days a year (24/7/365) mental health admission, evaluation, referral, and evidence-based psychiatric treatment services. Services encompass all necessary mental health treatment and care required for the entire period the individual is under the facility’s care in accordance with the Lanterman-Petris-Short (LPS) Act (Welfare and Institutions Code, or WIC, Section 5000 et seq.), which establishes the legal framework for involuntary mental health treatment, including criteria for 72-hour holds, conservatorships, and rights of individuals under psychiatric care. -Transportation Responsibility (Section 2.4.4): The contractor (the facility) is responsible for transporting inpatient conserved individuals to and from conservatorship hearings. -Quality and Compliance (Section 4.0): The contractor (the facility) must comply with and cooperate with all applicable provisions of the following: -Welfare and Institutions Code (WIC): A set of California statutes governing mental health care, conservatorships, and social services for individuals unable to care for themselves due to mental illness or developmental disabilities. -California Code of Regulations (CCR): The official compilation of regulations adopted by California state agencies, including standards related to mental health care facilities and practices. -Code of Federal Regulations (CFR): Federal regulations governing healthcare facilities, patient rights, and Medicaid/Medicare compliance. -Policies and procedures from the Department of Health Care Services (DHCS) and the [County] Department of Mental Health (DMH) related to Quality Improvement and Quality Assurance, ensuring the facility maintains a complete and integrated quality management system. During a review of the facility’s bylaws of the Board of the Governing Body (defined as the entity legally responsible for the operation and oversight of the hospital, including ensuring compliance with all applicable laws, regulations, and standards), Article V, Duties and Responsibilities, it was indicated that the principal duties and responsibilities of the Board included the following: 1. Advise on policies and procedures related to hospital operation and management to ensure compliance with all applicable laws, regulations, and accreditation standards. 2. Advise the Chief Executive Officer (CEO) regarding matters pertaining to hospital operation. 10. Advise on reasonable steps needed to ensure that the hospital conforms to all applicable federal, state, and local laws and regulations. During a review of the facility’s policy and procedure (P&P) titled, “Appropriate Use of Involuntary Commitment,” last revised 5/2022, the P&P indicated that involuntary commitment is a legal intervention by which persons designated by the State of California may order a person with symptoms of a serious mental disorder, and meeting other specified criteria, to be confined in a psychiatric hospital for a period of time as defined by the State. The facility recognizes and follows the laws of the State related to involuntary commitment. 2. During a record review of Patient 1’s medical record (MR) titled, “Initial Psychiatric (a medical specialty focusing on mental, emotional, and behavioral disorders) Evaluation,” dated 7/12/2024, the MR indicated that Patient 1 was admitted to the facility on 7/12/2024 on a 5150 hold (a 72-hour involuntary psychiatric hold authorized for individuals who, due to a mental health disorder, pose a danger to themselves, others, or are gravely disabled) for being gravely disabled (GD, defined as the inability to provide for basic personal needs, such as food, clothing, or shelter, due to a mental health condition). The MR also indicated that Patient 1 had a past medical history (PMH, the patient’s prior documented health conditions, including physical and mental health issues) of episodes of aggressive behavior, prior psychiatric hospitalizations, an extensive legal history (refers to a pattern or record of multiple encounters with the legal system, which may include arrests, charges, convictions, or incarcerations over an extended period), and polysubstance use (the use of multiple substances, often simultaneously or in a pattern, including legal or illicit drugs), specifically alcohol and methamphetamine (a powerful and highly addictive stimulant that affects the central nervous system [made up of the brain and the spinal cord]). During a review of Patient 1’s medical record (MR) titled, “The Application for Lanterman-Petris-Short (LPS) Conservatorship (gives legal authority to one adult (called a conservator) to make certain decisions for a seriously mentally ill person [called a conservatee] who is unable to take care of him/ herself)” [for Patient 1], dated 6/26/2024, the MR indicated that temporary conservatorship (T-con: temporary legal authority granted to a conservator to oversee and make decisions for a person deemed gravely disabled due to a mental disorder) for Patient 1 had been granted. The MR further indicated that Patient 1 had to be detained, evaluated, and treated for the mental disorder responsible for the condition of grave disability. Additionally, the MR indicated that the facility had been informed of the temporary conservatorship prior to Patient 1’s admission (7/12/2024) and that a court date was pending and scheduled for 7/22/2024. During an interview on 12/3/2024 at 2:39 p.m. with the Chief Nursing Officer (CNO), the CNO stated that on 7/24/2024, the day of Patient 1’s transportation to court, two staff members, the driver and the program coordinator, accompanied Patient 1. The staff brought breakfast, lunch, and snacks for the patient (Patient 1), anticipating that it would be a long day. The CNO further said that as they (the driver, the program coordinator/specialist, and Patient 1) entered the court building and passed through the metal detector, Patient 1 suddenly ran off. During an interview on 12/3/2024 at 2:53 p.m. with the Director of Quality Management (DQM), the DQM (a governing body member) stated that the Quality Improvement team conducted a review of the process following the incident involving Patient 1’s elopement on 7/24/2024. As part of the review, the team evaluated the relevant policies and implemented changes to address identified gaps. The DQM further stated that the review highlighted the need for clearer protocols regarding elopement (when individuals leave an area they are expected to stay within, for their safety) risk assessments, patient supervision, and documentation, and that these updates were shared with staff to ensure compliance and prevent similar incidents in the future. stated, “We made it very clear with the transportation,” referencing the updates made to the policy titled “Supervision of Patients/Patient Rounds,” which was revised in August 2024 following the July [2024] adverse event. The DQM further stated that there was no adequate policy in place prior to the incident to provide clear guidelines and procedures for the safe and secure transport of patients on involuntary hold. Immediate action was taken to establish and implement clear standards of practice to address the gaps identified during the review process. During an interview on 12/6/2024 at 2:53 p.m. with the Director of Quality Management (DQM), the DQM stated the following: “There was a need to review policies. I started working here in April 2024 and identified the need to develop a mechanism to review policies. I had this discussion with the prior CEO and provided a list of policies that required review. Then the prior CEO was no longer in their position, and we had an interim CEO who greatly supported reviewing the policies as I recommended. It has been a journey to establish policy review on an ongoing basis. We are utilizing PolicyStat, an electronic platform that houses all our policies. It’s user-friendly, alerts us when policies need to be updated, and provides us with a stronger foundation for policy making. It’s a standard of practice. We haven’t fully transitioned yet, and we still have some gaps. We now review policies annually.” During an interview on 12/6/2024 at 3:13 p.m. with the Director of Quality Management (DQM), the DQM stated: “We currently don’t have a defined and documented policy-making process, and I haven’t had the chance to look into this policy yet. Once I create a policy, I would present it to the governing body, and it can be approved pretty quickly. We are just learning about the process and are working on establishing a policy-making process.” During an interview on 12/6/2024 at 4:08 p.m. with the Chief Executive Officer (CEO, a key member of the governing body responsible for overseeing the hospital’s operations and ensuring compliance with policies and regulations), the CEO stated the following regarding the role of the governing body (GB) in providing oversight of policy development: “The oversight of policy development is the final stop before approval of the policy ... if anything is wrong with it, it would be rejected ... final approval and oversight is provided by the GB.” During the same interview on 12/6/2024 at 4:08 p.m., the Chief Executive Officer (CEO) stated the following regarding the process for developing and updating policies: “I don’t know if there is a defined process for developing policies, but policies go through committees, PI (Performance Improvement), MAC (Medical Advisory Committee), and GB (Governing Body). That would be the process for developing it ... same for updates ... it would be documented in the minutes for the governing board. We follow local and state regulations ... we look at federal regulations ... we have a corporate legal team, and they can be involved and may be involved in policy making. Right now, we are in the process of implementing PolicyStat, a web-based policy and procedure management tool designed to help organizations improve compliance, reduce risk, and streamline their policy library.” During an interview on 12/6/2024 at 4:18 p.m. with the Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO), both members of the governing body, the CNO stated the following regarding accountability for the implementation of policies, ensuring awareness, and monitoring compliance: “Each department is responsible for its own policies-the owner of the policy (the individual or role assigned responsibility for maintaining, updating, and ensuring compliance with a specific policy) is accountable for ensuring its implementation, awareness, and compliance within their department.” During a review of the facility’s bylaws of the Board of the Governing Body (defined as the entity legally responsible for the operation and oversight of the hospital, including ensuring compliance with all applicable laws, regulations, and standards), Article V, Duties and Responsibilities, it was indicated that the principal duties and responsibilities of the Board included the following: 3. Advise on policies and procedures related to hospital operation and management to ensure compliance with all applicable laws, regulations, and accreditation standards. 4. Advise the Chief Executive Officer (CEO) regarding matters pertaining to hospital operation. 10. Advise on reasonable steps needed to ensure that the hospital conforms to all applicable federal, state, and local laws and regulations. 3. During a review of Patient 10’s “Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 11/27/2024, the psych eval indicated, Patient 10 was admitted to the facility on a 5585-hold (allows a minor [patients under 18 years old] to be involuntarily detained for up to 72 hours in a psychiatric hospital [a specialized medical facility that focuses on treating individuals with severe mental disorders] for a mental health crisis) with diagnosis of disruptive mood dysregulation disorder (a mental health condition that causes children and adolescents to experience severe irritability and frequent temper outburst) for evaluation of her (Patient 10) mood state and self-harm behavior claiming, “I am going to take a bunch of gummy melatonin (medication that helps someone to fall asleep).” During an interview on 12/3/2024 at 11:38 a.m. with Patient 10 at Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) 5, Patient 10 stated the following: patient (Patient 10) was at the facility for about one week. There were a lot of fights going on with other patients and it happened in front of her (Patient 10). She (Patient 10) would just stay away and stay quiet. Patient 10 stated, “It took some time for staff to come and intervene.” During a concurrent interview and record review on 12/3/2024 at 11:51 a.m. with Charge Nurse (CN) 1 at BHU 5, [BHU 5] Patient Care Assignment (PCA, nursing assignment indicating who are the staff assigned to the patients and their tasks) 7 a.m. to 3:30 p.m. morning shift, dated 12/3/2024, was reviewed. The PCA indicated BHU 5 had census of 22 patients and was staffed four licensed nursing personnel (CN 1, Registered Nurse [RN] 2, RN 3 and Licensed Vocational Nurse [LVN] 2) and one Mental Health Technician (MHT, psychiatric assistant provides direct patient care support for patients with mental health issue under charge nurse direction) 3. CN 1 stated patients were currently assigned, and RN 3 just arrived at 11 a.m. LVN 2 was utilized to assist with 15-minute rounding (rounding done every 15 minutes in behavioral health unit to ensure patient safety) because there was only one (1) MHT (MHT 3) on the floor. During an interview on 12/4/2024 at 11:59 a.m. with Charge Nurse (CN) 2 at Behavioral Health Unit (BHU) 2, CN 2 stated it was the charge nurse’s responsibility to make the assignment for the unit and complete the acuity (a medical term that refers to the severity of a patient’s condition and how urgent their care needs are, the higher the acuity the more care is needed) sheet. CN 2 stated acuity reflected how heavy the patient load was. CN 2 stated the acuity sheet was not completed that day because other work tasks caused delays. CN 2 further explained that the assignment was split among three licensed nursing staff, including CN 2, based on the number of patients in the unit (BHU 2). During an interview on 12/4/2024 at 12:40 p.m. with Charge Nurse (CN) 3 at Behavioral Health Unit (BHU) 3, CN 3 stated patient acuity should be completed to ensure sufficient staffing. CN 3 stated the patient acuity was not completed that day [12/4/2024] due to being busy with other tasks. During an interview on 12/5/2024 at 2:42 p.m. with Nurse Manager (NM) 2 of BHU 2 and BHU 3, NM 2 stated the following: the facility was currently in the process of changing the acuity tool. Acuity was not being done currently. Acuity would tell how acute the patients were, and it played a role in making nursing assignments. It would be inappropriate to assign all high-acuity patients to one nurse because it would not be manageable. The nursing staff would not be able to provide quality care to patients when assigned all heavy (high acuity) patients. During an interview on 12/5/2024 at 2:53 p.m. with Nurse Manager (NM) 1 of BHU 5, NM 1 stated the following: patient acuity was used to determine how much staff was needed to ensure adequate staffing levels to provide quality care to patients and maintain safety. Acuity should be completed by the day shift charge nurse (CN) every day. However, the facility changed the acuity tool in August 2024 per corporate directive, but it was still in the process of implementation. Patient acuity had not been completed since August 2024 (five months). During a review of Patient 13’s “Initial Psychiatric Evaluation (psych eval),” dated 12/2/2024, the psych eval indicated, Patient 13 was admitted to the facility on an involuntary 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) due to danger to self by attempting carbon monoxide (colorless, odorless and tasteless gas that can be harmful to humans and deadly if inhaled in large amounts) poisoning in the car and with diagnosis of major depression (a serious mood disorder that can affect how you feel, think, and behave). During an interview on 12/6/2024 at 9:55 a.m. with Patient 13 in Behavioral Health Unit (BHU) 1, Patient 13 stated the following: patients were observed fighting in BHU 1, and staff attempted to intervene. During a concurrent interview and record review on 12/6/2024 at 10 a.m. with the Nurse Manager (NM) 3 of BHU 1, BHU 1’s unit staffing assignment, dated 12/6/2024, was reviewed. The staffing assignment did not indicate any patient acuity. NM 3 stated patient acuity was not done in BHU 1. During an interview on 12/6/2024 at 10:20 a.m. with Mental Health Technician (MHT) 2 at BHU 1, MHT 2 stated the following: MHTs would be assigned to one-to-one (1:1, constant supervision of a specific patient to ensure safety) observation of patients when needed. MHTs were responsible for performing rounding every fifteen (15) minutes on all patients in the unit to check on their location and behavior. MHTs would help intervene when patients got into fights by talking to and separating them. Additionally, MHTs would take patients out to the patio for activities and provide items such as snacks, juice, and shampoo upon request. There should be three (3) MHTs on the floor in BHU 1, but often there was not enough staff. Attending to patients’ needs in a timely manner was challenging because MHT 2 had to perform 15-minute rounding for all patients (44 patients). During a concurrent record review on 12/6/2024 at 11:01 a.m. with Nurse Manager (NM) 3 at BHU 1, BHU 1’s unit staffing assignment from 12/1/2024 to 12/6/2024, was reviewed. The staffing assignment indicated the following: -On 12/1/2024, 7 a.m. to 3:30 p.m. day shift with a census (the total number of patients admitted to the unit at a given time) of 44, BHU 1 was staffed with: three (3) licensed nursing staff (three RNs) and three (3) MHTs. One patient (Patient 15) required 1:1 observation. -On 12/1/2024, 3:30 p.m. to 11 p.m. evening shift with a census of 44, BHU 1 was staffed with four (4) licensed nursing staff and three (3) MHTs. One patient (Patient 15) required 1:1 observation. -On 12/2/2024, 11 p.m. to 7 a.m. night shift with a census of 42, BHU 1 was staffed with three (3) licensed nursing staff and three (3) MHTs. One patient (Patient 15) required 1:1 observation. NM 3 stated the following: there were not enough MHTs scheduled on the floor on 12/1/2024 day shift, 12/1/2024 evening shift and 12/2/2024 night shift. There were only 2 MHTs on the floor rounding because one of them was assigned to do 1:1 observation for Patient 15. MHTs were needed to perform rounding every 15 minutes on patients to maintain safety for patients. MHTs also needed to assist with patient’s needs such as getting water and respond to any emergency in the unit. During a review of Patient 15’s “Initial Psychiatric Evaluation (psych eval),” dated 11/26/2024, Patient 15 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 and treatment) due to danger to self by walking in front of on-coming traffic and hitting his (Patient 15) head with diagnosis of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 15’s physician order dated 12/1/2024, the physician order indicated, “one on one (1:1) observation for head banging/self-injurious behavior.” During an interview on 12/6/2024 at 11:49 a.m. with the Chief Executive Officer (CEO), the CEO stated the following: patient acuity should be incorporated into staffing decisions because the level of safety needs for patients varies from one to another. The CEO stated there should be additional Mental Health Technicians (MHTs) on the floor whenever a patient requires one-to-one (1:1) observation. The CEO further stated it was the responsibility of nursing administration to provide oversight on staffing. During an interview on 12/6/2024 at 4:08 p.m. with the Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO), who has been working at the facility since October 2024, the CEO stated the following regarding the responsibility of the Governing Body (GB, the group responsible for oversight of the facility’s operations and performance) and its role: “The GB reviews all PI (Performance Improvement) metrics. We monitor anywhere from safety issues in the hospital, monitoring turnover, staff-related controls, and all patient-related metrics. The vast majority of patient-related metrics include monitoring performance with physicians, allied professionals, and financial measures. We develop action plans, execute them for deficiencies, address environmental care issues, and monitor resolutions and deficiencies.” During an interview on 12/6/2024 at 5:10 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following: responsibility for overseeing staffing rests with the CNO. Appropriate staffing was crucial to providing care for patients. The facility did not have a staffing grid, but the facility staffed one licensed nurse and one Mental Health Technician (MHT) for every ten (10) patients. When the census reached forty (40), there should be four (4) MHTs, particularly during the day shift and evening shift when more activities occur. Additional MHTs should be provided when a patient required one-to-one (1:1) observation. High unit acuity required more nursing attention and additional staff. The goal was to distribute high-acuity patients evenly to balance staff workloads, which would also benefit the unit and enhance patient safety. The CNO stated, “we do not have a tool to evaluate patients’ acuity currently.” During an interview on 12/6/2024 at 5:59 p.m. with the Chief Nursing Officer (CNO, a member of the Governing Body who reports to the Chief Executive Officer [CEO]), the CNO stated the following regarding the role administrative leaders, nurse managers, or QAPI (Quality Assurance and Performance Improvement) teams play in evaluating the adequacy of staffing practices in the absence of acuity tools: the CNO said, “QAPI has no role in evaluating the adequacy of staffing practices. This is the CNO’s responsibility.” During a review of the facility’s policy and procedure (P&P) titled, “Appropriate Staffing Levels,” dated 9/2023, the P&P indicated the following: “It is the policy of [the facility] to utilize a defined procedure to determine staffing requirements based on patient needs ... In order to maintain quality nursing care, staffing will be planned according to the assessment of patient needs by the Registered Nurse Charge Nurse and in consultation with, as needed, the Chief Nursing Officer and/or the House Supervisor ... The criteria for assignment of nursing personnel is based on acuity (a patient classification system) that is approved by the Medical Executive Committee and the Board of Trustees of the hospital ... Multiple factors influence the functioning of a patient care unit, and the CNO and/or designee(s) are responsible to modify staffing as needs arise on a day-by-day and shift-by-shift basis to provide safety. Factors which affect the need to alter staffing levels up or down include but are not limited to a. Overall acuity on the unit based on formal scoring ... patients placed on one-on-one monitoring ... high-risk conditions such as aggressive and/or violent patients toward self or others.” During a review of the facility’s policy and procedure (P&P) titled, “Acuity System/ Report,” dated 3/2022, the P&P indicated, “To ensure that an acuity system is used that addresses patient care needs and satisfies these needs by providing the required nursing hours according to skill mix ... the department of nursing at [the facility] utilizes the patient acuity report to determine individual patient acuity and staffing requirements for each patient care unit ... acuity cane change from day to change and that staffing must fluctuate to assure quality care of each patient ... the charge nurse Registered Nurse (RN) completes the Acuity Report every day at 10:30 a.m. and submit the report to the Chief Nursing Officer (CNO) or Nursing Supervisor ... Biological needs, psychological needs and social needs are rated utilizing the Acuity Rating Criteria Grid. Each patient is rated a score of 1 for low, 2 for moderate and 3 for high acuity.” During a review of the facility’s policy and procedure (P&P) titled, “Minimum/ Core Nursing Staffing Plan Per Unit,” dated 5/2024, the P&P indicated, “It is the policy of [the facility] to ensure that the appropriate numbers and qualifications of nursing staff are available at all times for the care of patients. The Chief Nursing Officer (CNO) is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity.” During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for Nursing Services,” dated 3/2022, the P&P indicated, “The nursing staff at [the facility] provides quality psychiatric nursing services to all patients on a 24 hours, 7 days a week basis, in a continuous, consistent, safe and caring manner ... Assignment of nursing staff ... Each unit shall have a designated number of Licensed Psychiatric Technicians, Licensed Vocational Nurses, and/or Psychiatric Assistants working under the charge nurse based on unit census, patient acuity, and other patient care need requirement ... the Governing Board is kept informed of nursing activities via the Chief Nursing Officer (CNO), who attends Governing Board meetings quarterly.” During a review of the facility’s bylaws of the Board of the Governing Body (defined as the entity legally responsible for the operation and oversight of the hospital, including ensuring compliance with all applicable laws, regulations, and standards), Article V, Duties and Responsibilities, it was indicated that the principal duties and responsibilities of the Board include the following: 5. Advise on policies and procedures related to hospital operation and management to ensure compliance with all applicable laws, regulations, and accreditation standards. 6. Advise the Chief Executive Officer (CEO) regarding matters pertaining to hospital operation. 10. Advise on reasonable steps needed to ensure that the hospital conforms to all applicable federal, state, and local laws and regulations.”

“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: 36329 Based on interview and record review, the facility failed to ensure that one of 30 sampled patients (Patient 30) or Patient 30’s legal representative (Patient 30) had a documentation acknowledging information provided regarding her (Patient 30) rights (Example: the right to respectful care, the right to refuse treatment, etc. Patient Rights ensure a safe and equitable treatment during the patient’s stay in the hospital.) as a patient, in accordance with the facility’s policy and procedure regarding “Notification of Rights and Denial of Rights.” This deficient practice had the potential for Patient 30 to be unable to make informed decision (a choice made after thoroughly considering all relevant information and potential outcomes) about her (Patient 30) own healthcare, potentially leading to unwanted treatments, and missed opportunities for alternative options. Findings: During a review of Patient 30’s “Initial Psychiatric (focused on mental, emotional, and behavioral disorders) Evaluation (psych eval, a complete patient assessment including a review of the patient’s medical history, mental status, and current symptoms),” the psych eval indicated Patient 30 was admitted to the facility on 11/13/2024 to be evaluated for change in mood, aggression toward facility staff, and self-harm behavior. The psych eval also indicated Patient 30 had a history of polysubstance abuse (use of several drugs, illegal or prescription, at once) including the use of alcohol, methamphetamine (a powerful and highly addictive stimulant that affects the central nervous system [includes the brain and the spinal cord]), and marijuana. This report indicated Patient 30 had a history of psychiatric (branch of medicine that deals with mental, emotional, or behavioral disorders) hospitalizations and medication noncompliance (term used in regard to a patient who does not take prescribed medication or a course of treatment). During an interview on 12/6/2024 at 1:00 p.m. with the Risk Management and Performance Improvement Coordinator (CRMPI), in the conference room, CRMPI acknowledged Patient 30 had not signed and acknowledged her (Patient 30) understanding of her rights. CRMPI subsequently stated documents indicating patient understanding of patient rights should have been signed by Patient 30 at the time of admission and that Patient 30 should have access to the process for filing a complaint. During a review of the document titled, “Patient Rights,” dated 11/13/2024, this form indicated patients that were admitted to the facility were entitled to the following not all inclusive rights: to use the patient’s own personal belongings; to have access to a private storage for patient belongings; to see visitors each day; to have access to a telephone to receive and send confidential calls; to have access to letter writing materials; to refuse shock treatment (a medical procedure where a brief electrical current is passed through the brain to induce a small seizure [episode of abnormal electrical activity in the brain that can cause changes in movement, behavior, feeling, and awareness], primarily used to treat severe depression [a mental health condition that involves a prolonged low mood or loss of interest in activities that hasn’t responded to other treatments]); to refuse psychotherapy (a type of treatment that involves talking with a licensed mental health professional to help identify and change troubling thoughts, emotions, and behaviors) as defined in the Welfare and Institutions Code (a collection of state statutes that establish public social services and programs to promote the public welfare); to have access to a process for filing confidential complaints. The final statement in this document indicated the patient (Patient 30) attested to understanding these rights and had received the Patient’s Rights Handbook. However, there was no signature indicating Patient 30’s understanding of patients’ rights. During a review of the form titled, “[Name of facility] - Patient Acknowledgements,” dated 11/13/2024, this document indicated Patient 30 had been advised of the following: Patient guidelines; Patient visitation after being discharged; Patient understanding of rules against inappropriate sexual behavior; Fall (an unintentional event that results in the person coming to rest on the ground or another lower level) prevention information; Patient and family education regarding use of patient seclusion (the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and restraint (something that limits freedom of movement or action). This document was not acknowledged by Patient 30’s signature at the bottom of the form. During a review of the facility’s policy and procedure titled, “Notification of Rights and Denial of Rights” (Policy RI-13, updated 8/2019), this document indicated the intent was to notify each patient of his/her rights in understandable language as well as any denial of rights with good cause. This policy indicated the procedure for notifying patients of their rights: Upon admission each patient will be notified of his/her rights in understandable written form and given a copy of the Patient’s Rights Handbook; A copy of the notification of rights will be placed in the patient’s chart; If the patient refuses to sign the notification, this fact will be written on this form by the admitting nurse; The patient will be oriented to the poster containing the list of patient rights and the complaint procedure that is posted on the unit.”

“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: 1. Ensure the safety of one of 30 sampled patients (Patient 1) when Patient 1, who was admitted on a legal hold (an involuntary psychiatric hold due to being gravely disabled [GB, unable to provide for basic personal needs due to a mental health disorder]) and had a documented history of eloping (when individuals leave an area they are expected to stay within, for their safety) and aggressive behavior, was transported to an off-site location. This deficient practice resulted in Patient 1’s elopement from the court, potentially compromising the patient’s safety, disrupting the legal process, and posing a safety risk to the patient (Patient 1) and others. 2. Ensure that one of one sampled medication room (a secure area designated for the storage and preparation of medications) remained locked and the medication cart (a mobile unit used for storing and organizing medications for patient administration) inside the medication room remained locked when not in use, in accordance with the facility’s policy regarding medication areas. This deficient practice had the potential for medications to be stolen or tampered with, leading to potential overdoses or medication errors thus compromising patient safety. Findings: 1. During a record review of Patient 1’s medical record (MR) titled, “Initial Psychiatric (mental, emotional, or behavioral conditions) Evaluation,” dated 7/12/2024, the MR indicated that Patient 1 was admitted to the facility on 7/12/2024 on a 5150 hold (a 72-hour involuntary psychiatric hold authorized for individuals who, due to a mental health disorder, pose a danger to themselves, others, or are gravely disabled). The hold was initiated for being gravely disabled (GD), defined as the inability to provide for basic personal needs, such as food, clothing, or shelter, due to a mental health condition. The MR also indicated that Patient 1 had a history of noncompliance with medication treatment, acknowledging that they [Patient 1] only took medications when incarcerated (confined in a jail or prison) or hospitalized, as it was mandated. Additionally, the MR indicated that during an interview on 7/12/2024, Patient 1 exhibited episodes of angry outbursts, was verbally abusive, and made threatening remarks. During further record review of Patient 1’s MR titled, “Initial Psychiatric Evaluation,” dated 7/12/2024, the MR indicated that Patient 1 had a past medical history (PMH, the patient’s prior documented health conditions, including physical and mental health issues) of episodes of aggressive behavior, prior psychiatric hospitalizations, an extensive legal history (refers to a pattern or record of multiple encounters with the legal system, which may include arrests, charges, convictions, or incarcerations over an extended period), and polysubstance use (the use of multiple substances, often simultaneously or in a pattern, including legal or illicit drugs), specifically alcohol and methamphetamine (a powerful and highly addictive stimulant that affects the central nervous system [includes the brain and the spinal cord]). During a review of Patient 1’s medical record (MR) titled, “The Application for Lanterman-Petris-Short (LPS) Conservatorship (gives legal authority to one adult (called a conservator) to make certain decisions for a seriously mentally ill person [called a conservatee] who is unable to take care of him/ herself)” [for Patient 1], dated 6/26/2024, the MR indicated that temporary conservatorship (T-con: temporary legal authority granted to a conservator to oversee and make decisions for a person deemed gravely disabled due to a mental disorder) for Patient 1 had been granted. The MR further indicated that Patient 1 had to be detained, evaluated, and treated for the mental disorder responsible for the condition of grave disability. Additionally, the MR stated that the facility had been informed of the temporary conservatorship prior to Patient 1’s admission (7/12/2024) and that a court date was pending and scheduled for 7/22/2024. During a review of Patient 1’s medical record (MR) titled, “Notice of Certification for Intensive Treatment Pursuant to Section 5250,” dated 7/14/2024, the MR indicated that Patient 1’s hold was extended for an additional 14 days. Section 5250 refers to the California Welfare and Institutions Code, which allows for an extension of an initial 72-hour involuntary hold (Section 5150) by up to 14 days for individuals requiring intensive treatment due to a mental health condition that makes them a danger to themselves or others or gravely disabled. During an interview on 12/3/2024 at 2:19 p.m. with the facility’s Director of Quality Management (DQM) and Chief Nursing Officer (CNO), regarding Patient 1, who, on 7/24/2024, eloped (leaving a designated area without authorization or supervision, posing a safety risk) from the court, where Patient 1 was ordered to appear for a conservatorship hearing (the hearing determines whether the individual requires a permanent conservatorship based on their mental health condition and inability to care for themselves), the CNO stated that prior to the hearing, the facility had called ahead to notify the court of the patient’s (Patient 1) intention to escape. The patient (Patient 1) was on a temporary conservatorship (T-Con) and under a hold while awaiting placement (the process of securing a suitable long-term care facility to provide necessary mental health treatment and support) to ensure Patient 1 continues to receive mental health services. During an interview on 12/3/2024 at 3:24 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following regarding the facility’s assessment procedures for assessing patients for elopement risk: the assessment involves identifying behaviors, history, and statements that indicate a patient may attempt to leave a supervised setting without authorization. The CNO said that nursing patient care for all patients falls under the CNO’s responsibility and said that the responsibility for identifying patients at high risk for elopement lies with the facility’s manager, in whom the CNO has trust. During a review of Patient 1’s prior-to-admission medical record (MR), dated 6/13/2024, the MR indicated that Patient 1 had a history of, but not limited to: - Battery: Intentional and unlawful use of force or violence against another person. - Assault and Battery: A combination of an intentional threat or attempt to cause harm (assault) and the actual infliction of physical harm (battery). - Battery on Person: Specific physical contact or violence against an individual. - Willful Cruelty to Child/Child Endangerment: Intentionally inflicting harm, placing a child in danger, or failing to act to protect a child from harm. The MR also indicated that Patient 1 had a history of aggression in the community, refusal to take prescribed medications to manage their (Patient 1) mental health condition and was identified as a very high risk for elopement due to a prior history of ODR -AWOL (Outpatient Diversionary Rehabilitation Absence Without Leave: leaving a facility or treatment program without authorization). During a concurrent interview and record review on 12/4/2024 at 10:57 a.m. with the house supervisor (HS 1), Patient 1’s medical record (MR) titled, “Nursing Admission Assessment,” dated 7/12/2024, was reviewed. The MR indicated that Patient 1’s elopement risk assessment was documented as “none.” HS 1 stated that nurses only document what the patient reports during the assessment and do not include other information unless clearly disclosed by the patient. HS 1 added that the nurse can initiate a separate treatment plan and document in the progress notes if a patient is identified as having a risk based on the history. The HS 1 then reviewed Patient 1’s treatment plan (a documented plan outlining the care, interventions, and strategies to address a patient’s specific health issues or risks), dated 7/12/2024 through 7/24/2024 and said that a “Risk for Elopement” treatment plan was not initiated during Patient 1’s stay in the facility. During an interview on 12/4/2024 at 2:14 p.m. with the Program Specialist (PS 1), whose responsibilities include, but are not limited to, transporting patients to court, PS 1 stated the following: “It is my responsibility to ensure that patients get to court safely. Before the transport, I called the court multiple times to inform them of Patient 1’s high elopement risk and history of assault. Typically, this is not my responsibility, but I was told the patient still needed to appear in court in front of the judge.” The PSI also stated the following: “On 7/24/2024, I, along with the driver, took the patient (Patient 1) to court. When we arrived at the courthouse, we began walking the patient (Patient 1) inside. As I placed my belongings in the basket at the metal detector, the patient (Patient 1) walked through the metal detector, turned to the right, and fled out of the building.” During the same interview on 12/4/2024 at 2:14 p.m., the Program Specialist (PS 1) stated, “I have been working here for over seven years. We do take patients to off-site appointments aside from court hearings, and this was the first time I have experienced an issue with patient transport and elopement. There was a chance this patient (Patient 1) might elope.” PS 1 further said that there was no required documentation during transport, such as a rounds sheet (a tool used to track patient whereabouts and activities during specific intervals) or observations of patient behavior. PS 1 said, “I typically do not update patients’ charts. I was only required to document a progress note regarding the incident [Patient 1’s elopement incident on 7/24/2024] in Patient 1’s record.” During an interview on 12/6/2024 at 3:30 p.m. with the Director of Quality Management (DQM), the DQM stated that they (DQM) began working at the facility in April 2024. The DQM further stated that, following Patient 1’s elopement on 7/24/2024, an internal investigation and incident review were conducted. This review identified that the facility lacked an existing policy and procedure for transporting patients on a hold to off-site locations, such as court hearings. During an interview on 12/6/2024 at 5:07 p.m. with the Chief Nursing Officer (CNO), the CNO stated that there was no patient safety risk assessment or documentation completed prior to transporting patients to external appointments. The CNO also confirmed that patient behavior during transportation is neither documented nor tracked. During an interview on 12/6/2024 at 5:23 p.m. with the Chief Nursing Officer (CNO), the CNO said the following: The process for how nursing staff initially identifies and assesses patients for elopement risk includes assessing patients upon admission by asking direct questions and gathering collateral information (information obtained from external sources such as family, caregivers, or other professionals to supplement the patient’s self-reported data). The elopement risk assessment is conducted only during the admission process, and re-assessments are expected to be performed during every shift once the patient is identified as being at risk for elopement. Nurses are then required to initiate an elopement risk treatment plan. The corresponding intervention would be documented in the patient’s observation record, including 15-minute safety checks (regular checks performed every 15 minutes to monitor and ensure the safety and well-being of patients) and any required elopement risk precautions. During the same interview on 12/6/2024 at 5:23 p.m. with the Chief Nursing Officer (CNO), the CNO stated that the facility’s daily shift assessment forms do not include a built-in elopement risk assessment tool for nurses to document elopement risk. Instead, nurses are expected to re-assess elopement risk every shift and document their findings in the progress notes. The CNO further stated, “I just have to trust the staff. When the behavior is seen or observed, it should be documented in the progress note.” The CNO added that it is the responsibility of house supervisors and charge nurses to oversee the accuracy and completeness of required patient assessments to ensure that the assessments are conducted properly. During a review of the facility’s policy and procedure (P&P) titled, “Patient Precautions,” last revised 2/2022, the P&P indicated that “It is the facility’s policy to identify and assess risk factors of all patients in order to provide care in a safe and therapeutic environment. All patients are assessed for risks for ...assault, ...and elopement upon admission. All patients are also re-assessed for the same risk factors on a daily basis throughout their hospitalization to determine if there are any changes in their level of risk. II. Upon admission, patient information may be gathered from the patient, other hospitals, physicians, and documented in the nursing admission assessment form. The appropriate corresponding precautions are implemented. A physician or a charge nurse can initiate any precautions. A physician may order elopement precautions in the event of the following patient risk factors: a. History of elopement from a previous hospitalization or another facility ...The elopement risk will be included in the treatment planning process.” During a review of the facility’s policy and procedure (P&P) titled, “Supervision of Patient/Patient Rounds,” last revised on 7/2023, the P&P indicated that “10. When a patient leaves the hospital grounds (e.g., scheduled outings, dental appointments), a copy of the Rounds sheet must be completed by the staff member accompanying the patient, if applicable. The copy will be filed in the patient’s chart with the original upon the patient’s return.” During a review of the facility’s policy and procedure (P&P) titled, “Elopement of a Patient,” last reviewed 3/2022, the P&P indicated that all patients will be assessed upon admission for AWOL (Absent Without Leave, when a patient leaves a designated area without authorization or supervision) elopement potential. AWOL protocol will include early identification, observation, intervention, response, and a notification plan. Guidelines for staff: Patients are not to be physically contained unless they meet the criteria for an involuntary hold or are presenting dangerous behaviors while eloping, and sufficient staff are available to restrain the patient safely. During a review of the facility’s policy and procedure (P&P) titled, “Scope of Assessment,” last reviewed 3/2022, the P&P indicated that an interdisciplinary assessment process, involving the patient and family, includes data collected from pre-admission up to 72 hours after admission. Data sources shall include patient self-reported information, family, transfer documents, previous admission documents, observation, and current documentation information. Care decisions shall be made based on an analysis of the assessment information. During a review of the facility’s policy and procedure (P&P) titled, “Appropriate Use of Involuntary Commitment,” last revised 5/2022, the P&P indicated that involuntary commitment is a legal intervention by which persons designated by the State of California may order a person with symptoms of a serious mental disorder, and meeting other specified criteria, to be confined in a psychiatric hospital for a period of time as defined by the State. The facility recognizes and follows the laws of the State related to involuntary commitment. 2. During a concurrent interview and observation on 12/3/2024 at 11:37 a.m. in the Youth Services Unit (a specialized area providing psychiatric care for adolescent patients), inside the nurses’ station (a restricted area accessible to licensed nursing staff and other clinical team members), with Charge Nurse 1 (CN 1), the medication room (a secure area designated for the storage of medications, including controlled substances, patient-specific medications, and sharps [e.g., syringes, needles] required for medical procedures) door was observed to be unlocked and slightly open. Inside the medication room, the medication cart (a mobile unit used for storing and organizing medications for patient administration) was observed parked by the wall and was also unlocked. CN 1 stated that the door to the medication room should be locked, and when the door is locked, the medication cart can remain unlocked. During an interview on 12/5/2024 at 12:23 p.m. with Nurse Educator 1 (NE 1), NE 1 stated the following: The medication cart in the medication room must be locked when not in use, and the medication room should always be locked for safety. No one who is unauthorized to be in the medication room should enter. The medication room is only accessible to licensed staff. During a review of the facility’s policy and procedure (P&P) titled, “Medication Area Inspection,” dated 3/2010, the P&P indicated that nursing unit medication dispensing areas (e.g., medication rooms, medication carts, medication refrigerators) must comply with all State and Federal laws and local standards of practice, for the betterment of patient care. The P&P also indicated that the medication cart must be locked when not in use.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to provide adequate staffing based on census (number of patients in the unit) and ensure nursing staff consistently performed and documented patient acuity report (defined as evaluations of the severity of a patient’s condition and care needs to determine the appropriate level of nursing care required), in accordance with the facility’s policy and procedure regarding acuity system to determine appropriate nursing staffing levels and align staff assignments with patient care needs on four of four sampled behavioral health units (BHU [inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders] 1, 2, 3 and 5). This deficient practice had the potential to result in the inability to meet patients’ needs in a timely manner, thus compromising patients’ safety and the delivery of quality patient care. Findings: During a review of Patient 10’s “Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 11/27/2024, the psych eval indicated, Patient 10 was admitted to the facility on a 5585-hold (allows a minor to be involuntarily detained for up to 72 hours in a psychiatric hospital [a specialized medical facility that focuses on treating individuals with severe mental disorders] for a mental health crisis) with diagnosis of disruptive mood dysregulation disorder (a mental health condition that causes children and adolescents to experience severe irritability and frequent temper outburst) for evaluation of her (Patient 10) mood state and self-harm behavior claiming, “I am going to take a bunch of gummy melatonin (medication that helps someone to fall asleep).” During an interview on 12/3/2024 at 11:38 a.m. with Patient 10 at Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) 5, Patient 10 stated the following: she (Patient 10) was at the facility for about one week. There were a lot of fights going on with other patients and it happened in front of her (Patient 10). She (Patient 10) would just stay away and remained quiet. Patient 10 stated, “It took some time for staff to come and intervene.” During a concurrent interview and record review on 12/3/2024 at 11:51 a.m. with Charge Nurse (CN) 1 at BHU 5, BHU 5 Patient Care Assignment (nursing assignment indicating who are the staff assigned to the patients and their tasks) 7 a.m. to 3:30 p.m. morning shift, dated 12/3/2024, was reviewed. The Patient Care Assignment indicated BHU 5 had census of 22 patients and was staffed four licensed nursing staff (CN 1, Registered Nurse [RN] 2, RN 3 and Licensed Vocational Nurse [LVN] 2) and one Mental Health Technician (MHT, psychiatric assistant provides direct patient care support with mental health issue under charge nurse direction) 3. CN 1 stated he (CN 1) had patients currently and RN 3 just came in at 11 a.m. They had to utilize LVN 2 to help with 15-minute rounding (rounding done every 15 minutes in behavioral health unit to ensure patient safety) because there was only one (1) MHT (MHT 3) on the floor. During an interview on 12/4/2024 at 11:59 a.m. with Charge Nurse (CN) 2 at Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) 2, CN 2 stated it was the charge nurse’s responsibility to make the assignment for the unit and complete the acuity (a medical term that refers to the severity of a patient’s condition and how urgent their care needs are, the higher the acuity the more care is needed) sheet. CN 2 stated acuity reflected how heavy the patient load was. CN 2 stated she (CN 2) did not do the acuity today because she (CN 2) was behind with her (CN2) work. CN2 stated she (CN 2) split the assignment among her (CN 2) and two other licensed nursing staff based on the number of patients in the unit (BHU 2). During an interview on 12/4/2024 at 12:40 p.m. with Charge Nurse (CN) 3 at Behavioral Health Unit (BHU) 3, CN 3 stated patient acuity should be done to make sure there was enough staffing. CN 3 stated she (CN 3) did not do the patient acuity today because she (CN 3) was busy. During an interview on 12/5/2024 at 2:42 p.m. with Nurse Manager (NM) 2 of BHU 2 and BHU 3, NM 2 stated the following: the facility was currently in the process of changing the acuity tool. Acuity was not being done currently. Acuity would tell how acute the patients were, and it played a role in making nursing assignment. It would be inappropriate to assign all high acuity patients to one nurse because it would not be manageable. The nursing staff would not be able to provide quality care to patients when he or she had all heavy (high acuity) patients. During an interview on 12/5/2024 at 2:53 p.m. with Nurse Manager (NM) 1 of BHU 5, NM 1 stated the following: patient acuity was done to let the facility how much staff was needed to provide adequate staff to provide quality care to patients and maintain safety. Acuity should be done by the day shift charge nurse every day. However, the facility changed the acuity tool in August 2024 per corporate directive, but it was still in the process of implementation. Patient acuity had not been done since August 2024 (five months). During a review of Patient 13’s “Initial Psychiatric Evaluation (psych eval),” dated 12/2/2024, the psych eval indicated, Patient 13 was admitted to the facility on an involuntary 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) due to danger to self by attempting carbon monoxide (colorless, odorless and tasteless gas that can be harmful to humans and deadly if inhaled in large amounts) poisoning in the car with diagnosis of major depression. During an interview on 12/6/2024 at 9:55 a.m. with Patient 13 in Behavioral Health Unit (BHU) 1, Patient 13 stated she (Patient 13) saw patients fighting in BHU 1 and staff would try to intervene. During a concurrent interview and record review on 12/6/2024 at 10 a.m. with the Nurse Manager (NM) 3 of BHU 1, BHU 1’s unit staffing assignment dated 12/6/2024 was reviewed. The staffing assignment did not indicate any patient acuity. NM 3 stated patient acuity was not done in BHU 1. During an interview on 12/6/2024 at 10:20 a.m. with Mental Health Technician (MHT) 2 at BHU 1, MHT 2 stated the following: MHT would be assigned as one to one observation on patient when needed. MHTs were responsible to perform rounding every fifteen (15) minutes on all patients in the unit to check on patients’ location and behavior. MHT would help to intervene when patients got into fights by talking to and separating patients. MHT would also take patients out to patio for activity and provide patients items such as snacks, juice and shampoo upon request. There should be three (3) MHTs on the floor in BHU 1 but a lot of time there was not enough staff. It was hard to attend to patient’s need in a timely manner because he (MHT 2) needed to perform rounding every 15 minutes for all patients. During a concurrent record review on 12/6/2024 at 11:01 a.m. with the Nurse Manager (NM) 3 at BHU 1, BHU 1’s unit staffing assignment from 12/1/2024 to 12/6/2024, was reviewed. The staffing assignment indicated the following: -On 12/1/2024, 7 a.m. to 3:30 p.m. day shift with census of 44, BHU 1 was staffed with three (3) licensed nursing staff (three RNs) and three (3) MHTs. One patient (Patient 15) requiring one on one observation. -On 12/1/2024, 3:30 p.m. to 11 p.m. evening shift with census of 44, BHU 1 was staffed with four (4) licensed nursing staff and three (3) MHT. One patient (Patient 15) requiring one on one observation. -On 12/2/2024, 11 p.m. to 7 a.m. night shift with census of 42, BHU 1 was staffed with three (3) licensed nursing staff and three (3) MHT. One patient (Patient 15) requiring one on one observation. During the same interview on 12/6/2024 at 11:01 a.m. with the Nurse Manager (NM 3), NM 3 stated the following: there were not enough MHTs scheduled on the floor on 12/1/2024 day shift, 12/1/2024 evening shift and 12/2/2024 night shift. There are only 2 MHTs on the floor rounding because one of them was assigned to do one on one observation for Patient 15. MHTs are needed to perform rounding every 15 minutes on patients to maintain safety for patients. MHTs also needed to assist with patient’s needs such as getting water and respond to any emergency in the unit. During a review of Patient 15’s “Initial Psychiatric Evaluation (psych eval),” dated 11/26/2024, the psych eval indicated Patient 15 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 and treatment) due to danger to self by walking in front of on-coming traffic and hitting his (Patient 15) head and with diagnosis of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 15’s physician order dated 12/1/2024, the physician order indicated, “one on one observation (a type of care where a patient is constantly monitored by a staff member) for head banging/self-injurious behavior.” During an interview on 12/6/2024 at 11:49 a.m. with the Chief Executive Officer (CEO), CEO stated patient acuity should be incorporated when it came to staffing because of the level of safety needs for patients, varies from one to another. CEO stated there should be additional MHTs on the floor when there was any patient needing one on one observation. CEO stated it was nursing administration responsibility to provide oversight on staffing. During an interview on 12/6/2024 at 5:10 p.m. with the Chief Nursing Officer (CNO), CNO stated the following: she (CNO) was responsible to oversee staffing. Appropriate staffing was important to provide care for patients. The facility did not have a grid for staffing but the facility staff one licensed nurse and one MHT for every ten (10) patients. When the census was at forty (40), there should be four (4) MHTs especially for day shift and evening shift because there are more activities going on. Additional MHT should be provided when there’s patients requiring one on one observation. When the unit acuity was high, it would require more nursing attention and more staff. The goal was to spread out high acuity patients in order to balance staff workload. It would also benefit the floor and patient safety. CNO stated, “we do not have a tool to evaluate patients’ acuity currently.” During a review of the facility’s policy and procedure (P&P) titled, “Appropriate Staffing Levels,” dated 9/2023, the P&P indicated, “It is the policy of [the facility] to utilize a defined procedure to determine staffing requirements based on patient needs ... In order to maintain quality nursing care, staffing will be planned according to the assessment of patient’s needs by the Registered Nurse Charge Nurse and in consultation with, as needed, the Chief Nursing Office and/or the House Supervisor ... The Criteria for assignment of nursing personnel is based on acuity (A patient classification system) that is approved by the Medical Executive Committee and the Board of Trustees of the hospital ... Multiple factors influence the functioning of a patient care unit and the CNO and/or designee(s) are responsible to modify staffing as needs arise on a day-by-day and shift-by-shift basis to provide safety. Factors which affect the need to alter staffing levels up or down include but are not limited to: a. Overall acuity on unit based on formal scoring ... patients place on one on one monitoring ... high risk conditions such as aggressive and/or violent patient towards self and other.” During a review of the facility’s policy and procedure (P&P) titled, “Acuity System/Report,” dated 3/2022, the P&P indicated, “To ensure that an acuity system is used that addresses patient care needs and satisfies these needs by providing the required nursing hours according to skill mix ... the department of nursing at [the facility] utilizes the patient acuity report to determine individual patient acuity and staffing requirements for each patient care unit ... acuity cane change from day to change and that staffing must fluctuate to assure quality care of each patient ... the charge nurse Registered Nurse (RN) completes the Acuity Report every day at 10:30 a.m. and submit the report to the Chief Nursing Officer (CNO) or Nursing Supervisor ... Biological needs, psychological needs and social needs are rated utilizing the Acuity Rating Criteria Grid. Each patient is rated a score of 1 for low, 2 for moderate and 3 for high acuity.” During a review of the facility’s policy and procedure (P&P) titled, “Minimum/ Core Nursing Staffing Plan Per Unit,” dated 5/2024, the P&P indicated, “It is the policy of [the facility] to ensure that the appropriate numbers and qualifications of nursing staff are available at all times for the care of patients. The Chief Nursing Officer (CNO) is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity.” During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for Nursing Services,” dated 3/2022, the P&P indicated, “The nursing staff at [the facility] provides quality psychiatric nursing services to all patients on a 24-hours, 7 days a week basis, in a continuous, consistent, safe and caring manner ... Assignment of nursing staff ... Each unit shall have a designated number of Licensed Psychiatric Technicians, Licensed Vocational Nurses, and/or Psychiatric Assistants working under the charge nurse based on unit census, patient acuity, and other patient care need requirement ... the Governing Board is kept informed of nursing activities via the Chief Nursing Officer (CNO), who attends Governing Board meetings quarterly.””

“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: 46238 Based on interview and record review the facility failed to: 1. Ensure for two of 30 sampled patients (Patients 16 and 18), a proper screening and assessment of risk of self-harm or suicide (death caused by injuring oneself with the intent to die) were completed and appropriate steps to protect the patient were implemented, in accordance with the facility’s policy and procedure regarding “Assessment for Suicide risk Potential.” This deficient practice had the potential result in patient harm and or death when patients are not properly screened to determine risks for suicide. 2. Ensure the nursing staff performed accurate patient assessment to assess and evaluate a patient’s care needs for one of 30 sampled patients (Patient 9), in accordance with the facility’s policy and procedure regarding nutritional screening (a process used to quickly identify individuals who might be at risk of malnutrition [a condition that occurs when the body doesn’t have the right amount of nutrients to function properly] by asking a series of brief questions about their dietary habits, weight changes, and medical history), when nursing staff failed to identify Patient 9’s nutritional risk and need for dietician (a healthcare professional who is specifically trained in nutrition and food science) evaluation. This deficient practice had the potential for Patient 9 not to receive the appropriate therapeutic diet (a meal plan that limits certain foods or nutrients to treat a medical condition) due to lack of dietician evaluation. This deficient practice also had the potential to result in complications such as weight loss, delayed recovery, etc. Findings: 1.a. During a concurrent interview and record review on 12/4/2024 at 11:56 a.m. with the House Supervisor (HS), Patient 16’s medical record titled, “Nursing Admission Assessment,” dated 11/2/2024, was reviewed. Patient 16’s medical record indicated that Patient 16 was admitted to the hospital on 11/2/2024 at 8:00 p.m. and was being admitted for high-risk behavior, passive suicide ideation (a type of suicidal thought that involves thinking about death or suicide without a specific plan to act on those thoughts) attempted on 10/19/2024. Patient 16 told her friend she (Patient 16) wanted to harm herself. The Medical record also indicated that a suicide screen was completed with the use of a Columbia-Suicide Severity Rating Scale ([C-SSRS], a tool that supports suicide risk screening through a series of simple, plain-language questions that nurses ask. The answers help nurses identify whether a patient is at risk for suicide, determine the severity and immediacy of that risk, and gauge the level of support that the patient needs) where admitting nurse identified Patient 16 to be at low risk for suicide. During the same interview on 12/4/2024 at 11:56 a.m., HS stated that the assessment was not completed correctly, the admitting nurse identified patient (Patient 16) to be “Low Risk” but did not consider the collateral information available to her (nurse) where records indicated of a suicide attempt by patient (Patient 16) on 10/19/2024. HS stated that the Nurse should have elevated risk to “Moderate” or “High” and completed those set of question for that level of risk in the CSSRS tool. This could have explored and accurately assessed patient 16’s 10/19/2024 incident of suicide attempt. HS further said it was important for nurses to complete the CSSRS tool and take into consideration other collateral information as this helps identify a patient’s level of risk accurately, and that proper interventions would be implemented based on the level of risk identified. During a review of the facility’s policy and procedure (P&P) titled, “Assessment for Suicide risk Potential,” with last revised date of 4/2022, the P&P indicated the following: Suicide Screening: 1.Intake/Admitting Staff will screen all patients with an evidence-based tool presenting for a face -to- face admission to identify specific patient characteristics that may indicate an increased risk of suicide. 2.Nursing Staff will screen all patients with an evidence -based tool who are admitted to the hospital to identify specific patient characteristics that may indicate an increased risk of suicide. 3. As indicated by the screening tool, the identified intervention will be enacted. Assessment of Risk: 1.Patients who are admitted into the hospital will be screened with an evidenced based tool. Based on the screening, the RN will determine risk level and document the individualized actions to take and contact the physician for appropriate orders, including the level of observation and precaution orders. If the patient scores high on the screening tool they will be assessed further regarding intensity of ideation and suicidal behavior. An RN may initiate suicide precautions or an increased level of observation while awaiting a formal order from the physician. An RN may not discontinue precautions or reduce the level of observation. Nursing may request a change in Observation Level when they assess patient acuity, but a physician’s order is required for any change in Level of Observation. 2.The Psychiatrist will assess suicide risk of each patient during the initial psychiatric evaluation. 3.All assessments shall be considered by the treatment team and incorporated into the patient’s individualized treatment plan. 1.b. During a concurrent interview and record review on 12/5/2024 at 12:00 p.m. with Nurse Manager 3 (NM 3), Patient 18’s medical record titled, “Nursing Admission Assessment,” dated 10/20/2204, was reviewed. Patient 18’s medical record indicated that patient (Patient 18) was admitted to the hospital on 10/20/2024 at 9:15 p.m. The medical record also indicated that a suicide screen (a procedure in which a standardized instrument or protocol is used to identify individuals who may be at risk for suicide) was completed with the use of a Columbia-Suicide Severity Rating Scale ([C-SSRS], a tool that supports suicide risk screening through a series of simple, plain-language questions that nurses ask. The answers help nurses identify whether a patient is at risk for suicide (death caused by injuring oneself with the intent to die), determine the severity and immediacy of that risk, and gauge the level of support that the patient needs) where a nurse identified Patient 18 to be at low risk for suicide. During the same interview on 12/5/2024 at 12:00 p.m. with Nurse Manager 3 (NM 3), NM 3 stated that the assessment was not completed correctly, the admitting nurse identified patient to be “Low Risk” but did not complete the second part of the CSSRS tool where the risk may be elevated to “Moderate” or “High,” depending on how patient answers those set of question on the CSSRS tool. NM 3 said the nurse failed to ask those questions and complete that part of the CSSRS tool. Nurse should have completed the CSSRS tool correctly and ask the questions that would have potentially identified patient (Patient 18) to be at moderate or high risk of suicide. NM 3 further stated it was important for nurses to complete the CSSRS tool correctly as this helps identify a patient’s level of risk accurately, and that proper intervention would be implemented. During a review of the facility’s policy and procedure (P&P) titled, “Assessment for Suicide risk Potential,” with last revised date of 4/2022, the P&P indicated the following: Suicide Screening: 1.Intake/Admitting Staff will screen all patients with an evidence-based tool presenting for a face -to- face admission to identify specific patient characteristics that may indicate an increased risk of suicide. 2.Nursing Staff will screen all patients with an evidence -based tool who are admitted to the hospital to identify specific patient characteristics that may indicate an increased risk of suicide. 3. As indicated by the screening tool, the identified intervention will be enacted. Assessment of Risk: 1.Patients who are admitted into the hospital will be screened with an evidenced based tool. Based on the screening, the RN will determine risk level and document the individualized actions to take and contact the physician for appropriate orders, including the level of observation and precaution orders. If the patient scores high on the screening tool they will be assessed further regarding intensity of ideation and suicidal behavior. An RN may initiate suicide precautions or an increased level of observation while awaiting a formal order from the physician. An RN may not discontinue precautions or reduce the level of observation. Nursing may request a change in Observation Level when they assess patient acuity, but a physician’s order is required for any change in Level of Observation. 2.The Psychiatrist will assess suicide risk of each patient during the initial psychiatric evaluation. 3.All assessments shall be considered by the treatment team and incorporated into the patient’s individualized treatment plan. 2. During a review of Patient 9’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 9/12/2024, the psych eval indicated Patient 9 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 and treatment) due to danger to self with plan to ingest helium (exposure to high level of helium [a gas that is lighter than air] can cause dizziness, headache, loss of consciousness and death). The psych eval also indicated Patient 9’s admitting diagnoses included but not limited to major depression disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), generalized anxiety disorder (a mental health condition that causes people to experience excessive, uncontrollable worry about everyday activities), and diabetes (a chronic disease when the body cannot regulate blood sugar resulting blood sugar too high). During an interview on 12/5/2024 at 10:18 a.m. with the Registered Dietician (RD, a healthcare professional who is specifically trained in nutrition and food science) 1, RD 1 stated the following: she (RD 1) would perform nutrition consultation based on nursing referral and per patient’s request. During nutrition consultation, she (RD 1) would obtain patient’s medical history and spoke with patient to determine which type of diet would be best for the patient. It would be better for diabetic patients to be on consistent carbohydrate (CCHO, a dietary approach that involves eating the same amount of carbohydrates each day to help manage blood sugar levels) diet for better control in blood sugar. During an interview on 12/5/2024 at 10:27 a.m. with RD 1, RD 1 stated there was no dietician referral and consult notes done on Patient 9. During a concurrent interview and record review on 12/5/2024 at 4 p.m. with the Nurse Manager (NM) 2, Patient 9’s “Nursing Admission Assessment,” dated 9/12/2024, was reviewed. The nursing admission assessment indicated Patient 9’s height of five (5) feet (ft, a unit of measure), weight of 200 pounds (lb, a unit of measure) and body mass index (BMI, a calculation that estimates body fat based on a person’s weight and height) of 39. The nursing admission assessment also indicated “no issues identified” was checked off under nutritional screen. The nutritional screen indicated a list of problems including but not limited to “BMI greater than 36” or “BMI less than 19.” During the same interview on 12/5/2024 at 4 p.m. with the Nurse Manager 2 (NM 2), NM 2 stated the following: the admitting nurse did not complete Patient 9’s nutritional screen (a quick process used to identify individuals who may be at risk of malnutrition by evaluating certain factors like weight loss, dietary intake, and medical history) correctly. Patient 9’s BMI was 39 which would fit the problem listed in nutritional screen of “BMI greater than 36.” If a patient reported or nurse observed any of the problems listed in nutritional screen, the nurse should refer the patient for dietician consult. Patient 9 was diabetic, it was important to have a dietician to see her (Patient 9) for blood sugar control and to recommend appropriate diet. Patient 9 could be at risk for elevated blood sugar when diet was not being managed. During an interview on 12/6/2024 at 10:41 a.m. with physician (MD 4), MD 4 stated a diabetic patient should be on therapeutic diet with CCHO diet to control blood sugar. MD 4 stated it was important to control blood sugar level for diabetic patients during the hospital stay because symptoms of hypoglycemia (when blood sugar level was too low) and hyperglycemia (when blood sugar level was too high) might falsely present as mental illness symptoms or be mistaken as psychiatric condition. During a review of Patient 9’s physician order, dated 9/12/2024, the physician order indicated Patient 9 was placed on regular diet. During a review of the facility’s policy and procedure (P&P) titled, “Nutritional Screening/Assessment Request,” dated 3/2022, the P&P indicated, “Nutritional screening will be completed on all patients admitted to [the facility]. Nutritional assessment will be requested by nursing for all patients identified as having nutritional risk ... Nursing staff will complete the ‘Nutrition Screening’ portion of nursing assessment for each patient, including all of the following: a. actual height and weight of the patient, b. under ‘Nutritional Screening,’ check boxes which apply to the patient, c. if any boxes are checked ‘yes’ a nutritional assessment is required ... If a nutritional assessment is required, nursing is to leave a voicemail for the dietician ... the Registered Dietician will complete a ‘nutritional assessment record’ within 72 hours of assessment notification ... an assessment and plan will be formulated ... dietary staff will be notified of any diet changes.” During a review of the facility’s policy and procedure (P&P) titled, “Nutritional Charting/Care Planning,” dated 3/2022, the P&P indicated, “Nursing will complete the nutrition screening portion of the nursing assessment and notify the dietician with request of nutritional assessment ... the dietician will complete the ‘nutritional assessment record’ by gathering additional subjective and objective information to formulate a nutritional assessment and plan ... Plan includes any recommendations for diet changes, supplement orders or diet education.””

“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: 46238 Based on observation, interview, and record review, the facility failed to: 1. Ensure one of 30 sampled patients (Patient 18) had a care plan for hyperglycemia (high blood sugar) and dysphagia (difficulty swallowing), initiated upon admission, in accordance with the facility’s policy and procedure regarding patient centered care planning (a detailed document that outlines a patient’s specific healthcare needs, goals, and the interventions required to achieve those goals). Patient 18 was identified with hyperglycemia, was on insulin (medication use to treat high blood sugar levels) and had dysphagia on admission. This deficient practice had the potential to result in Patient 18’s needs and risks not identified and may cause a delay in the delivery of necessary treatment to address hyperglycemia which might result in complications such as coma (a state of prolonged unconsciousness where a person is unresponsive to their surroundings and cannot be awakened), and/or death. This deficient practice may also result in complications such as aspiration (the accidental inhalation of foreign material, such as food, liquid, or vomit, into the lungs), weight loss, malnutrition (a condition that occurs when the body doesn’t have the right amount of nutrients to function properly), etc. when Patient 18’s dysphagia problem is not properly addressed. 2. Ensure one of 30 sampled patients (Patient 23) had a comprehensive care plan initiated upon admission including a care plan with interventions to prevent falls (an unintentional event that results in the person coming to rest on the ground or another lower level), in accordance with the facility’s policy and procedure regarding patient centered care planning and fall risk assessment and prevention. Patient 23 fell and hit her head on the floor, ten days after admission. This deficient practice resulted in Patient 23’s needs and risks not identified and may cause a delay in the implementation of preventive measures such as fall precautions to prevent complications from a fall such as concussion (a mild traumatic brain injury [TBI] that occurs when the brain bounces or twists inside the skull due to a blow, bump, or jolt to the head), fracture (break in the bone), etc. Findings: 1. During a review of Patient 18’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/21/2024, the H&P indicated that patient (Patient 18) had dysphagia (difficulty swallowing) and hyperglycemia (high blood sugar). During a concurrent interview and record review on 12/5/2024 at 12:27 p.m. with the Nurse Manager (NM) 3, Patient 18’s medical record titled, “Initial and Master Treatment Plan (is the first comprehensive document outlining a patient’s mental health diagnosis, treatment goals, specific interventions, and monitoring strategies, created after an initial psychiatric evaluation, serving as a roadmap for the patient’s ongoing therapy and care),” was reviewed. The medical record indicated that Hyperglycemia and dysphagia were not included in the treatment plan. During the same interview on 12/5/2024 at 12:27 p.m. with the Nurse Manager (NM) 3, NM 3 stated that the admitting nurse failed to identify and include hyperglycemia and dysphagia on the master treatment plan. NM 3 added that it was important to include hyperglycemia and dysphagia in the treatment plan problem list because the care team need to determine the progress and measure the effectiveness of interventions with each identified medical problem. NM 3 said the patient (Patient 18) was on insulin (medication to used to treat high blood sugar levels) and was on a mechanical soft diet (a dietary plan where food is modified to be soft and easy to chew and swallow, allowing patient with difficulty chewing or swallowing due to conditions swallowing disorders [dysphagia] to eat safely). During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Patient Centered Care Planning,” with effective date of 1/2023, the P&P indicated the following: Developing the Treatment Plan 1. The Nurse completing the Nursing Assessment or designee shall develop the Initial Treatment Plan within eight (8) hours of admission. The nurse will utilize the problems and specific behavioral manifestations identified in the initial assessment and nursing assessment to develop clinically appropriate and individualized goals and interventions which will be included in the Initial Treatment Plan. A. Any medical problems or diagnoses that are not receiving treatment will be listed on the Treatment Plan cover sheet/problem list as deferred with justification provided. If the medical problem requires active treatment, it will either be included in the plan as a “Chronic/Stable” medical problem if only routine care is provided or on a separate problem sheet if more than routine care is indicated. B. At the time of the development of the Interdisciplinary Master Treatment Plan (MTP), the Initial Treatment Plan will be considered resolved, with psychiatric problems either moved to the MTP or fully resolved and medical problems moved to the MTP. 2. During an observation on 12/5/2024 at 11:45 a.m., the room that Patient 23 had stayed on 7/18/2024 was located approximately 30 feet from the nursing station. This was the closest patient room to the nursing station. During a record review of the “Initial and Master Treatment Plan,” this form indicated one of the problems assessed for care planning was fall (an unintentional event that results in the person coming to rest on the ground or another lower level) risk. The short-term goal for prevention of fall in this plan included Patient 23 not falling for 7 consecutive days and Patient 23 will be able to describe 2 fall prevention techniques. The goals did not include specific nursing activities to prevent Patient 23 from falling. During a record review of a “Progress Note,” dated 7/18/2024 at 2:30 p.m., the progress note indicated Patient 23 was walking in the hallway when she (Patient 23) suddenly lost her balance and fell to the floor and hit her (Patient 23) head. The attending doctor was notified and 911 was called at 1:50 p.m., vitals (vital signs, includes heart rate, blood pressure, respiratory rate) were taken and Patient 23 was transferred out by 911 team at 2:10 p.m. During an interview on 12/5/2024 at 11:40 a.m. with Nurse Manager (NM) 2, NM 2 stated the falls care plan for Patient 23 was incomplete. The specific activities to prevent falling should be in the ‘Treatment Team Interventions’ (Modality/Activity) part of the ‘Multidisciplinary Treatment Plan - Potential for Falls.’ Concurrently, after reviewing Patient 23’s medical record, NM 2 stated there was no documentation of Patient 23 being instructed on fall precautions. During a review of Patient 23’s “Edmonson Psychiatric Fall Risk Assessment (a specific assessment designed to evaluate the risk of falls in inpatient psychiatric [focused on mental, emotional, and behavioral disorders] patients, taking into account unique factors like medication changes, sleep disturbances, mental status, and nutritional issues that can contribute to falls in this population),” this document indicated the risk factors included in a fall prevention plan. Some of the risk for patient fall included the following: Intermittent (irregular intervals) confusion; Psychotropic medications (drugs affecting emotions and behavior and used to treat mental illness, depression (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and a significant impact on daily functioning, often accompanied by changes in sleep, appetite, energy levels, and concentration), and anxiety [a feeling of fear and uneasiness]); Psychiatric diagnosis; Ability of patient to ambulate. This tool displayed Patient 30’s fall risk score was 93 and that any score greater than 90 indicated a fall risk. Finally, this assessment verified Patient 23 needed to be placed on fall precautions. During a review of the facility’s Policy and Procedure (P&P) titled, “Fall Risk Assessment and Prevention” (Policy PC-8, effective 10/97), the P&P indicated its purpose was to: Identify patients at risk for falls; Implement a fall prevention plan for those patients at risk of falls; Manage patients who fall; Educate patients and families on measures to prevent falls and promote safety. This policy specified that after a patient is assessed for risk of falls, the following fall risk precautions should be implemented (not all inclusive): Develop and implement an individualized treatment plan with interventions specific to the patient’s needs; Consider placing the patient in a room close to the nursing station; Provide easy access to wheelchair or other assistive devices; Give patient ‘Fall Risk’ yellow wristband to wear; Encourage patient to wear non slip footwear; Document education provided to the patient and family about fall prevention measures. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Patient Centered Care Planning,” with effective date of 1/2023, the P&P indicated the following: Developing the Treatment Plan 1. The Nurse completing the Nursing Assessment or designee shall develop the Initial Treatment Plan within eight (8) hours of admission. The nurse will utilize the problems and specific behavioral manifestations identified in the initial assessment and nursing assessment to develop clinically appropriate and individualized goals and interventions which will be included in the Initial Treatment Plan.”

“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: 42937 Based on interview and record review, the facility failed to: 1. Ensure the nursing staff performed medication reconciliation (a process that ensures patients have the correct list of medications they are taking at home, and that any discrepancies are identified and addressed) and communicate with the physician regarding the medication list, in accordance with the facility’s policy and procedure regarding medication reconciliation for five of 30 sampled patients (Patient 8, 17, 18, 19, and 22), when home medications were not evaluated by physician during their hospitalization at the facility. This deficient practice had the potential to compromise patient’s medical condition such as worsening infection, worsened mental or behavioral issues, etc. as their (Patient 8, 17, 18, 19, and 22) routine home medications were not reviewed and resumed by the hospital staff. 2. Complete and document a skin assessment for one of 30 sampled patients (Patient 2), in accordance with the facility’s policy on skin checks. This deficient practice had the potential to result in delayed identification and treatment of skin conditions for Patient 2 including lack of monitoring and follow-up, thus placing Patient 2 at higher risk for skin breakdown (damage to the skin and underlying tissue, usually caused by prolonged pressure on a specific area). 3. Ensure that a medication brought in from home for one of 30 sampled patients (Patient 2) was documented in the Home Medication List section of Patient 2’s chart. This deficient practice had the potential for a patient’s medication, brought in from home, to be unverified by pharmacy and may not be administered to a patient in a timely manner following a physician’s order. Findings: 1.a. During a review of Patient 8’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated, 6/21/2024, the psych eval indicated, Patient 8 was admitted to the facility on a 5150-hold (a 72-hour involuntary psychiatric hold authorized for individuals who, due to a mental health disorder, pose a danger to themselves, others, or are gravely disabled) because he was found naked covered in feces and was unable to provide a self-care plan with diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During an interview on 12/6/2024 at 12:17 p.m. with the Registered Nurse (RN) Nursing Educator (NE 1), NE 1 stated the process of home medication reconciliation (a process that ensures patients have the correct list of medications they are taking at home, and that any discrepancies are identified and addressed) was to obtain a list of patient’s home medications which could be auto populated by the facility’s electronic health record system or recorded by the Registered Nurse (RN). The admitting RN was responsible to confirm the home medications with the patient to see which medications he or she was still taking or no longer taking. Then the RN should communicate with the physician to go over each home medication for continuation or discontinuation. During a concurrent interview and record review on 12/6/2024 at 12:20 p.m. with the Registered Nurse (RN) Nursing Educator (NE 1), Patient 8’s “Admission Home Medication Orders (home med recon, list of patient’s home medications), undated, was reviewed. The home med recon indicated five medications on the list: aripiprazole (medication to treat mental condition) 662 milligram (mg, a unit of measure) per 2.4 milliliters (ml, a unit of measure) injection (medication delivered directly into a muscle), clotrimazole (skin cream to treat skin fungal [characterized by rash and itchiness] or yeast infection [with symptoms like itching, redness, and a white discharge depending on the affected area of the body]) one (1) percent (%, a unit of measure) cream, hydrocortisone (medication to treat a variety of skin conditions such as insect bites and dermatitis [a general term for a group of skin conditions that cause inflammation and irritation]) 1% cream, polymyxin B and trimethoprim (eye drop to treat bacterial infection of the eyes) eye drops 1000 units 1mg/ml, and triamcinolone (skin cream to treat various skin condition such as itchiness, redness, and dryness) 0.1% cream. NE 1 stated based on review, Patient 8’s admission home medication reciliation was not done as there was no confirmation that it was reviewed by nursing and physician. NE 1 stated Patient 8 did not receive any of his (Patient 8’s) home medications during his (Patient 8) hospitalization. During an interview on 12/6/2024 at 5:06 p.m. with the Chief Nursing Officer (CNO), CNO stated she (CNO) expected nursing staff to document what patients were on as home medications and to get an order from the physician to continue or discontinue the home medications within 24 hours upon admission. CNO stated the home medication reconciliation process was important because “We do not want the patient to miss doses of their usual medications. CNO also stated it was important for patients to continue their home medications to manage their current medical illness for stability. During a review of the facility’s policy and procedure (P&P) titled, “Medication Reconciliation Record,” dated 6/2019, the P&P indicated, “To accurately reconcile medications across the continuum of care. To provide a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s entry to the hospital with the involvement of the patient. This includes a comparison of the medications the organization provides to those on the list ... the admitting nurse will document ... patient’s current medications with dose, route, frequency and date/time of last dose and compliance.” 1.b. During a concurrent interview and record review on 12/4/2024 at 3:37 p.m. with the House Supervisor (HS) Patient 17’s medical record titled, “Admission Home Medication Orders,” was reviewed. Patient 17’s medical record indicated (1) unreconciled admission medication of azithromycin (an antibiotic medicine used to treat infections). HS stated that the admitting nurse failed to complete and confirm the home medication list for Patient 17. HS said it was the admitting nurse’s responsibility to document and confirm patient’s current home medications with its dose, route, and frequency. Physician will then review the list and decide on which home medication patient will continue taking while patient was admitted in the facility. During an interview on 12/6/2024 at 12:17 p.m. with the Registered Nurse (RN) Nursing Educator (NE 1), NE 1 stated the process of home medication reconciliation (a process that ensures patients have the correct list of medications they are taking at home, and that any discrepancies are identified and addressed) was to obtain list of patient’s home medications which could be auto populated by the facility’s electronic health record system or recorded by the Registered Nurse (RN). The admitting RN was responsible to confirm the home medications with the patient to see which medications he or she was still taking or no longer taking. Then the RN should communicate with the physician to go over each home medication for continuation or discontinuation. During an interview on 12/6/2024 at 5:06 p.m. with the Chief Nursing Officer (CNO), CNO stated she (CNO) expected nursing staff to document what patients were on as home medications and to get an order from the physician to continue or discontinue the home medications within 24 hours upon admission. CNO stated the home medication reconciliation process was important because “We do not want the patient to miss doses of their usual medications. CNO also stated it was important for patients to continue their home medications to manage their current medical illness for stability. During a review of the facility’s policy and procedure (P&P) titled, “Medication Reconciliation Record,” with effective date of 6/2019, the P&P indicated the following: -The Admitting Nurse will document patient’s admitting weight, height, allergies, patient’s current medications with dose, route, frequency and date/ time of last dose and compliance. -The Attending Physician or Discharging Nurse will list new medications, discontinued medications, compliance, and returned patient-owned medications which is given to the patient and/or family/guardian. -Patient receives a copy of the completed form; original form goes to the patient chart. 1.c. During a concurrent interview and record review on 12/5/2024 at 12:19 p.m. with the Nurse Manager (NM) 3, Patient 18’s medical record titled, “Admission Home Medication Orders,” was reviewed. Patient 18’s medical record indicated no record found pertaining to a list of home medication orders for Patient 18. NM 3 stated that the admitting nurse failed to confirm the home medication list for Patient 18. The system indicated “no records found” because it auto generates patient medication from other facilities. It was still the admitting nurse’s responsibility to confirm that the list was accurate. Confirming it in the system would indicate that the nurse reviewed the list, showing up in the system, with the patient, and that the medication list was accurate. During an interview on 12/6/2024 at 12:17 p.m. with the Registered Nurse (RN) Nursing Educator (NE 1), NE 1 stated the process of home medication reconciliation (a process that ensures patients have the correct list of medications they are taking at home, and that any discrepancies are identified and addressed) was to obtain list of patient’s home medications which could be auto populated by the facility’s electronic health record system or recorded by the Registered Nurse (RN). The admitting RN was responsible to confirm the home medications with the patient to see which medications he or she was still taking or no longer taking. Then the RN should communicate with the physician to go over each home medication for continuation or discontinuation. During an interview on 12/6/2024 at 5:06 p.m. with the Chief Nursing Officer (CNO), CNO stated she (CNO) expected nursing staff to document what patients were on as home medications and to get an order from the physician to continue or discontinue the home medications within 24 hours upon admission. CNO stated the home medication reconciliation process was important because “We do not want the patient to miss doses of their usual medications. CNO also stated it was important for patients to continue their home medications to manage their current medical illness for stability. During a review of the facility’s policy and procedure (P&P) titled, “Medication Reconciliation Record,” with effective date of 6/2019, the P&P indicated the following: -The Admitting Nurse will document patient’s admitting weight, height, allergies, patient’s current medications with dose, route, frequency and date/ time of last dose and compliance. -The Attending Physician or Discharging Nurse will list new medications, discontinued medications, compliance, and returned patient-owned medications which is given to the patient and/or family/guardian. -Patient receives a copy of the completed form; original form goes to the patient chart. 1.d. During a concurrent interview and record review on 12/5/2024 at 3:30 p.m. with Nurse manager (NM) 3, Patient 19’s medical record titled, “Admission Home Medication Orders,” was reviewed. Patient 19’s medical record indicated one (1) unreconciled admission medication of Ozempic (a weekly injection medication that helps lower blood sugar). NM 3 stated that the admitting nurse failed to complete and confirm the home medication list for Patient 19. NM 3 said it was the admitting nurse’s responsibility to document and confirm a patient’s current home medications with its dose, route, and frequency. Physician will then review the list and decide on which home medication patient will continue taking while patient was admitted in the facility. During an interview on 12/6/2024 at 12:17 p.m. with the Registered Nurse (RN) Nursing Educator (NE 1), NE 1 stated the process of home medication reconciliation (a process that ensures patients have the correct list of medications they are taking at home, and that any discrepancies are identified and addressed) was to obtain list of patient’s home medications which could be auto populated by the facility’s electronic health record system or recorded by the Registered Nurse (RN). The admitting RN was responsible to confirm the home medications with the patient to see which medications he or she was still taking or no longer taking. Then the RN should communicate with the physician to go over each home medication for continuation or discontinuation. During an interview on 12/6/2024 at 5:06 p.m. with the Chief Nursing Officer (CNO), CNO stated she (CNO) expected nursing staff to document what patients were on as home medications and to get an order from the physician to continue or discontinue the home medications within 24 hours upon admission. CNO stated the home medication reconciliation process was important because “We do not want the patient to miss doses of their usual medications. CNO also stated it was important for patients to continue their home medications to manage their current medical illness for stability. During a review of the facility’s policy and procedure (P&P) titled, “Medication Reconciliation Record,” with effective date of 6/2019, the P&P indicated the following: -The Admitting Nurse will document patient’s admitting weight, height, allergies, patient’s current medications with dose, route, frequency and date/ time of last dose and compliance. -The Attending Physician or Discharging Nurse will list new medications, discontinued medications, compliance, and returned patient-owned medications which is given to the patient and/or family/guardian. -Patient receives a copy of the completed form; original form goes to the patient chart 1.e. During a concurrent interview and record review on 12/5/2024 at 3:30 p.m. with Nurse Manager (NM) 3, Patient 22’s medical record titled, “Admission Home Medication Orders,” was reviewed. Patient 22’s medical record indicated five (5) unreconciled admission medications as follows: -Lamotrigine (a medication that treats epilepsy (a chronic brain disorder characterized by recurrent seizure [abnormal electrical activity in the brain that can cause a range of symptoms] and bipolar disorder [a mental illness that causes extreme shifts in mood, energy, activity, and concentration]) -Acetaminophen (a medication used to treat many conditions such as headache, muscle aches, arthritis [a group of conditions that cause inflammation of the joints], backache, toothaches, colds and fevers) -Azithromycin (an antibiotic medicine used to treat infections) -Ibuprofen (a medication that can reduce a fever and also treats mild to moderate pain, inflammation and arthritis) -Penicillin (an antibiotic used to treat bacterial infections). During the same interview on 12/5/2024 at 3:30 p.m., NM 3 stated that the admitting nurse failed to complete and confirm the home medication list for Patient 22. NM 3 said it was the admitting nurse’s responsibility to document and confirm a patient’s current home medications with its dose, route, and frequency. Physician will then review the list and decide on which home medication the patient will continue taking while patient was admitted in the facility. During an interview on 12/6/2024 at 12:17 p.m. with the Registered Nurse (RN) Nursing Educator (NE 1), NE 1 stated the process of home medication reconciliation (a process that ensures patients have the correct list of medications they are taking at home, and that any discrepancies are identified and addressed) was to obtain list of patient’s home medications which could be auto populated by the facility’s electronic health record system or recorded by the Registered Nurse (RN). The admitting RN was responsible to confirm the home medications with the patient to see which medications he or she was still taking or no longer taking. Then the RN should communicate with the physician to go over each home medication for continuation or discontinuation. During an interview on 12/6/2024 at 5:06 p.m. with the Chief Nursing Officer (CNO), CNO stated she (CNO) expected nursing staff to document what patients were on as home medications and to get an order from the physician to continue or discontinue the home medications within 24 hours upon admission. CNO stated the home medication reconciliation process was important because “We do not want the patient to miss doses of their usual medications. CNO also stated it was important for patients to continue their home medications to manage their current medical illness for stability. During a review of the facility’s policy and procedure (P&P) titled, “Medication Reconciliation Record,” with effective date of 6/2019, the P&P indicated the following: -The Admitting Nurse will document patient’s admitting weight, height, allergies, patient’s current medications with dose, route, frequency and date/ time of last dose and compliance. -The Attending Physician or Discharging Nurse will list new medications, discontinued medications, compliance, and returned patient-owned medications which is given to the patient and/or family/guardian. -Patient receives a copy of the completed form; original form goes to the patient chart. 2. During a review of Patient 2’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 9/20/2024, the psych eval indicated that Patient 2 was admitted on 9/20/2024 for a chief complaint of feeling suicidal (experiencing thoughts or ideations of self-harm or ending one’s life). The psych eval also indicated that Patient 2 had a past medical history of depression (a mental health condition characterized by persistent sadness, loss of interest, and emotional distress that interferes with daily functioning) and anxiety (a mental health condition marked by excessive worry, fear, or nervousness that can be persistent and difficult to control). During a concurrent interview and record review on 12/5/2024 at 12:30 p.m. with Nurse Educator 1 (NE 1), Patient 2’s medical chart titled, “Progress Record,” included a photograph depicting multiple scratches/cuts on Patient 1’s bilateral (both sides of the body) forearms, labeled with Patient 1’s name, and attached to a progress note. NE 1 stated that a date written next to the photograph indicated 9/20/2024 at 12:45 a.m., on arrival; however, no signature or printed nurse’s name was recorded. NE 1 also stated that the facility’s policy does not require nurses to obtain photographs of patients’ skin wounds. NS 1 then said that the staff likely took the photograph upon admission. During a concurrent interview and record review on 12/5/2024 at 12:38 p.m. with Nurse Educator 1 (NE 1), NE 1 reviewed Patient 2’s History and Physical (H&P, a document summarizing the patient’s medical history and findings from a physical examination), dated 9/20/2024, and stated that the H&P did not include any documented skin issues in Patient 2’s physical assessment. During a review of Patient 2’s medical record (MR) titled, “Nursing Admission Assessment,” dated 9/20/2024 at 12:05 a.m., the MR indicated that Patient 2 had a left elbow scar, left shin scar, and left ankle scar. The MR also indicated that two staff members signed the completed skin assessment for Patient 1 on 9/20/2024. During an interview on 12/5/2024 at 12:41 p.m. with Nurse Educator 1 (NE 1), NE 1 reviewed Patient 1’s “Nursing Admission Assessment,” dated 9/20/2024, and stated that areas identified on Patient 2’s skin assessment record were scars, not cuts or scratches. This information was verified by two staff members who signed the assessment form. However, NE 1 was unable to identify the staff members because they did not write their full names as required on the assessment form and only provided signatures. During further review of Patient 1’s medical record (MR) titled, “Nursing Admission Assessment-Narrative Summary,” dated 9/20/2024, the MR indicated that Patient 2 reported cutting themself (Patient 2) with scissors. The MR also did not include a printed nurse’s name under the section designated for “Printed Name and Title,” only a handwritten signature was present. During a concurrent interview and record review on 12/5/2024 at 12:42 p.m. with Nurse Educator 1 (NE 1), Patient 2’s medical record (MR) titled, “Daily Nursing Shift Assessments,” dated 9/20/2024 at 6:45 a.m. and 11:00 p.m., was reviewed. The MR indicated that Patient 2 had no marked skin issues, such as scratches or scars, and the assessments were marked as within normal limits (WNL). NE 1 stated that if nurses had identified skin issues, such as cuts or scratches, they should have documented the findings in the daily shift assessments but did not. During a review of the facility’s policy and procedure (P&P) titled, “Nursing Assessment and Reassessment,” last reviewed 3/2022, the P&P indicated that the Nursing Admission Assessment must be completed within 8 hours of admission by a registered nurse (RN). The Body/Skin Check must be completed by two staff members, with at least one being a licensed staff member, such as an RN or licensed vocational nurse (LVN). 3. During a review of Patient 2’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 9/20/2024, the psych eval indicated that Patient 2 was admitted on 9/20/2024 for a chief complaint of feeling suicidal (experiencing thoughts or ideations of self-harm or ending one’s life). The psych eval also indicated that Patient 2 had a past medical history of depression (a mental health condition characterized by persistent sadness, loss of interest, and emotional distress that interferes with daily functioning) and anxiety (a mental health condition marked by excessive worry, fear, or nervousness that can be persistent and difficult to control). During a review of Patient 2’s medical record (MR) titled, “Home Medication List,” dated 9/20/2024, the medical record indicated that the Home Medication List section of the MR contained no documentation of the medications Patient 2 had brought to the hospital upon admission. During a concurrent interview and record review on 12/5/2024 at 12:23 p.m. with Nurse Educator 1 (NE 1), Patient 1’s “Medication Administration Record (MAR),” dated 9/20/2024 through 9/24/2024, was reviewed. NE 1 stated that the MAR contained documentation of the administration of 25 milligrams (mg) of Pristiq (a prescription antidepressant used to treat major depressive disorder) as brought from home. NE 1 further explained that medications brought from home should be documented in the Home Medication List section of the patient’s chart. The medication is then sent to the pharmacy, where it is verified, a scanning label is created, and the medication is dispensed if a physician’s order for administration is present. NE 1 also said that the facility does not have a specific policy regarding the process of patient’s own home medications being sent to pharmacy for verification, creating a scanning label, and administering the medication to the patient once ordered by the physician. During further review of Patient 2’s medical record (MR) titled, “Belongings List,” dated 9/24/2024, the MR indicated that a bottle of Pristiq medication was returned to Patient 2 on 9/24/2024 upon discharge. During a review of the facility’s policy and procedure (P&P) titled, “Patient’s Own Medications,” last reviewed 1/2013, the P&P indicated that all medications brought to the hospital from home by a patient should be given to the person accompanying them at the time of admission. If this is not possible, the medication must be placed in the Patient’s Valuables Envelope. The name, strength, and quantity of the medication must be recorded in the Record of Patient’s Own Medications section of the patient’s belongings. The envelope is then sealed and stored in a locked box in the nursing unit’s medication room. Before the patient is discharged, the medication is retrieved by nursing staff and returned to the patient.”

“COMPETENT DIETARY STAFF CFR(s): 482.28(a)(3) There must be administrative and technical personnel competent in their respective duties. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure there was mechanism to ensure kitchen staff are competent in their duties for two of two sampled dietary staff (Dietary Aide [DA] 1 and Certified Dietary Manager [CDM]) when: 1. DA 1 failed to follow menu instruction to provide fourteen French fries on patients’ lunch tray 2. CDM failed to identify the correct serving size of a gray handle scoop in the kitchen This deficient practice had the potential to result in serving patients with incorrect food serving and portion in meals and not meeting patients’ nutritional needs due to overeating or undereating. Findings: 1. During a concurrent observation and interview on 12/4/2024 at 11:38 a.m. with the Dietary Aide (DA 1) at the facility’s kitchen, the Dietary Adie (DA) 1 was at the tray line using tongs to grip French fries two times into a food tray. There was no menu visible at the tray line. DA 1 stated she (DA 1) was busy preparing forty (40) lunch trays for patients and did not count how many French fries for each lunch tray. DA 1 stated, “I just estimated.” During a concurrent interview and record review on 12/4/2024 at 11:40 a.m. with the Dietary Manager (CDM), the dietary master menu (a comprehensive list of meals, carefully planned by a registered dietitian, that outlines a variety of food options designed to meet specific nutritional needs, often catering to different dietary restrictions or medical conditions, and serves as a foundational guide for meal planning in a healthcare setting or institution), dated 10/2024, was reviewed. The Dietary Master Menu Cycle 1 Regular/NAS (No Added Salt, dietary approach that involves avoiding adding salt while cooking or preparing food) indicated, today’s menu to serve eight (8) ounces (oz, a unit of measure) milk, three (3) oz beef, hamburger with one (1) bun, one (1) slice cheese, one (1) slice each lettuce and tomato, fourteen (14) French fries, half cup coleslaw, one (1) chocolate chip cookie. CDM stated each patient’s tray should have fourteen (14) French fries per master menu and staff should follow the menu when preparing food. CDM also stated the master menu should be at the tray line for the staff to see when preparing food to make sure they prepare the exact portion as stated on the master menu. During an interview on 12/5/2024 at 10:31 a.m. with the Registered Dietician (RD 1), RD 1 stated dietary staff must follow the master menu when preparing food for patients because everything was calculated on the master menu to provide the exact calories and protein in order to meet patient nutritional needs. RD 1 stated there would be risk for patients overeating or undereating when food was not prepared per master menu. During an interview on 12/6/2024 at 2:24 p.m. with the Director of Human Resources (HRD), HRD stated it was important to have unit specific competency (directly impacts patient safety by ensuring healthcare professionals possess the necessary knowledge, skills, and abilities to deliver high-quality care) done on staff to make sure he/she was qualified and competent to do the job. During an interview on 12/6/2024 at 4:04 p.m. with CDM, CDM stated there was no unit specific competency done for dietary staff, CDM stated staff performance was monitored through qualification, experience and supervision. During a review of the facility’s policy and procedure (P&P) titled, “Master Menu,” dated 3/2022, the P&P indicated, “The patient master menu ... is planned to provide adequate nutrition in accordance with approved [facility’s] diet manual.” During a review of the facility’s policy and procedure (P&P) titled, “Tray Identification,” dated 3/2022, the P&P indicated, “during tray-line dietary workers use menu as guide in serving each patient.” 2. During a concurrent interview and record review on 12/4/2024 at 11:40 a.m. with the Dietary Manager (CDM), the dietary master menu dated 10/2024, was reviewed. The Dietary Master Menu Cycle 1 Regular/NAS indicated, today’s menu to serve eight (8) ounces (oz, a unit of measure) milk, three (3) oz beef, hamburger with one (1) bun, one (1) slice cheese, one (1) slice each lettuce and tomato, fourteen (14) French fries, half cup coleslaw, one (1) chocolate chip cookie. CDM stated each patient’s tray should have fourteen (14) French fries per master menu and staff should follow the menu when preparing food. CDM also stated the master menu should be at the tray line for the staff to see when preparing food to make sure they prepare the exact portion as stated on the master menu. During a concurrent observation and interview on 12/4/2024 at 11:45 a.m. with the Dietary Manager (CDM) at the facility’s kitchen, a dietary aide (DA 1) was using a gray color handle scoop to scoop coleslaw. CDM stated DA 1 was using a number twelve (12) scoop which did not provide half cup serving size. During an interview on 12/4/2024 at 11:46 a.m. with DA 1, DA 1 stated different color handle scoops provided different serving size. DA 1 stated she (DA 1) believed the gray handle scoop was the number eight (8) scoop but there was number or serving size indicated on the gray handle scoop. DA 1 also stated there was no scoop guide in the kitchen for staff to reference different scoops and their serving sizes. During an interview on 12/4/2024 at 2:05 p.m. with the CDM, CDM stated the following: she (CDM) looked up the information from the internet and noted she (CDM) provided the wrong information. DA 1 actually used number eight (8) scoop which would provide half cup serving. CDM stated there should be a guide in the kitchen for staff to reference the scoops and serving sizes. During a concurrent interview and record review on 12/6/2024 at 2:24 p.m. with the Director of Human Resources (HRD), CDM’s personnel file was reviewed. CDM’s personnel file indicated there was no competency completed in relation to food handling or kitchen related tasks. HRD stated it was important to have unit specific competency done on staff to make sure he/she was qualified and competent to do the job. During an interview on 12/6/2024 at 3:36 p.m. with the Director of Plant Operation (DPO), DPO stated he (DPO) oversee dietary department. DPO stated all dietary staff including the CDM should be familiar with the sizes of the scoops to make sure portion of food was properly maintained to provide adequate nutrition. During a review of the CDM’s job description titled, “Dietary Manager,” dated 8/22/2024, the job description indicated “specialized skills and knowledge ... 5. Industrial equipment and utensils, and skill in utilizing such... essential job duties/responsibilities ... provide in-service education and orientation to the food service staff, and when appropriate, to other facility staff.” During a review of the facility’s policy and procedures (P&P) titled, “Hiring Procedure,” dated 4/2020, the P&P indicated, “The Human Resources Department is responsible for an individual orientation of new employees for the processing of all employment forms. The Manager is responsible for any necessary job training and competencies.””

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its staff provided accurate nutritional screening (a process used to quickly identify individuals who might be at risk of malnutrition [a condition that occurs when the body doesn’t have the right amount of nutrients to function properly] by asking a series of brief questions about their dietary habits, weight changes, and medical history) for one of 30 sampled patients (Patient 9), in accordance with the facility’s policy and procedure regarding nutritional screening and assessment, when nursing staff failed to identify Patient 9’s nutritional risk and need for nutritional assessment by a registered dietician (RD, a healthcare professional who is specifically trained in nutrition and food science). Hence, Patient 9 did not receive the proper menu as a diabetic (high blood sugar level) patient. This deficient practice had the potential for Patient 9 not to receive the appropriate therapeutic diet (a meal plan that limits certain foods or nutrients to treat a medical condition) due to lack of dietician evaluation. This deficient practice also had the potential to result in complications such as delayed recovery, increased blood sugar level, etc. Findings: During a review of Patient 9’s “Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 9/12/2024, Patient 9 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 and treatment) due to danger to self with plan to ingest helium (exposure to high level of helium [a gas that is lighter than air] can cause dizziness, headache, loss of consciousness and death). The psych eval indicated Patient 9’s admitting diagnoses including but not limited to major depression disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), generalized anxiety order (a mental health condition that causes people to experience excessive, uncontrollable worry about everyday activities), and diabetes (a chronic disease when the body cannot regulate blood sugar resulting blood sugar too high). During an interview on 12/5/2024 at 10:18 a.m. with the Registered Dietician (RD) 1, RD 1 stated the following: she (RD 1) would perform nutrition consultation based on nursing referral and per patient’s request. During nutrition consultation, she (RD 1) would obtain patient’s medical history and spoke with patient to determine which type of diet would be best for the patient. It would be better for diabetic patients to be on consistent carbohydrate (CCHO, a dietary approach that involves eating the same amount of carbohydrates each day to help manage blood sugar levels) diet for better control in blood sugar. During an interview on 12/5/2024 at 10:27 a.m. with RD 1, RD 1 stated there was no dietician referral and consult notes done on Patient 9. During a concurrent interview and record review on 12/5/2024 at 4 p.m. with the Nurse Manager (NM) 2, Patient 9’s “Nursing Admission Assessment,” dated 9/12/2024, was reviewed. The nursing admission assessment indicated Patient 9’s height of five (5) feet (ft, a unit of measure), weight of 200 pounds (lb, a unit of measure) and body mass index (BMI, a calculation that estimates body fat based on a person’s weight and height) of 39. The nursing admission assessment also indicated “no issues identified” was checked off under nutritional screen. The nutritional screen indicated a list of problems including but not limited to “BMI greater than 36” or “BMI less than 19.” NM 2 stated the following: the admitting nurse did not complete Patient 9’s nutritional screen correctly. Patient 9’s BMI was 39 which would fit the problem listed in nutritional screen of “BMI greater than 36.” If a patient reported or nurse observed any of the problems listed in nutritional screen, the nurse should refer the patient for dietician consult. Patient 9 was diabetic, it was important to have a dietician to see her (Patient 9) for blood sugar control and to recommend appropriate diet. Patient 9 could be at risk for elevated blood sugar when diet was not being managed. During an interview on 12/6/2024 at 10:41 a.m. with physician (MD 4), MD 4 stated diabetic patient should be on therapeutic diet with CCHO diet to control blood sugar. MD 4 stated it was important to control blood sugar level for diabetic patients during the hospital stay because symptoms of hypoglycemia (when blood sugar level was too low) and hyperglycemia (when blood sugar level was too high) might falsely present mental illness symptoms or be mistaken as psychiatric condition. During a review of Patient 9’s physician order, dated 9/12/2024, the physician order indicated Patient 9 was placed on regular diet. During a review of the facility’s policy and procedure (P&P) titled, “Nutritional Screening/Assessment Request,” dated 3/2022, the P&P indicated, “Nutritional screening will be completed on all patients admitted to [the facility]. Nutritional assessment will be requested by nursing for all patients identified as having nutritional risk ... Nursing staff will complete the ‘Nutrition Screening’ portion of nursing assessment for each patient, including all of the following: a. actual height and weight of the patient, b. under ‘Nutritional Screening,’ check boxes which apply to the patient, c. if any boxes are checked ‘yes’ a nutritional assessment is required ... If a nutritional assessment is required, nursing is to leave a voicemail for the dietician ... the Registered Dietician will complete a ‘nutritional assessment record’ within 72 hours of assessment notification ... an assessment and plan will be formulated ... dietary staff will be notified of any diet changes.” During a review of the facility’s policy and procedure (P&P) titled, “Nutritional Charting/Care Planning,” dated 3/2022, the P&P indicated, “Nursing will complete the nutrition screening portion of the nursing assessment and notify the dietician with request of nutritional assessment ... the dietician will complete the ‘nutritional assessment record’ by gathering additional subjective and objective information to formulate a nutritional assessment and plan ... Plan includes any recommendations for diet changes, supplement orders or diet education.””

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to provide adequate mental health workers based on census (number of patients in the unit) and ensure nursing staff consistently performed and documented patient acuity report (defined as evaluations of the severity of a patient’s condition and care needs to determine the appropriate level of nursing care required), in accordance with the facility’s policy and procedure regarding acuity system to determine the appropriate staffing levels and align staff assignments with patient care needs for four of four sampled behavioral health units (BHU [inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders] 1, 2, 3 and 5). This deficient practice had the potential to result in the inability to meet patients’ needs in a timely manner, thus compromising patients’ safety and the delivery of quality patient care. Findings: During a review of Patient 10’s “Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 11/27/2024, the psych eval indicated, Patient 10 was admitted to the facility on a 5585-hold (allows a minor to be involuntarily detained for up to 72 hours in a psychiatric hospital [a specialized medical facility that focuses on treating individuals with severe mental disorders] for a mental health crisis) with diagnosis of disruptive mood dysregulation disorder (a mental health condition that causes children and adolescents to experience severe irritability and frequent temper outburst) for evaluation of her (Patient 10) mood state and self-harm behavior claiming, “I am going to take a bunch of gummy melatonin (medication helps someone to fall asleep).” During an interview on 12/3/2024 at 11:38 a.m. with Patient 10 at Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) 5, Patient 10 stated the following: she (Patient 10) was at the facility for about one week. There were a lot of fights going on with other patients and it happened in front of her (Patient 10). She (Patient 10) would just stay away and remain quiet. Patient 10 stated, “It took some time for staff to come and intervene.” During a concurrent interview and record review on 12/3/2024 at 11:51 a.m. with Charge Nurse (CN) 1 at BHU 5, BHU 5 Patient Care Assignment (nursing assignment indicating who are the staff assigned to the patients and their tasks) 7 a.m. to 3:30 p.m. morning shift, dated 12/3/2024, was reviewed. The Patient Care Assignment indicated BHU 5 had census of 22 patients and was staffed four licensed nursing staff (CN 1, Registered Nurse [RN] 2, RN 3 and Licensed Vocational Nurse [LVN] 2) and one Mental Health Technician (MHT, psychiatric assistant provides direct patient care support with mental health issue under charge nurse direction) 3. CN 1 stated he (CN 1) had patients currently and RN 3 just came in at 11 a.m. They had to utilize LVN 2 to help with 15-minute rounding (rounding done every 15 minutes in behavioral health unit to ensure patient safety) because there was only one (1) MHT (MHT 3) on the floor. During an interview on 12/4/2024 at 11:59 a.m. with Charge Nurse (CN) 2 at Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) 2, CN 2 stated it was the charge nurse’s responsibility to make the assignment for the unit and complete the acuity (a medical term that refers to the severity of a patient’s condition and how urgent their care needs are, the higher the acuity the more care is needed) sheet. CN 2 stated acuity reflected how heavy the patient load was. CN 2 stated she (CN 2) did not do the acuity today because she (CN 2) was behind with her (CN2) work. CN2 stated she (CN 2) split the assignment among her (CN 2) and two other licensed nursing staff based on the number of patients in the unit (BHU 2). During an interview on 12/4/2024 at 12:40 p.m. with Charge Nurse (CN) 3 at Behavioral Health Unit (BHU) 3, CN 3 stated patient acuity should be done to make sure there was enough staffing. CN 3 stated she did not do the patient acuity today because she (CN 3) was busy. During an interview on 12/5/2024 at 2:42 p.m. with Nurse Manager (NM) 2 of BHU 2 and BHU 3, NM 2 stated the following: the facility was currently in the process of changing the acuity tool. Acuity was not being done currently. Acuity would tell how acute the patients were, and it played a role in making nursing assignment. It would be inappropriate to assign all high acuity patients to one nurse because it would not be manageable. The nursing staff would not be able to provide quality care to patients when he or she had all heavy (high acuity) patients. During an interview on 12/5/2024 at 2:53 p.m. with Nurse Manager (NM) 1 of BHU 5, NM 1 stated the following: patient acuity was done to let the facility how much staff was needed to provide adequate staff to provide quality care to patients and maintain safety. Acuity should be done by the day shift charge nurse every day. However, the facility changed the acuity tool in August 2024 per corporate directive, but it was still in the process of implementation. Patient acuity had not been done since August 2024 (five months). During a review of Patient 13’s “Initial Psychiatric Evaluation (psych eval),” dated 12/2/2024, the psych eval indicated, Patient 13 was admitted to the facility on an involuntary 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) due to danger to self by attempting carbon monoxide (colorless, odorless and tasteless gas that can be harmful to humans and deadly if inhaled in large amounts) poisoning in the car and with diagnosis of major depression (a serious mood disorder that can affect how you feel, think, and behave). During an interview on 12/6/2024 at 9:55 a.m. with Patient 13 in Behavioral Health Unit (BHU) 1, Patient 13 stated she (Patient 13) saw patients fighting in BHU 1 and staff would try to intervene. During a concurrent interview and record review on 12/6/2024 at 10 a.m. with the Nurse Manager (NM) 3 of BHU 1, BHU 1’s unit staffing assignment dated 12/6/2024, was reviewed. The staffing assignment did not indicate any patient acuity. NM 3 stated patient acuity was not done in BHU 1. During an interview on 12/6/2024 at 10:20 a.m. with Mental Health Technician (MHT) 2 at BHU 1, MHT 2 stated the following: MHT would be assigned as one to one observation on patient when needed. MHTs were responsible to perform rounding every fifteen (15) minutes on all patients in the unit to check on patients’ location and behavior. MHT would help to intervene when patients got into fights by talking to and separating patients. MHT would also take patients out to patio for activity and provide patients items such as snacks, juice and shampoo upon request. There should be three (3) MHTs on the floor in BHU 1 but a lot of time there was not enough staff. It was hard to attend to patient’s need in a timely manner because he (MHT 2) needed to perform rounding every 15 minutes for all patients. During a concurrent record review on 12/6/2024 at 11:01 a.m. with the Nurse Manager (NM) 3 at BHU 1, BHU 1’s unit staffing assignment from 12/1/2024 to 12/6/2024 was reviewed. The staffing assignment indicated the following: -On 12/1/2024, 7 a.m. to 3:30 p.m. day shift with census of 44, BHU 1 was staffed with three (3) licensed nursing staff (three RNs) and three (3) MHTs. One patient (Patient 15) requiring one on one observation. -On 12/1/2024, 3:30 p.m. to 11 p.m. evening shift with census of 44, BHU 1 was staffed with four (4) licensed nursing staff and three (3) MHT. One patient (Patient 15) requiring one on one observation. -On 12/2/2024, 11 p.m. to 7 a.m. night shift with census of 42, BHU 1 was staffed with three (3) licensed nursing staff and three (3) MHT. One patient (Patient 15) requiring one on one observation. NM 3 stated the following: there were not enough MHTs scheduled on the floor on 12/1/2024 day shift, 12/1/2024 evening shift and 12/2/2024 night shift. There are only 2 MHTs on the floor rounding because one of them was assigned to do one on one observation for Patient 15. MHTs are needed to perform rounding every 15 minutes on patients to maintain safety for patients. MHTs also needed to assist with patient’s needs such as getting water and respond to any emergency in the unit. During a review of Patient 15’s “Initial Psychiatric Evaluation (psych eval),” dated 11/26/2024, Patient 15 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 and treatment) due to danger to self by walking in front of on-coming traffic and hitting his (Patient 15) head and with diagnosis of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 15’s physician order dated 12/1/2024, the physician order indicated, “one on one observation for head banging/self-injurious behavior.” During an interview on 12/6/2024 at 11:49 a.m. with the Chief Executive Officer (CEO), CEO stated patient acuity should be incorporated when it came to staffing because of the level of safety needs for patients varies from one to another. CEO stated there should be additional MHTs on the floor when there was any patient needing one on one observation. CEO stated it was nursing administration’s responsibility to provide oversight on staffing. During an interview on 12/6/2024 at 5:10 p.m. with the Chief Nursing Officer (CNO), CNO stated the following: she (CNO) was responsible to oversee staffing. Appropriate staffing was important to provide care for patients. The facility did not have a grid for staffing, but the facility staffed one licensed nurse and one MHT for every ten (10) patients. When the census was at forty (40), there should be four (4) MHTs especially for day shift and evening shift because there are more activities going on. Additional MHT should be provided when there’s a patient requiring one on one observation. When the unit acuity was high, it would require more nursing attention and more staff. The goal was to spread out high acuity patients in order to balance staff workload. It would also benefit the floor and patient safety. CNO stated, “we do not have a tool to evaluate patients’ acuity currently.” During a review of the facility’s policy and procedure (P&P) titled, “Appropriate Staffing Levels,” dated 9/2023, the P&P indicated, “It is the policy of [the facility] to utilize a defined procedure to determine staffing requirements based on patient needs ... In order to maintain quality nursing care, staffing will be planned according to the assessment of patient’s needs by the Registered Nurse Charge Nurse and in consultation with, as needed, the Chief Nursing Office and/or the House Supervisor ... The Criteria for assignment of nursing personnel is based on acuity (A patient classification system) that is approved by the Medical Executive Committee and the Board of Trustees of the hospital ... Multiple factors influence the functioning of a patient care unit and the CNO and/or designee(s) are responsible to modify staffing as needs arise on a day-by-day and shift-by-shift basis to provide safety. Factors which affect the need to alter staffing levels up or down include but are not limited to: a. Overall acuity on unit based on formal scoring ... patients place on one on one monitoring ... high risk conditions such as aggressive and/or violent patient towards self and other.” During a review of the facility’s policy and procedure (P&P) titled, “Acuity System/Report,” dated 3/2022, the P&P indicated, “To ensure that an acuity system is used that addresses patient care needs and satisfies these needs by providing the required nursing hours according to skill mix ... the department of nursing at [the facility] utilizes the patient acuity report to determine individual patient acuity and staffing requirements for each patient care unit ... acuity cane change from day to change and that staffing must fluctuate to assure quality care of each patient ... the charge nurse Registered Nurse (RN) completes the Acuity Report everyday at 10:30 a.m. and submit the report to the Chief Nursing Officer (CNO) or Nursing Supervisor ... Biological needs, psychological needs and social needs are rated utilizing the Acuity Rating Criteria Grid. Each patient is rated a score of 1 for low, 2 for moderate and 3 for high acuity.” During a review of the facility’s policy and procedure (P&P) titled, “Minimum/Core Nursing Staffing Plan Per Unit,” dated 5/2024, the P&P indicated, “It is the policy of [the facility] to ensure that the appropriate numbers and qualifications of nursing staff are available at all times for the care of patients. The Chief Nursing Officer (CNO) is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity.” During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for Nursing Services,” dated 3/2022, the P&P indicated, “The nursing staff at [the facility] provides quality psychiatric nursing services to all patients on a 24-hours, 7 days a week basis, in a continuous, consistent, safe and caring manner ... Assignment of nursing staff ... Each unit shall have a designated number of Licensed Psychiatric Technicians, Licensed Vocational Nurses, and/or Psychiatric Assistants working under the charge nurse based on unit census, patient acuity, and other patient care need requirement ... the Governing Board is kept informed of nursing activities via the Chief Nursing Officer (CNO), who attends Governing Board meetings quarterly.””

“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 failed to ensure Medical Staff followed the facility’s “Medical Staff Bylaws, Rules and Regulations,” when Physician Orders were incomplete for one of 30 sampled patients (Patient 6) and telephone orders were not signed within 48 hours for one of 30 sampled patients (Patient 4). These deficient practices had the potential for any staff to fill out physician’s orders including unsigned physician’s orders, which may result in inaccurate orders carried out thus resulting in patient harm. (Refer to A-0047) 2. The facility’s Governing Body failed to ensure oversight on the Nursing Department to ensure that the standard of care on patient safety was implemented for one of 30 sampled patients (Patient 8), when Patient 8 was found unresponsive (not reacting or unable to react in a normal way when touched, spoken to, etc.), pulseless, not breathing, and when Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) was not initiated immediately and the automatic external defibrillator (AED, delivers an electric shock through the chest to the heart when it detects an abnormal rhythm) was not applied on Patient 8. This deficient practice resulted in a delay in life-saving measures, which may have contributed to Patient 8’s death. (Refer to A-0063) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe setting and contributed to Patient 8’s death.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48186 Based on observation, interview, and record review the facility failed to ensure the Condition of Participation for Patient’s Rights was met as evidenced by: 1. The facility failed to ensure that two of 30 sampled patients (Patients 21 and 30) and their (Patient 21 and 30) designated representatives were informed of the patients’ (Patient 21 and 30) condition, in accordance with the facility’s policy and procedure regarding the appropriate use of involuntary commitment (the legal process in which a person is confined in a psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] hospital because of a treatable mental disorder, against his or her wishes) when: 1.a. Patient 21’s designated representative was not informed of the patient’s (Patient 21) condition when Patient 21 was put on a psychiatric 14-day hold (a certification also known as 5250 hold, for intense treatment for a period of involuntary hospitalization for up to 14 days due to mental disorder) on 7/1/2024. 1.b. Patient 30 and the patient’s (Patient 30) designated representative was not informed of the patient’s (Patient 30) condition when Patient 30 was put on a 5250 hold on 4/27/2024. These deficient practices resulted in the patients (Patient 21 and 30) and the patients’ designated representative not able to exercise the right to make informed decisions (a decision that patients or their designated representatives can make once they have all the information related to the decision topic) regarding the patients’ care. (Refer to A-0131) 2. The facility failed to initiate Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) immediately and apply the automatic external defibrillator (AED, delivers an electric shock through the chest to the heart when it detects an abnormal rhythm) for one of 30 sampled patients (Patient 8), when Patient 8 was found unresponsive (not reacting or unable to react in a normal way when touched, spoken to, etc.), pulseless, and not breathing, in accordance with the facility’s policy and procedure regarding Code Blue (hospital announcement means that someone is having a medical emergency, usually cardiac arrest [absent or abnormal heart activity] or respiratory arrest [absent breathing]) and Change of Condition. This deficient practice resulted in a delay in life-saving measures, which may have contributed to Patient 8’s death. (Refer to A-0144). 3. The facility failed to ensure the safety for one of 30 sampled patients (Patient 12), identified to be at risk for self-harm (hurting oneself), when Patient 12 took six (6) unspecified pills and cut wrist with a hairbrush while admitted to the facility, in accordance with the facility’s policy and procedure regarding Medication Administration. This deficient practice resulted in Patient 12 being transferred to another hospital for treatment, after the patient (Patient 12) self-harmed. (Refer to A-0144) 4. The facility failed to check for the presence of one of six emergency equipment (emergency bag that contains medications, etc.) daily on one of six units (Del Sol [Adult Inpatient]), in accordance with the facility’s protocol regarding Emergency Medical Equipment Daily Checklist and the facility’s policy and procedure regarding medical emergencies. This deficient practice had the potential for emergency equipment not to be readily available in the event of a medical emergency and compromise patient safety. (Refer to A-0144) 5. The facility failed to conduct patient rounding (best practice intervention of checking in on patients to meet patient care needs) every 15 minutes for one of 30 sampled patients (Patient 6) in accordance with the facility’s policy and procedure regarding supervision of patients. This deficient practice had the potential for the whereabouts of patients to be unknown and had the potential for harm, injury, medical emergency, or elopement (a patient who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected). (Refer to A-0144) 6. The facility failed to Ensure one of 30 sampled patients (Patient 21, a child [the facility considered patients in the age group of 5 years old to 12 years old as child]) was not left alone with Patient 2, an adolescent patient (the facility considered patients in the age group of 13 years old to 17 years old as adolescent) inside the Youth Services Unit’s Day room (activity room) with no staff supervision, in accordance with the facility’s policy and procedure regarding supervision of patients. This deficient practice had the potential for the patients, who were admitted with behavioral issues, to inflict self-harm or harm to others. (Refer to A-0144) 7. The facility failed to ensure there was continuous observation and direct line of vision (a level of observation in which the patient remains in staff view) for two of 30 sampled patients (Patient 27 and 28) in a group setting in accordance with the facility’s policy and procedure (P&P) “Supervision of Patients/Patient Rounds.” This deficient practice had the potential for the patients, who were admitted with behavioral issues, to inflict self-harm or harm to others. (Refer to A-0144) 8. The facility failed to ensure patient safety, in accordance with the facility’s policy and procedure regarding patient precautions, for one of 30 sampled patients (Patient 17) when Patient 17 was involved in two physical altercations with Patients 18 and 19 within a 24-hour period. This deficient practice resulted in Patient 17 suffering a laceration (wound produced by tearing of soft body tissue) to the forehead that required sutures (stitch made to join the open parts of the wound) and had the potential for further psychological harm (harm that causes mental or emotional trauma). (Refer to A-0144) 9. The facility failed to provide proper supervision for two of 30 sampled patients (Patients 18 and 19), both of whom had a known history of aggression towards staff and other patients, to ensure that both patients (Patient 18 and Patient 19) did not physically attack Patient 17 twice, in accordance with the facility’s policy and procedure regarding supervision of patients. This deficient practice resulted in Patients 18 and 19 physically attacking Patient 17 twice within a 24-hour time frame. Patient 17 had to be transferred to a General Acute Care Hospital (GACH) Emergency Room (ER, responsible for the provision of medical care to patients arriving at the hospital in need of immediate treatment) for evaluation. Patient 17 suffered a laceration (wound produced by tearing of soft body tissue) to the forehead that required sutures (stitch made to join the open parts of the wound) after the first altercation and the laceration re-opened after the second altercation. (Refer to A-0145) 10. The facility failed to provide annual Abuse (any action or failure to act which causes unreasonable suffering, misery, or harm to the patient. Includes physical abuse, neglect, sexual abuse, emotional and financial abuse) Training for five of six staff (Charge Nurses [CN) 1, 2, and Mental Health Technicians [MHT] 1, 2, 4), in accordance with the facilities policies and procedures regarding abuse training. This deficient practice had the potential for staff not to be able to identify signs and symptoms of abuse or take appropriate actions in the event a patient is identified to be a victim of abuse, which may result in patient harm. (Refer to A-0145) 11. The facility failed to ensure that an age appropriate sleeping arrangement and therapeutic environment was provided for one of 30 sampled patients (Patient 21), in accordance with the facility’s policy and procedure regarding therapeutic environment when, Patient 21 was placed in a seclusion room (PRA - Private room Areas, a room used when a patient is being actively secluded/separated from other patients due to an aggressive behavior) at night to sleep. This deficient practice resulted in Patient 21 not having an age-appropriate room and furnishings which could negatively affect the patient’s emotional well-being and quality of care received. (Refer to A-0162) 12. The facility failed to ensure that one of 30 sampled patients (Patient 21), was assessed and monitored, in accordance with the facility’s policy and procedure regarding Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion (confinement of a patient alone in a room in which the patient is physically prevented from leaving), when Patient 21 was placed on chemical restraints (a drug given to a person to control their behavior or restrict their movement). Patient 21 was administered Benadryl (medication used with sedation effects [a state of calmness or sleepiness]) and Thorazine (medication used to manage mental illness or behavior disorders). This deficient practice had the potential to cause a delay in determining Patient 21’s change of condition and/or provision of emergent treatment needed as a result of chemical restraint, which can lead to worsening of patient’s condition and/or death. (Refer to A-0175) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe setting, potentially placing patients at risk for a delay in care and treatments, abuse, self-harm, harm to others, and/or death.”

“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: 48186 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 perform a reassessment (reevaluation of a patient’s health status) for one of 30 sampled patients (Patient 8) within one hour after PRN (as needed) medications Vistaril (a medication used to relieve itching caused by allergic skin reactions with sedative [cause drowsiness or sleepiness] effects) and Trazodone (a medication used to treat depression and anxiety) were administered to Patient 8. This deficient practice had the potential to cause irregular heart rhythms, when Vistaril and Trazodone were taken together, resulting in patient harm or death. (Refer to A-0395) 2. The facility failed to complete an admission assessment (a process where a nurse gathers, sorts, and analyzes a patient’s health information) for one of 30 sampled patients (Patient 8), in accordance with the facility’s policy and procedure regarding Assessment and reassessment. This deficient practice had the potential for delayed provision of medical care and treatment of identified concerns, resulting in patient harm and/or death. (Refer to A-0395) 3. The facility failed to ensure two of 30 sampled patients (Patients 25 and 28) vital signs (VS, includes blood pressure, heart rate, respiration [breathing], and temperature) were assessed and documented in accordance with the physician’s order and the facility’s policy and procedure regarding Vital Signs assessment and documentation. This deficient practice had the potential to cause a delay in determining Patients’ 25 and 28’s change of condition and/or a delay in the provision of emergent treatment needed which could worsen the patients’ condition and may result in death. (Refer to A-0395) 4. The facility failed to ensure that two of 30 sampled patients (Patients 29 and 30’s) Colombia Suicide Severity Rating Scale (CSSRS - suicidal risk assessment tool) assessment were completed daily in accordance with the facility’s policy and procedure regarding Nursing Assessment and Reassessment. This deficient practice had the potential for Patients’ 29 and 30’s assessment and reassessment to be inaccurate and may cause delay in the provision of medical care and treatment that could result in patient harm and or death. (Refer to A-0395) 5. The facility failed to ensure four of six sampled clinical staff (Registered Nurse [RN] 1, Mental Health Technicians [MHT] 1, MHT 4, and Charge Nurse (CN) 1), were evaluated to ensure the staff were competent in their respective positions, in accordance with the facility’s policy and procedure regarding staff competency (the application and demonstration of appropriate knowledge, skills and behavior in the clinical setting) and training. This deficient practice had the potential for staff’s inability to perform the essential functions of their respective positions, which may compromise patient safety when necessary patient care interventions are not performed appropriately. (Refer to A-0397) 6. The facility failed to ensure two of 30 sampled patients’ (Patients 29 and 30) nursing assessment (involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected) was completed in accordance with the facility’s guideline regarding Changes to Nursing Admit Assessment and Nursing Progress Notes when, Patient 29 and 30’s daily assessment, completed by the Licensed Psychiatric Technician (LPT), did not have a Registered Nurse (RN) co-signature to indicate the LPT’s assessment was verified by the RN. This deficient practice had the potential for Patients’ 29 and 30’s nursing assessment to be inaccurate and may cause delay in the provision of medical care and treatment that could 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 care in a safe environment, potentially putting patients at risk for harm.”

“MEDICAL STAFF - BYLAWS CFR(s): 482.12(a)(3) [The governing body must] assure that the medical staff has bylaws. This Standard is not met as evidenced by: 36206 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,” when Physician Orders were incomplete for one of 30 sampled patients (Patient 6) and telephone orders were not signed within 48 hours for one of 30 sampled patients (Patient 4). This deficient practice had the potential for any staff to fill out physician’s orders including unsigned physician’s orders, which may result in inaccurate orders carried out thus resulting in patient harm. Findings: 1. During an interview and record review on 7/10/2024 at 11:39 a.m. with the Chief Nursing Officer (CNO), the CNO verified that Patient 6’s “Physician’s Order,” dated 7/3/2024 and timed at 7:48 a.m., was signed by a physician. However, there were no orders documented. The CNO stated the physician should have entered orders in the electronic medical record, and orders on the chart (paper chart) should not be blank. The CNO verified that any staff could just fill out the orders that were signed by the physician. During a review of Patient 6’s “Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation,” dated 7/2/2024, the Evaluation indicated the following: Patient 6 was admitted to the facility on 7/2/2024 on a 5150 (an involuntary 72-hour hold for the treatment of a psychiatric condition) due to increasing thoughts of suicide (taking one’s own life) ... Patient 6 admitted he (Patient 6) has been hearing a lot of voices telling him to kill himself ... During a review of Patient 6’s “Physician Order,” the Physician order form indicated that the order was dated 7/3/2024 at 7:48 a.m. and signed by a physician. The Physician’s order form did not contain any orders. All areas that needed to be checked off and filled out by the physician were blank and unsigned. Areas indicated Patient 6’s level of precautions, supervision level, primary treatment focus, diet, PRN (as needed) medications, including medications such as Tylenol (over the counter pain reliever and fever reducer) and Benadryl (a sleep aid). During a review of the facility’s “Medical Staff Bylaws, Rules & Regulations,” undated, the Medical Staff Bylaws, Rules & Regulations indicated the following: All orders for treatment and/or medications shall be in writing ... All orders dictated over the telephone shall be signed by the nurse per the name of the practitioner. The responsible practitioner shall sign such orders with date and time at the next visit, within forty-eight (48) hours. Orders must be written clearly, legibly, and completely ... 2. During an interview and record review on 7/10/2024 at 12:25 p.m. with the Chief Nursing Officer (CNO), the CNO verified that Patient 4’s Telephone order dated 6/25/2024 was not signed, dated, or timed by the Physician (1). The CNO stated telephone orders should be signed within 48 hours. During a review of Patient 4’s “Initial Psychiatric Evaluation,” dated 6/25/2024, the Evaluation indicated the following: Patient 4 was admitted to the facility on 6/24/2024 on a 5585 (a minor who is put on an involuntary 72-hour hold [for psychiatric treatment and evaluation]) for a danger to self ... “As I (Physician 1) started talking to her (Patient 4) ... she (Patient 4) jumped up and started banging her head against the wall ...I (Physician 1) have ordered Thorazine (treats mental health conditions by regulating mood) ...to sedate (to put to sleep or calm down) her (Patient 4) ...” During a review of Patient 4’s telephone order titled, “Hospital Seclusion (confinement of a patient alone in a room in which the patient is physically prevented from leaving/Restraint (a device that limits a patient’s movement) Order,” dated 6/25/2024 at 11:20 a.m., the order included, “Thorazine (a medication used to treat certain mental/mood disorders) 100 milligrams (mg, a unit of measurement) IM (in the muscle) x 1 Now to improve function.” Charge Nurse (CN) 2 signed the telephone order. Physician 1 did not sign, date, or time the telephone order. This absence of a signature, date or time on the telephone order was verified by the CNO during an interview. During a review of the facility’s “Medical Staff Bylaws, Rules & Regulations,” undated, the Medical Staff Bylaws, Rules & Regulations indicated the following: All orders for treatment and/or medications shall be in writing ...All orders dictated over the telephone shall be signed by the nurse per the name of the practitioner. The responsible practitioner shall sign such orders with date and time at the next visit, within forty-eight (48) hours. Orders must be written clearly, legibly, and completely ...”

“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: 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 oversight on the Nursing Department to ensure that the standard of care on patient safety was implemented for one of 30 sampled patients (Patient 8), when Patient 8 was found unresponsive (not reacting or unable to react in a normal way when touched, spoken to, etc.), pulseless, not breathing, and when Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) was not initiated immediately and the automatic external defibrillator (AED, delivers an electric shock through the chest to the heart when it detects an abnormal rhythm) was not applied on Patient 8. This deficient practice resulted in a delay in life-saving measures, which may have contributed to Patient 8’s death. Findings: During a review of Patient 8’s “Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation,” dated 4/17/2024, the Psychiatric Evaluation indicated Patient 8 was admitted to the facility on an involuntary hold (a legal process in which someone is unwillingly hospitalized), on 4/17/2024, with a diagnosis of schizoaffective disorder (a mood disorder where someone may experience depression, mania [extreme euphoria-intense feeling of excitement/happiness or irritability]). During a review of Patient 8’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/18/2024, the H&P indicated Patient 8 had diagnosis of headaches, somatic complaints (an extreme focus on physical symptoms causing major emotional distress and problems functioning), obesity (weighing 100 pounds over the recommended weight), and tachycardia (increased heart rate). During a concurrent record review on 7/9/2024 at 1:10 p.m. with Nurse Manager 2 (NM 2), Patient 8’s “Progress Note,” dated 4/22/2024 at 1:10 p.m., was reviewed. The progress note indicated the following: Registered Nurse (RN) note ... at 8:37 a.m., “paramedics declared that time of death was 8:37 a.m...” During a concurrent interview and record review on 7/10/2024 at 1:32 p.m. with Mental Health Technician 2 (MHT 2), MHT 2 stated the following: On 4/22/2024, MHT 2 was assigned to perform patient observations (“rounding- best practice intervention of checking in on patients to meet patient care needs”) every 15 minutes to check for patient behavior, location, position, and breathing. During rounding, staff were required to enter the patient room and check for rise and fall of the chest. Following rounding at approximately 8:00 a.m., MHT 2 was asked by Mental Health Technician 1 (MHT 1) to check Patient 8 in his (Patient 8’s) room, because he (Patient 8) was not moving or responding. MHT 2 tapped Patient 8 (on the body) and there was no response. MHT 1 left Patient 8’s room to notify Charge Nurse 1 (CN 1) Patient 8 was unresponsive (not reacting or unable to react in a normal way when touched, spoken to, etc.), while MHT 2 stayed with Patient 8. CN 1 arrived to Patient 8’s room and attempted to obtain a set of vital signs (a measurement of blood pressure, temperature, pulse, respiratory rate, and oxygen saturation [measures the amount of oxygen circulating in the blood]). CN 1 observed Patient 8 was not breathing, called a code blue (hospital announcement means that someone is having a medical emergency, usually cardiac arrest [absent or abnormal heart activity] or respiratory arrest [absent breathing]) and Cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) was initiated. During a review of Patient 8’s “Patient Observation Record,” dated 4/22/2024 at 8:00 a.m., the patient Observation Record indicated Patient 8 was sleeping in his (Patient 8’s) room on his (Patient 8’s) back. MHT 2 confirmed his (MHT 2’s) initials and documentation on Patient 8’s 8:00 a.m. patient observation record. MHT 2 stated the following: During 7:45 a.m. and 8:00 a.m. rounding, MHT 2 did not go completely into Patient 8’s room to check Patient 8’s breathing, instead he (MHT 2) stood at the doorway. Patient 8 was breathing during 7:45 a.m. and 8:00 a.m. rounds. MHT 2 should have completely entered Patient 8’s room while rounding to ensure the safety of the patient. MHT 2 should have called a code blue, when Patient 8 was found unresponsive. Any staff could call a code blue for a patient that was not breathing. During an interview on 7/10/2024 at 2:40 p.m. with MHT 1, MHT 1 stated the following: On 4/22/2024 at approximately 7:30 a.m., MHT 1 was waking patients up for breakfast. At approximately 7:40 a.m., MHT 1 entered Patient 8’s room and knocked on the door and wall to wake Patient 8. Patient 8 did not respond and was not arousable (cannot be woken up). Patient 8 “did not look right, he (Patient 8) looked sickly.” MHT 1 did not check for breathing or a pulse. MHT 1 continued with waking other patients then returned to Patient 8’s room. MHT 1 knocked on the wall and touched Patient 8’s arm. Patient 8 remained unresponsive. MHT 1 attempted to simultaneously count respirations and obtain Patient 8’s blood pressure on the vital signs machine (a device that measures blood pressure, temperature, pulse, respiratory rate, and oxygen saturation), which was unreadable. MHT 1 was unsure if Patient 8 was breathing and MHT 1 notified MHT 2 to come to Patient 8’s room to verify if the patient was breathing. MHT 1 and MHT 2 were unsure if the patient was breathing, and MHT 1 went to get CN 1. CN 1 performed a sternal rub (rubbing the knuckles of a closed fist firmly and vigorously on the patient’s chest), and Patient 8 was unarousable. CN 1 verified the patient was pulseless and a code blue was called. MHT 1 started chest compressions (the act of applying pressure to someone’s chest to help blood flow through the heart in an emergency) and CPR. The AED (Automated Electrical Defibrillator, delivers an electric shock through the chest to the heart when it detects an abnormal rhythm) was not applied to Patient 8 during the code. It is the responsibility of the code blue lead to instruct someone to apply the AED. During the same interview on 7/10/2024 at 2:40 p.m. with MHT 1, MHT 1 further stated the following: If a patient is unresponsive, it is important to get the nurse immediately, so the nurse is aware something has changed with the patient. The nurse has more training and can assess the patient. Vital signs should not be obtained before notifying the nurse, when a patient is unresponsive. When Patient 8 was unresponsive, the nurse should have been notified right away so there was no delay in care. During a concurrent interview and record review on 7/11/2024 at 9:20 a.m. with Nurse Manager 1 (NM 1), NM 1 stated the following: All direct patient care staff are CPR certified. If a patient is unresponsive, anyone can check a pulse and start CPR. If unlicensed staff find a patient unresponsive, they should shout for help to get licensed staff- so not leave the patient. The licensed nurse should be notified immediately when a patient is unresponsive to avoid further decompensation (the inability of an organ such as the heart to maintain its function) or loss of life. If vital signs are obtained prior to notifying the nurse, there would be a delay in care. It is not best practice to use the vital signs machine during a code blue. The Charge Nurse is responsible and oversees the code blue. The AED should be applied if a patient is pulseless and not breathing. If the AED is unavailable, a carotid (major blood vessel that provides the brain’s blood supply) or radial pulse (pulse between the wrist bone and the thumb side of the wrist). should be checked after every 5 rounds of CPR. It is important to apply the AED because it will give prompts (instructions) and measure whether the patient requires a shock. “Patient condition at departure or end of code: deceased.” During a review of Patient 8’s “Code Blue/Medical Emergency Documentation,” dated 4/22/2024, the documentation indicated the following: Patient 8 was “found not breathing, pulseless, not responding.” A code blue was called at 8:04 a.m. The AED was not applied. During an interview on 7/11/2024 at 10:02 a.m. with Charge Nurse 1 (CN 1), CN 1 stated the following: On 4/22/2024, at 8:03 a.m., CN 1 was notified by MHT 1 that Patient 8 was not breathing. CN 1 and MHT 1 entered Patient 8’s room. MHT 1 told CN 1 that vital signs were attempted and unable to be obtained, prior to notifying CN 1. MHT 1 told CN 1 that he (MHT 1) also called MHT 2 into Patient 8’s room, prior to notifying CN 1. CN 1 attempted painful stimuli by performing a sternal rub and pressing the nail bed, Patient 8 was unresponsive. CN 1 did not immediately check a pulse. CN 1 attempted to obtain a blood pressure and was unable to obtain a reading. MHT 1 performed a pulse check and Patient 8 was pulseless. CN 1 stated to call a Code Blue and MHT 1 started compressions. CN 1 left Patient 8’s room to call the code blue and obtain emergency equipment including the AED. CN 1 did not instruct MHT 1 or MHT 2 to call the code blue. When CN 1 returned to Patient 8’s room with the emergency equipment, the code blue team (emergency response team, rendering lifesaving measures) arrived and CPR was in progress. The AED was not applied to patient 8. During the code, the vital signs machine was used to measure blood pressure and heart rate. A physical carotid pulse was not obtained during the code. The paramedics arrived and took over the code blue. After 30 minutes of CPR, the patient died. During an interview on 7/12/2024 at 4:30 p.m. with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Risk Management and Performance Improvement (DRPI), and Director of Clinical Services Regional Compliance (DRC), the CEO stated the following: The Governing Board provides broad oversight and is responsible for the entire facility. Oversight includes staff competency (the application and demonstration of appropriate knowledge, skills and behavior in the clinical setting). The Governing Board was aware of Patient 8’s death, but an action plan with corrective actions was not presented to the Governing Board. It was the responsibility of the Governing Board to take immediate action once an adverse (a harmful and negative outcome that happens when a patient has been provided with medical care)/sentinel event (a patient safety event that results in death, permanent harm, or severe temporary harm) was identified. The DRPI stated there was a gap because the Governing Board was not given an action plan for Patient 8’s death. During a review of the facility’s policy and procedure (P&P) titled, “Code Blue and Transferring Patients to the Emergency Room,” revised 3/2022, the policy indicated: “Policy: [the facility] provides for the medical needs of all patients requiring emergency medical evaluation or treatment ... Procedure: 1. The staff member who finds/witnesses the medical emergency will immediately call for help and to have a Code Blue paged overhead ... The staff member will not leave the patient alone ... 2. The staff from the unit housing the patient will bring the ...AED ... 3. The staff will assess the patient’s condition and provide immediate intervention based on the patient’s presentation and symptoms ... d) If the patient is not breathing and has no pulse, initiate cardiopulmonary resuscitation (CPR) ... During a review of the facility’s policy and procedure (P&P) titled, “Medical Emergencies and Acute Change in Condition,” revised 3/2022, the policy indicated: “Purpose: It is our policy to provide safe and competent care to all patients experiencing medical emergencies or an acute change in condition ... 2. Breathing Problems ... b) If the following symptoms are demonstrated, it could indicate a significant medical problem and the RN should be notified immediately ... d. If the rate of breathing is too rapid or too slow, if breath sounds are diminished (lessened)/absent ... c) If the patient is found in cardiac/respiratory arrest (heart stops/not breathing), 911 and Code Blue will be called immediately ... During a review of the facility’s policy and procedure (P&P) titled, “Supervision of Patients/Patient Rounds,” revised 7/2021, the policy indicated: “Purpose: To establish a process for supervising patients as a means to diminish the risk of harm and/or injury ... Conducting General Supervision via Rounds Process ... 8. Observe patients in bed resting or sleeping by: Looking for the rise and fall of the chest ... 12. Identify and report any findings while conducting observation rounds: Report any findings to the Charge Nurse ...””

“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: 48186 Based on interview and record review, the facility failed to ensure that two of 30 sampled patients (Patients 21 and 30) and their (Patient 21 and 30) designated representatives were informed of the patients’ (Patient 21 and 30) condition, in accordance with the facility’s policy and procedure regarding the appropriate use of involuntary commitment (the legal process in which a person is confined in a psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] hospital because of a treatable mental disorder, against his or her wishes) when: 1. Patient 21’s designated representative was not informed of the patient’s (Patient 21) condition when Patient 21 was put on a psychiatric 14-day hold (a certification also known as 5250 hold, for intense treatment for a period of involuntary hospitalization for up to 14 days due to mental disorder) on 7/1/2024. 2. Patient 30 and the patient’s (Patient 30) designated representative was not informed of the patient’s (Patient 30) condition when Patient 30 was put on a 5250 hold on 4/27/24. These deficient practices resulted in the patients (Patient 21 and 30) and the patients’ designated representative not able to exercise the right to make informed decisions (a decision that patients or their designated representatives can make once they have all the information related to the decision topic) regarding the patients’ care. Findings: 1. During a review of Patient 21’s “Face Sheet (a document containing a patient’s medical and demographic information),” undated, the face sheet indicated Patient 21 was admitted to the facility on 6/28/2024. During a review of Patient 21’s “72 hour hold (5585, a law that allows for the involuntary detention of someone with a mental illness in a psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] hospital for up to 72 hours),” dated 6/28/2024, the hold indicated Patient 21 was a danger to himself and others. Patient 21 was agitated, violent and trying to jump out of a moving car. Patient 21 had an open case with Department of Children and Family Services (DCFS - agency that oversees Los Angeles County’s 24/7 child abuse and neglect hotline and responds to the immediate needs of any child at risk). During a review of Patient 21’s “5250 hold (5250-hold, allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric evaluation and treatment),” dated 7/1/2024, the 5250 hold form indicated Patient 21 continued to be a danger to self and others, “aggressive, assaulted peers.” During a concurrent interview and record review on 7/10/2024 at 2:37 p.m., with Nurse Administrator Program Specialist (NAPS), the NAPS stated after 5585, if the psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) determines the patient was not stable and needed to extend the treatment plan, then 5250 would be initiated. The NAPS stated the psychiatrist or the nurse must inform the patient and the patient’s designated representative regarding the 5250 hold. In the same interview on 7/10/2024 at 2:37 p.m., the NAPS stated Patient 21’s record did not have documentation of Patient 21 and/or Patient 21’s designated representative being notified of the 5250 hold. During a review of the facility’s policy and procedure (P&P) titled, “Appropriate Use of Involuntary Commitment (the legal process in which a person is confined in a psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] hospital because of a treatable mental disorder, against his or her wishes),” revised in 3/2022, the P&P indicated, “The attending psychiatrist must then read and present a copy of the Notice of Certification for Additional 14 Day to the patient on the date it is issued. The physician must inform the patient that he/she may designate any person whom he/she wishes to be informed of this certification. The Social Worker must: Inform patient of his legal right to judicial review by Writ of Habeas Corpus (orders the custodian of an individual in custody to produce the individual before the court to make an inquiry concerning his/her detention) with representation by counsel at any time during this 14-day period and explain that no hearing will be held unless requested by the patient...” 2. During a review of Patient 30’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), the H&P indicated Patient 30, who was under the care of DCFS (Department of Children and Family Services, agency that oversees Los Angeles County’s 24/7 child abuse and neglect hotline and responds to the immediate needs of any child at risk), was admitted on 4/23/2024 for 5585 hold (involuntary 72 hour hold for minors) due to Suicidal Ideation (SI, thoughts of causing one’s own death) with a plan to overdose (taking too much of a substance such as medications). The H&P further indicated, Patient 30’s medical history included major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities) and substance abuse (a state of psychological and/or physical dependence on the use of drugs or other substances such as alcohol). During a review of Patient 30’s medical record, the record indicated the following: - On 4/25/2024, Patient 30 was on a 5585 hold; - On 4/26/2024, Patent 30’s admission status was changed to voluntary admission; and, - On 4/27/2024, Patient 30 was put on 5250 hold (for intense treatment for a period of involuntary hospitalization for up to 14 days due to mental disorder). During a concurrent interview and record review on 7/10/2024 at 3:01 p.m., with the Nurse Administrator Program Specialist (NAPS), the NAPS stated it is the physician’s decision to put the patient on 5250 hold. The NAPS stated the patient and the patient’s designated representative must be notified of the hold to comply with the patient’s rights (a subset of human rights such as the right to be informed of the treatment plan). The NAPS verified there was no documentation the DCSF, Patient 30’s designated representative, was notified when Patient 30 was put on 5250 hold. During a concurrent interview and record review on 7/10/2024 at 3:45 p.m., with NM 2, NM 2 stated there was no 5250 advisement (written notification of an involuntary hold) provided to Patient 30 or Patient 30’s designated representatives. During a review of the facility’s policy and procedure (P&P) titled, “Appropriate Use of Involuntary Commitment (the legal process in which a person is confined in a psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] hospital because of a treatable mental disorder, against his or her wishes),” revised in 3/2022, the P&P indicated, “The attending psychiatrist must then read and present a copy of the Notice of Certification for Additional 14 Day to the patient on the date it is issued. The physician must inform the patient that he/she may designate any person whom he/she wishes to be informed of this certification. The Social Worker must: Inform patient of his legal right to judicial review by Writ of Habeas Corpus (orders the custodian of an individual in custody to produce the individual before the court to make an inquiry concerning his/her detention) with representation by counsel at any time during this 14-day period and explain that no hearing will be held unless requested by the patient ...””

“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: 50515 Based on observation, interview and record review, the facility failed to: 1. Initiate Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) immediately and apply the automatic external defibrillator (AED, delivers an electric shock through the chest to the heart when it detects an abnormal rhythm) for one of 30 sampled patients (Patent 8), when Patient 8 was found unresponsive (not reacting or unable to react in a normal when touched, spoken to, etc.), pulseless, and not breathing, in accordance with the facility’s policy and procedure regarding Code Blue (hospital announcement means that someone is having a medical emergency, usually cardiac arrest [absent or abnormal heart activity] or respiratory arrest [absent breathing]) and Change of Condition. This deficient practice resulted in a delay in life-saving measures, which may have contributed to Patient 8’s death. 2. Ensure the safety for one of 30 sampled patients (Patient 12), identified at risk for self-harm (hurting oneself), when Patient 12 took six (6) unspecified pills and cut wrist with a hairbrush while admitted in the facility, in accordance with the facility’s policy and procedure regarding Medication Administration. This deficient practice resulted Patient 12 being transferred to another hospital for treatment, after the patient (Patient 12) self-harmed. 3. Check for the presence of one of six emergency equipment (emergency bag that contains medications, etc.) daily on one of six units (Del Sol [Adult Inpatient]), in accordance with the facility’s protocol regarding Emergency Medical Equipment Daily Checklist and the facility’s policy and procedure regarding medical emergencies. This deficient practice had the potential for emergency equipment not to be readily available in the event of a medical emergency and compromise patient safety. 4. Conduct patient rounding (best practice intervention of checking in on patients to meet patient care needs) every 15 minutes for one of 30 sampled patients (Patient 6) in accordance with the facility’s policy and procedure regarding supervision of patients. This deficient practice had the potential for the whereabouts of patients to be unknown and had the potential for harm, injury, medical emergency, or elopement (a patient who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected). 5. Ensure one of 30 sampled patients (Patient 21, a child [the facility considered patients in the age group of 5 years old to 12 years old as child]) was not left alone with Patient 2, an adolescent patient (the facility considered patients in the age group of 13 years old to 17 years old as adolescent) inside the Youth Services Unit’s Day room (activity room) with no staff supervision, in accordance with the facility’s policy and procedure regarding supervision of patients. This deficient practice had the potential for the patients, who were admitted with behavioral issues, to inflict self-harm or harm to others. 6. Ensure there was continuous observation and direct line of vision (a level of observation in which the patient remains in staff view) for two of 30 sampled patients (Patient 27 and 28) in a group setting in accordance with the facility’s policy and procedure regarding “Supervision of Patients/Patient Rounds.” This deficient practice had the potential for the patients, who were admitted with behavioral issues, to inflict self-harm or harm to others. 7. Ensure patient safety, in accordance with the facility’s policy and procedure regarding patient precautions, for one of 30 sampled patients (Patient 17) when Patient 17 was involved in two physical altercations with Patients 18 and 19 within a 24-hour period. This deficient practice resulted in Patient 17 suffering a laceration (wound produced by tearing of soft body tissue) to the forehead that required sutures (stitch made to join the open parts of the wound) and had the potential for further psychological harm (harm that causes mental or emotional trauma). On 7/11/2024 at 4:07 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 Divisional Clinical Services-Regulatory Compliance (DRC) , Director of Risk Management and Performance Improvement (DRPI), and Regional Vice President (RVP). Patient 8’s medical history included schizoaffective disorder (a mood disorder where someone may experience depression [a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities], mania [extreme euphoria- intense feeling of excitement/happiness or irritability], and hallucinations [sensing things such as visions, sounds or smells that seem real but are not] or delusions [a fixed false belief based on an inaccurate interpretation of an external reality despite evidence to the contrary]), headaches, obesity (weighing 100 pounds over the recommended weight) and dyspepsia (upset stomach). On 4/22/2024, Patient 8 was administered the medications Vistaril (a medication used to relieve itching caused by allergic skin reactions with sedative effects [can cause sleepiness, calms a person down, etc.]) 50mg (milligram, a unit of measurement) by mouth at 12:43 a.m. for anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure), and Trazodone (a medication used to treat depression and anxiety) 50mg (milligram, a unit of measurement) by mouth at 12:50 a.m. for insomnia (inability to sleep). Following administration of medications (Vistaril and Trazodone), there was no reassessment (re-evaluation of a patient’s health status) of vital signs (includes temperature, heart rate, respiratory rate, blood pressure and pain level) and physical condition for Patient 8, per policy and procedure. On 4/22/2024 at 7:40 a.m., Patient 8 was unarousable (cannot be woken up) when Mental Health Technician 1 (MHT 1, provides care for people who have mental health conditions) tried to wake Patient 8 for breakfast by knocking on the bedroom door and wall. MHT 1 did not attempt to touch Patient 8 or check for breathing at this time. MHT 1 left Patient 8’s bedroom and continued to wake other patients for breakfast, and once completed, went back to Patient 8’s room for a second attempt to try to wake Patient 8 by knocking on the wall and touching Patient 8’s arm. Patient 8 remained unarousable. MHT 1 left Patient 8’s room to gather the vital signs machine (a device that measures blood pressure, temperature, pulse, respiratory rate, and oxygen saturations), and when MHT 1 returned to patient 8’s room, attempted to obtain a blood pressure for Patient 8. The vital signs machine read an error message. MHT 1 then called a second MHT (MHT 2) passing by in the hallway into the bedroom, to verify if Patient 8 was breathing. Mental Health Technician 2 (MHT 2) verified Patient 8 did not appear to be breathing. MHT 1 left Patient 8’s bedroom to find Charge Nurse 1 (CN 1). MHT 2 remained at the bedside with Patient 8. Cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) was not initiated at this time. At 8:03 a.m., CN 1 was notified by MHT 1 that Patient 8 was unresponsive and not breathing. CN 1 entered Patient 8’s bedroom and performed painful stimuli by performing a sternal rub (rubbing the knuckles of a closed fist firmly and vigorously on the patient’s chest) and applying pressure to the nailbeds. Patient 8 was unresponsive to painful stimuli (a technique used to determine the consciousness level of a person who is not responding to normal interaction, voice commands or gentle physical stimuli). CN 1 attempted to obtain Patient 8’s blood pressure and was unable to obtain a reading on the vital signs machine. MHT 1 performed a pulse check and Patient 8 was pulseless. CN 1 started to call a code blue (hospital announcement means that someone is having a medical emergency, usually cardiac arrest [absent or abnormal heart activity] or respiratory arrest [absent breathing]) and MHT 1 started chest compressions (the act of applying pressure to someone’s chest to help blood flow through the heart in an emergency). CN 1 left Patient 8’s bedroom to call the code blue and obtain emergency equipment (life-saving equipment) to include the automatic external defibrillator (AED, delivers an electric shock through the chest to the heart when it detects an abnormal rhythm), instead of instructing MHT 1 or MHT 2 to call a code blue and obtain the emergency equipment. When CN 1 returned to Patient 8’s room, the code blue team arrived. CPR was in progress. The AED brought by CN 1 was never applied to Patient 8, and a pulse check was not reassessed during the code. During the code blue, the vital signs machine was used to measure blood pressure and heart rate. The paramedics arrived and took over the code blue and CPR. After 30 minutes of CPR, Patient 8 expired. On 7/12/2024 at 7:41 p.m., the IJ was removed in the presence of the Chief Executive Officer (CEO), DRC, DRPI, and RVP, 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: 1. Immediate training of licensed staff, Registered Nurses (RN), Licensed Vocational Nurses (LVN), and Licensed Psychiatric Technicians (LPT), related to the reassessment of patients after PRN (as needed) medication administration to include physical condition, effectiveness, and vital signs within one hour. This will be documented in the electronic health record by the licensed nurse. 2. Immediate training of nursing staff including RNs, LVNs, LPTs, and MHTs, related to medical emergencies and acute changes in condition (a sudden, clinically important deviation from a patient’s baseline in physical, cognitive [thinking and understanding], behavioral, or functional [activity or tasks] abilities) including responsiveness to code blue. Direct patient care staff will be current in CPR. When a patient is found unresponsive, staff will immediately initiate CPR, yell for the nurse, call a code blue and immediately initiate CPR. The Nurse Manager and/or Nurse Supervisor will instruct code blue drills (hands-on-training) one per month per shift (3 shifts) with direct patient care staff. The Nurse Manager and/or Nurse Supervisor will evaluate code blue drills and identify training needs. Training needs are immediately addressed with staff. When a patient is unresponsive, the licensed nurse will remain with the patient and delegate the MHT to call code blue and get the emergency equipment. Patient observations are every 15 minutes, minimally. During patient observations, the staff will observe patients in bed for at least three respirations and whether the patient has moved from previous sleeping position. 3. Immediate training of nursing staff of AED use. AED training will include indications for use, checking for patient responsiveness, ensuring the AED is turned on, proper application of defibrillator pads, following AED prompts, and what to do if a shock (an electric current used to restart the heart) is advised. Staff will use the AED when the patient has a lack of circulation indicated by unconsciousness, absence of normal breathing, and absence of pulse. The nurse will turn the AED on and follow AED prompts (directions) based on what the nurse sees and hears. The patient will be checked for responsiveness, by shaking the patient and shouting “are you ok?,” and electrode pads (adhere to the chest of an individual who needs defibrillation [an electric current used to restart the heart]) will be applied to the patient’s bare chest. While the AED is analyzing, do not touch the patient. The nurse will follow the directions if shock is advised. If shock is advised, the nurse will advise staff to stand clear and not to touch the patient. The shock will be delivered by pressing the “heart” button. Once the shock is delivered, follow prompts to resume CPR. The nurse will continue to follow AED prompts; CPR for 5 cycles, stop CPR, analyzing, advisement of shock followed by CPR. Additionally, licensed staff will be trained when to reassess a patient’s pulse during a code blue, using the carotid (major blood vessel that provides the brain’s blood supply) or radial pulse (pulse between the wrist bone and the thumb side of the wrist). Findings: 1. During a review of Patient 8’s “Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation,” dated 4/17/2024, the Psychiatric Evaluation indicated Patient 8 was admitted to the facility on a 5150 (an involuntary 72-hour hold for the treatment of a psychiatric [relating to mental illness or treatment] condition), on 4/17/2024, with a diagnosis of schizoaffective disorder (a mood disorder where someone may experience depression [a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities], mania [extreme euphoria- intense feeling of excitement/happiness or irritability], and hallucinations [sensing things such as visions, sounds or smells that seem real but are not] or delusions [a fixed false belief based on an inaccurate interpretation of an external reality despite evidence to the contrary). During a review of Patient 8’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/18/2024, the H&P indicated Patient 8 had diagnosis of headaches, somatic complaints (an extreme focus on physical symptoms causing major emotional distress and problems functioning), obesity (weighing 100 pounds over the recommended weight) and tachycardia (increased heart rate). During a concurrent record review on 7/9/2024 at 1:10 p.m. with Nurse Manager 2 (NM 2), Patient 8’s “Progress Note,” dated 4/22/2024 at 1:10 p.m., was reviewed. The progress note indicated the following: Registered Nurse (RN) note ... at 8:37 a.m., paramedics declared that time of death was 8:37 a.m...” on 4/22/2024. During a concurrent interview and record review on 7/10/2024 at 1:32 p.m. with Mental Health Technician 2 (MHT 2), MHT 2 stated the following: On 4/22/2024, MHT 2 was assigned to perform patient observations (“rounding [best practice intervention of checking in on patients to meet patient care needs]”) every 15 minutes to check for patient behavior, location, position, and breathing. During rounding, staff were required to enter the patient room and check for rise and fall of the chest which MHT 2 did not do. Following rounding at approximately 8:00 a.m., MHT 2 was asked by Mental Health Technician 1 (MHT 1) to check Patient 8 in his (Patient 8’s) room, because he (Patient 8) was not moving or responding. MHT 2 tapped Patient 8 (on the body) and there was no response. MHT 1 left Patient 8’s room to notify Charge Nurse 1 (CN 1) that Patient 8 was unresponsive, while MHT 2 stayed with Patient 8. CN 1 arrived to Patient 8’s room and attempted to obtain a set of vital signs (a measurement of blood pressure, temperature, pulse, respiratory rate, and oxygen saturation). CN 1 observed Patient 8 was not breathing, called a code blue (hospital announcement means that someone is having a medical emergency, usually cardiac arrest [absent or abnormal heart activity] or respiratory arrest [absent breathing]) and Cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) was initiated. During a review of Patient 8’s “Patient Observation Record,” dated 4/22/2024 at 8:00 a.m., the Patient Observation Record indicated Patient 8 was sleeping in his (Patient 8’s) room on his (Patient 8’s) back. MHT 2 stated the following: MHT 2 did not go completely into Patient 8’s room to check Patient 8’s breathing, instead he (MHT 2) stood at the doorway. MHT 2 said he (MHT 2) should have completely entered Patient 8’s room and he (MHT 2) had no reason not to completely enter the room. MHT 2 should have called a code blue, when Patient 8 was found unresponsive. Any staff could call a code blue for a patient that was not breathing. During an interview on 7/10/2024 at 2:40 p.m. with MHT 1, MHT 1 stated the following: On 4/22/2024 at approximately 7:30 a.m., MHT 1 was waking patients up for breakfast. At approximately 7:40 a.m., MHT 1 entered Patient 8’s room and knocked on the door and wall to wake Patient 8. Patient 8 did not respond and was not arousable (unable to wake up). Patient 8 “did not look right, he (Patient 8) looked sickly.” MHT 1 did not check for breathing or a pulse. MHT 1 continued with waking other patients then returned to Patient 8’s room. MHT 1 knocked on the wall and touched Patient 8’s arm. Patient 8 remained unresponsive. MHT 1 attempted to simultaneously count respirations and obtain Patient 8’s blood pressure on the vital signs machine (a device that measures blood pressure, temperature, pulse, respiratory rate, and oxygen saturation), which was unreadable. MHT 1 was unsure if Patient 8 was breathing and MHT 1 notified MHT 2 to come to Patient 8’s room to verify if the patient was breathing. MHT 1 and MHT 2 were unsure if the patient was breathing, and MHT 1 went to get CN 1. CN 1 performed a sternal rub (rubbing the knuckles of a closed fist firmly and vigorously on the patient’s chest), and Patient 8 was unarousable. CN 1 verified the patient (Patient 8) was pulseless and a code blue was called. MHT 1 started chest compressions (the act of applying pressure to someone’s chest to help blood flow through the heart in an emergency) and CPR (Cardiopulmonary Resuscitation, an emergency lifesaving procedure performed when the heart stops beating). The AED (Automated External Defibrillator, delivers an electric shock through the chest to the heart when it detects an abnormal rhythm) was not applied to Patient 8 during the code. It was the responsibility of the code blue lead to instruct someone to apply the AED. During the same interview on 7/10/2024 at 2:40 p.m. with MHT 1, MHT 1 further stated the following: If a patient was unresponsive, it was important to get the nurse immediately, so the nurse was aware something had changed with the patient. The nurse had more training and can assess the patient. Vital signs should not be obtained before notifying the nurse, when a patient was unresponsive. When Patient 8 was unresponsive, the nurse should have been notified so there was no delay in care. During a concurrent interview and record review on 7/11/2024 at 9:20 a.m. with Nurse Manager 1 (NM 1), NM 1 stated the following: All direct patient care staff are CPR certified. If a patient is unresponsive, anyone can check a pulse and start CPR. If unlicensed staff find a patient unresponsive, they should shout for help to get licensed staff- so as not to leave the patient. The licensed nurse should be notified immediately when a patient is unresponsive to avoid further decompensation (worsening of symptoms) or loss of life. If vital signs are obtained prior to notifying the nurse, there would be a delay in care. It is not best practice to use the vital signs machine during a code blue. The Charge Nurse is responsible and oversees the code blue. The AED should be applied if a patient is pulseless and not breathing. If the AED is unavailable, a carotid or radial pulse should be checked after every 5 rounds of CPR. It is important to apply the AED because it will give prompts (instructions) and measure whether the patient requires a shock (to deliver a dose of electric current to the heart). During a review of Patient 8’s “Code Blue/Medical Emergency Documentation,” dated 4/22/2024, the document indicated the following: Patient 8 was “found not breathing, pulseless, not responding.” A code blue was called at 8:04 a.m., 14 minutes after MHT 1 initially observed Patient 8 unresponsive. The AED was not applied. “Patient condition at departure or end of code: deceased.” During an interview on 7/11/2024 at 10:02 a.m. with Charge Nurse 1 (CN 1), CN 1 stated the following: On 4/22/2024, at 8:03 a.m. CN 1 was notified by MHT 1 that Patient 8 was not breathing. CN 1 and MHT 1 entered Patient 8’s room. MHT 1 told CN 1 that vital signs were attempted and unable to be obtained, prior to notifying CN 1. MHT 1 told CN 1 that he (MHT 1) also called MHT 2 into Patient 8’s room, prior to notifying CN 1. CN 1 attempted painful stimuli by performing a sternal rub and pressing the nail bed, Patient 8 was unresponsive. CN 1 did not immediately check a pulse. CN 1 attempted to obtain a blood pressure and was unable to obtain a reading. MHT 1 performed a pulse check and Patient 8 was pulseless. CN 1 stated to call a Code Blue and MHT 1 started compressions. CN 1 left Patient 8’s room to call the code blue and obtain emergency equipment including the AED. CN 1 did not instruct MHT 1 or MHT 2 to call the code blue. When CN 1 returned to Patient 8’s room with the emergency equipment, the code blue team (emergency response team, rendering lifesaving measures) arrived and CPR was in progress. The AED was not applied to patient 8. During the code, the vital signs machine was used to measure blood pressure and heart rate. A physical carotid (arteries located on either side of the neck) pulse was not obtained during the code. The paramedics arrived and took over the code blue. After 30 minutes of CPR, the patient died. During a review of the facility’s policy and procedure (P&P) titled “Code Blue and Transferring Patients to the Emergency Room,” revised 3/2022, the P&P indicated: “Policy: [the facility] provides for the medical needs of all patients requiring emergency medical evaluation or treatment ... Procedure: 1. The staff member who finds/witnesses the medical emergency will immediately call for help and to have a Code Blue paged overhead ... The staff member will not leave the patient alone ... 2. The staff from the unit housing the patient will bring the ...AED ... 3. The staff will assess the patient’s condition and provide immediate intervention based on the patient’s presentation and symptoms ... d) If the patient is not breathing and has no pulse, initiate cardiopulmonary resuscitation (CPR) ...” During a review of the facility’s policy and procedure (P&P) titled, “Medical Emergencies and Acute (severe and sudden in onset) Change in Condition,” revised 3/2022, the policy indicated: “Purpose: It is our policy to provide safe and competent care to all patients experiencing medical emergencies or an acute change in condition ... 2. Breathing Problems ... b) If the following symptoms are demonstrated, it could indicate a significant medical problem and the RN should be notified immediately ... d. If the rate of breathing is too rapid or too slow, if breath sounds are diminished (lessened)/absent ... c) If the patient is found in cardiac/respiratory arrest (heart stops/not breathing), 911 and Code Blue will be called immediately ...” During a review of the facility’s policy and procedure (P&P) titled, “Supervision of Patients/Patient Rounds,” revised 7/2021, the P&P indicated: “Purpose: To establish a process for supervising patients as a means to diminish the risk of harm and/or injury ... Conducting General Supervision via Rounds Process (best practice intervention of checking in on patients to meet patient care needs) ... 8. Observe patients in bed resting or sleeping by: Looking for the rise and fall of the chest ... 12. Identify and report any findings while conducting observation rounds: Report any findings to the Charge Nurse ...” 2. During a review of Patient 12’s “Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation,” dated 5/29/2024, the Psychiatric Evaluation indicated Patient 12 was admitted to the facility on a voluntary hold (a process in which someone is willingly hospitalized), on 5/29/2024, with diagnoses of attention deficit hyperactivity disorder (ADHD, a condition that causes inattention and hyperactivity), suicide (the act of taking one’s own life) attempts and self-harm (injury to oneself) by cutting self. During a concurrent interview and record review on 7/11/2024 at 4:46 p.m. the with Nurse Manager 2 (NM 2), Patient 12’s medical record was reviewed. The NM 2 verified that on 6/3/2024, Patient 12 cut her (Patient 12’s) own wrist with a broken brush and took six (6) pills of unknown type and origin inside the patient’s (Patient 12) room. The NM 2 further verified that Patient 12’s contraband (prohibited items) check was completed on admission, and the patient was not identified to have contraband. The NM 2 stated the following: Contraband included medications. Patient 12 should not have been in the possession of pills. Per policy, Patient 12 should have received all medications witnessed by licensed staff, followed by a mouth check, to ensure the medications were swallowed. Mouth checks should have been performed for Patient 12, per policy, to prevent cheeking (storage of pills in the cheek of the mouth) of medications. Since it was unknown what pills were taken, Patient 12 could have had a reaction to the pills or an overdose (an excessive and dangerous dose of a medication/drug). Since the hairbrush was provided by the facility, Patient 12 should have had personal care items, such as a hairbrush, used only in the direct observation of facility staff. Once the hairbrush was no longer in use by Patient 12, the item should have been locked away with Patient 12’s personal items in a locked storage room. Patient 12 should not have been left alone with the hairbrush because it could have been used to further self-harm or harm others. During a review of Patient 12’s “Multidisciplinary Treatment Plan (a unified group approach in a healthcare setting where the responsibility of plans of treatment and delivery of care does not lie on a single person but a group of qualified professionals),” dated 5/30/2024, the Multidisciplinary Treatment Plan indicated a treatment plan for “self-injurious (hurting oneself) behavior.” The treatment plan further indicated the following information: “Long term goals/discharge (leaving the hospital) criteria: Patient will demonstrate no dangerous/self-harm behavior for 2 days prior to discharge- target date 6/4/2024 ...” During a review of Patient 12’s “Suicide/Self Injury Risk Assessment,” dated 6/1/2024, the assessment indicated the “suicide/self-injury risk assessment” had indicators for suicide or self-harm. During a review of Patient 12’s progress notes, dated 6/3/2024 at 8:30 p.m., the progress notes indicated the following: “At approximately 4:00 p.m., patient (Patient 12) was witnessed by staff ingesting [taking] six unknown pills. Patient (Patient 12) also had broken brush by her bed that she (Patient 12) verbalized going to use (broken brush) for self-harm ...ordered to send her to the [hospital] Emergency Room (ER, the department of a hospital that provides immediate treatment for acute illnesses and trauma) for further evaluation ... transfer[ed] to ER for evaluation ... Left arm laceration (cut) caused by broken brush ...” During a review of Patient 12’s “Nursing Orders,” dated 6/3/2024 at 5:00 p.m., the Nursing Orders indicated a Nurse Practitioner’s order to “transfer to the emergency department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma).” During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” revised 7/2019, the policy indicated: “Policy: Medications shall be prepared and administered in a safe and timely manner by a licensed nursing staff ... 14. After giving the patient oral (by mouth) medications, observe him/her until he/she has swallowed it. Ask the patient to open his/her mouth to verify proper consumption and prevent cheeking of medications ...” During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” revised 3/2022, the P&P indicated: “Policy: Certain items are unsafe on the units and are considered contraband ... Procedure: Upon admission, a patient search is conducted by nursing to assess for contraband and itemize personal property ... The following items are considered CONTRABAND and are NOT allowed on the Units ... All medications ...” 3. During an observation on 7/8/2024 at 3:16 p.m. in Del Sol (Adult Inpatient unit), with Nurse Manager (NM) 2, an Emergency Bag (contains emergency medical equipment), a backboard (placed on a person’s back while person is receiving chest compressions [the act of applying pressure to someone’s chest to help blood flow through the heart in an emergency], to increase the quality of chest compressions, when a person’s heart stops), and automatic external defibrillator (AED, a machine that analyzes a person’s heart rhythm and delivers an electric shock if indicated) were observed. Concurrently, during an interview and review of a Checklist titled, “Emergency Medical Equipment Daily Checklist,” on 7/8/2024 at 3:16 p.m., NM 2 verified that there was no evidence that emergency equipment was checked on 6/20/2024, 6/21/2024, 6/30/2024, and 7/7/2024. NM 2 stated nursing staff should check emergency equipment daily and document the date on the Checklist daily to ensure emergency equipment is available during a medical emergency. During a review of a Checklist in Del Sol Unit titled, “Emergency Medical Equipment Daily Checklist,” dated 6/2024, the Checklist indicated missing documentation of emergency equipment being checked on 6/20/2024, 6/21/2024, and 6/30/2024. During a review of a Checklist in Del Sol Unit titled, “Emergency Medical Equipment Daily Checklist,” dated 7/2024, the Checklist indicated missing documentation of emergency equipment being checked on 7/07/2024. During a review of the facility’s policy and procedure (P&P) titled, “Medical Emergencies and Acute Change in Condition,” dated 2/2017, the P&P indicated, “It is our policy to provide safe and competent care to all patients experiencing medical emergencies or acute change in condition (a sudden, clinically important deviation from a patient’s baseline in physical, cognitive [thinking and understanding], behavioral, or functional [activity or tasks] abilities).” 4. During a concurrent interview and record review, on 7/10/2024 at 11:39 a.m., with the Chief Nursing Officer (CNO), the CNO verified that Patient 6’s “Patient Observation Record & Milieu Group,” dated 7/3/2024, was missing documentation for observing (rounding) Patient 6 every 15 minutes, between 1 p.m., and 3:29 p.m. The CNO stated rounding should be conducted every 15 minutes for the safety of the patients. During an interview, on 7/10/2024 at 3:22 p.m. with Registered Nurse (RN) 1, RN 1 stated patient rounds should be conducted every 15 minutes to verify the location and behaviors of patients. During a review of Patient 6’s “Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation,” dated 7/2/2024, the Evaluation indicated the following: Patient 6 was admitted to the facility on 7/2/2024 on a 5150 hold (an involuntary 72-hour hold for the treatment of a psychiatric [relating to mental illness or treatment] condition) due to increasing thoughts of suicide (taking one’s own life) ... Patient 6 admitted he (Patient 6) had been hearing a lot of voices telling him to kill himself ... During a review of Patient 6’s “Patient Observation Record & Milieu Groups,” dated 7/3/2024, the Patient Observation Record indicated Patient 6 was on Suicide Precautions (monitoring patients for high-risk behaviors of suicide). There was no documentation of Patient 6’s behavior or location from 1 p.m., to 3:29 p.m. During a review of the facility’s policy and procedure (P&P) titled, “Patient Precautions,” dated 2/2010, the P&P indicated the following: “Suicide ...All patients identified to be on Suicide Precautions will have the following measures initiated: Indicate the suicide precautions on the patient’s rounds sheet ...May be restricted to the unit ...Staff will monitor for high risk behaviors, including but not limited to hoarding linen, trying to obtain contraband items, bathroom areas, and potential blind spots ...” During a review of the facility’s policy and procedure (P&P) titled, “Supervision of Patients/Patient Rounds,” dated 8/1998, the P&P indicated the following: “It is the policy of the Hospital that patients be supervised to diminish the risk of harm and/or injury ... All patients require supervision and rounds are conducted continuously with each patient’s location and behavior documented every 15 minutes ...Document patient location and behavior when the observation occurs on the Rounds Sheet and initial in the appropriate section for the observation.” 5. During a concurrent observation and interview on 7/08/2024 at 2:21 p.m., with Nurse Manager 2 (NM 2), Patient 21 (a child [the facility considered patients in the age group of 5 years old to 12 years old as child]) was observed sitting, slumped on a chair inside the Youth Services Unit’s Day room. Patient 2 (an adolescent patient [the facility considered patients in the age group of 13 years old to 17 years old as adolescent]) was sitting in a chair across the room watching television, there was no staff observed inside the room for the patients’ supervision. In the same observation and interview, on 7/8/2024 at 2:26 p.m., Patient 24 (adolescent patient) was observed to enter the dayroom and touched Patient 21’s head. NM 2 stated its not ideal for the patients that are children (5 years to 12-year-old) mixed with the adolescent group (13 years to 17 years old) in the unit because adolescents have more ideas and experience compared to younger children. During a follow-up interview on 7/8/2024 at 2:41 p.m., with Charge Nurse 2 (CN 2), CN 2 stated usually when there is an age gap, patients are kept in separate units. CN 2 stated due to census being low, children unit was closed, and the patients (considered as child) were moved to the unit with the adolescent patients. During a concurrent observation and interview on 7/8/2024 at 2:46 p.m., with NM 2, CN 2 was observed unlocking the bathroom for Patient 21 and walking away as he (Patient 21) entered the bathroom. NM 2 stated staff is not expected to wait for the patient to come out of the bathroom and that the bathrooms cannot be locked from inside. NM 2 acknowledged that another patient could enter the bathroom while Patient 21 was in there. NM 2 stated she (NM 2) voiced out her concern regarding patient safety of children age-group mixed with adolescent age-group in the unit during a staff meeting with the Chief Executive Officer (CEO). During an observation on 7/8/2024 at 2:52 p.m., Patient 21 was heard screaming in the Dayroom with a group of four older children (unknown age), sitting and watching television. No staff supervision was observed. Subsequently, Mental Health Technician 4 (MHT 4) entered the room and told Patient 21 to quiet down. During a review of Patient 24’s “Face Sheet (a document containing a patient’s medical and demographic information),” undated, the face sheet indicated Patient 24 was admitted to the facility on 6/28/2024 with a medical diagnosis of other persistent mood [affective]. During a review of Patient 24’s “Patient Observation Record & Milieu groups (a document used to record rounding),” dated 7/8/2024, the record indicated Patient 24 was on special precautions for suicide (taking one’s own life), assault and sexual aggression. During a review of Patient 2’s “Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation,” dated 7/01/2024, the Evaluation indicated Patient 2 was admitted to the facility on 6/30/2024, on a 5585 (an involuntary 72-hour hold involving a minor for the treatment of a psychiatric condition) for danger to self. “Patient (2) was placed on a hold for danger to self after recently Patient (2) was punching on the walls.” During an interview on 7/9/2024 at 9:38 a.m. with the Director of Clinical Services Regional Compliance (DRC), the DRC stated the patients within the age group of 5 to 12 years old should have a specific staff member assigned to provide individualized care when mixed with the adolescent patients in the unit. The DRC stated there were safety concerns regarding children and adolescent in same unit because the adolescents have way more ideas to get into trouble, the patients considered as children should have a 1:1 sitter (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed) if they are mixed with the adolescent patients in the unit. During a review of the facility’s policy and procedure (P&P) titled, “Supervision of Patients/Patient Rounds,” revised July 2021, the P&P indicated, “It is the policy of (name of the facility) that patients be supervised to diminish the risk of harm and/or injury. While monitoring hallways and patient care areas, ensure patients are: Not left in “Treatment Areas” without direct staff supervision.” 6. During an observation on 7/8/2024 at 3:05 p.m. with Mental Health Technician 6 (MHT 6), Patient 27 was observed sitting on the sofa and Patient 28 was sitting at the table watching TV inside the activity room. There was no continuous staff monitoring inside the activity room. In addition, there was no staff in line of sight (a level of observation in which the patient remains in staff view) of the activity room while the patients (Patients 27 and 28) were inside the room. MHT 6 verified the patients (Patient 27 and Patient 28) inside the activity room were not continuously monitored. During an interview on 7/8/2024 at 3:05 p.m. with Mental Health Technician (MHT) 5, MHT 5 stated there has to be someone monitoring the patients at all times to ensure patient safety. During an interview on 7/8/2024 at 3:10 p.m. with the Director of Risk Management and Performance Improvement (DRPI), the DRPI stated when MHT needed to step out from watching the patient, the MHT should notify the charge nurse to cover for the MHT and to ensure the patients were monitored continuously. During an interview on 7/8/2024 at 3:10 p.m. with Charge Nurse (CN) 3, CN 3 stated there should be a staff inside the activity room with the patients. CN 3 stated anything could happen and the patients could harm self or others. During an interview on 7/11/2024 at 3:38 p.m. with the Clinical Director (CD), the CD verified that there should always be a staff in the group/activity room to ensure patient safety when patients were in the group/activity room. During a review of Patient 27’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), the H&P indicated Patient 27 was admitted to the facility on 7/8/2024, on a 5150 hold (an involuntary 72-hour hold for the treatment of a psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] condition) for suicidal ideations (SI, thoughts of ending one’s own life]). The H&P also indicated Patient 27’s medical history included Bipolar (mood swings ranging from depressive lows to manic highs [abnormally elevated mood]) and Suicidal Ideation (SI, thoughts of causing one’s own death). During a review of Patient 28’s H&P, the H&P indicated Patient 28 was admitted to the facility on 7/8/2024, for acute exacerbation (symptom worsening) of schizophrenia (mental disorder). Patient 28 was on a 5150 hold. During a review of the facility’s policy and procedure (P&P) titled, “Supervision of Patients/Patient Rounds,” revised July 2021, the P&P indicated, “It is the policy of (name of the facility) that patients be supervised to diminish the risk of harm and/or injury. While monitoring hallways and patient care areas, ensure patients are: Not left in “Treatment Areas” without direct staff supervision.” 7. During a review of Patient 17’s face sheet (document that gives a patient’s information at a quick glance), the face sheet indicated Patient 17 was admitted to the facility on 11/09/2023 at 3:30 p.m. with the diagnosis of major depressive disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities). During a review of Patient 17’s progress note, dated 11/11/2023 and timed at 10:30 p.m., the progress note indicated that patient 17 was involved in an altercation (First physical altercation) instigated by patients 18 and 19, that resulted in Patient 17 being transferred to the GACH (General Acute Care Hospital) ER (Emergency Room, responsible for the provision of medical care to patients arriving at the hospital in need of immediate treatment) for further evaluation. During a review of Patient 17’s Post (after) ER Visit Reassessment document, dated 11/12/2023 and timed at 1:23 a.m., the document indicated Patient 17 returned from the ER. Patient 17 suffered a laceration (wound produced by tearing of soft body tissue) to the forehead that required sutures (stitch made to join the open parts of the wound). During a review of Patient 17’s Physician Order dated 11/12/2023 and timed at 7:00 a.m., the physician order indicated that patient 17 was to be transferred to the GACH ER for a second evaluation (following the second altercation that happened around 6:30 a.m.). During a review of Patient 17’s progress note dated 11/12/2023 and timed at 2:00 p.m., the progress noted indicated that patient 17 was transferred to another facility from the GACH ER after Patient 17 was taken to the GACH ER for the second time following the second altercation involving Patients 18 and 19. During a review of Patient 18’s face sheet, the face sheet indicated that Patient 18 was admitted to the facility on 11/6/2023 at 3:45 p.m., with the diagnosis of oppositional defiant disorder (frequent and ongoing pattern of anger, irritability, arguing and defiance toward parents and other authority figures). During a review of Patient 18’s Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation (first interview between physician and patient to help identify disorders and help to the treatment team develop a treatment plan), dated 11/6/2023, the evaluation indicated Patient 18 was admitted for danger to self and also meeting the criteria for danger to others as well. During a review of Patient 18’s psychiatric progress note (physician progress notes written by psychiatric doctor [physician who specializes in mental, emotional and behavioral disorders]), dated 11/11/2023, the progress report indicated Patient 18 remains unpredictable, has thoughts of self-harm and very aggressive. During a review of Patient 18’s physician orders dated 11/10/2023 the physician orders indicated Patient 18 was on a 1:1 (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed) DAY only, Not evening and nocturnal (night) [the two physical altercations happened in the evening and early morning]. During a review of Patient 18’s progress notes dated for 11/11/2023 and timed at 11:00 p.m. and 11/12/2023 and timed at 6:45 a.m., the progress notes indicated that Patient 18 was involved in two physical altercations involving Patient 17. During a review of Patient 19’s face sheet, the face sheet indicated that Patient 19 was admitted to the facility on 11/3/2023 with the diagnosis of major depressive disorder. During a review of Patient 19’s psychiatric progress note (physician progress notes written by psychiatric doctor [physician who specializes in mental, emotional and behavioral disorders]) dated 11/11/2023, the progress note indicated that Patient 19 has anger management issues, very reckless, easily agitated and verbally aggressive. During a review of Patient 19’s progress note, dated for 11/11/2023 and 11/12/2023 timed at 10:30 p.m., and 6:45 a.m., the progress note indicated that Patient 19 was involved in a physical altercation with Patient 17. During a review of Patient 19’s physician order dated for 11/12/2023 and timed at 7:00 a.m., the physician order indicated Patient 19 had a 1:1 order for all shifts (the 1:1 order for all shifts was written after the second altercation). During an interview on 7/11/2024 at 10:02 a.m. with Nurse Manage (NM 3), NM 3 stated that when an altercation occurs, a 1:1 order can be ordered by the physician, it depends on the “situation.” NM 3 stated that 1:1 is done for the safety of not only patients but for staff also. NM 3 stated if the aggressor had a history of previous 1:1 orders, then the aggressor would be put on a 1:1 after the altercation. During a record review on 7/12/2024 at 11:02 a.m., with Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Risk Management and performance improvement (DRPI) and NM 1 and 2, the facility’s video recording (no audio, second altercation incident) dated 11/12/2023 beginning at 6:27 a.m., the video captured Patient 18 and 19 walking into Patient 17’s room. Patient 17’s room was verified by NM 2 and Patients 18 and 19 were verified by NM 1. Approximately 25 seconds, roommate of Patient 17 was seen exiting the room with Patient 18 and 19 following shortly after. During a concurrent interview and record review on 7/12/2024 with Nurse Manager (NM) 2 at 3:22 p.m., the medical chart for Patient 18 was reviewed. NM 2 stated that Patient 18 had a known history of being aggressive and having orders of 1:1 in the past. NM 2 stated that after the first incident with Patient 17, both Patients 18 and 19 should have been put on a 1:1 in order to protect the safety of other patients and staff. NM 2 stated that safety is a priority for everyone. During a concurrent interview and record review on 7/12/2024 at 3:27 p.m. with NM 2, the medical chart for Patient 17 was reviewed. NM 2 stated that Patient 17 received a laceration during the first altercation (on 11/11/2023) and the laceration was reopened on the second altercation (on 11/12/2023). NM 2 stated that Patient 17 did not return to the facility after being sent to the GACH ER once more following the second altercation on 11/12/2023. During a review of the facility’s policy and procedure (P&P) titled, “Patient Precautions,” revised 2/2022, the P&P indicated that it was the policy of the facility to identify and assess risk factors of all patients in order to provide care in a safe and therapeutic milieu.”

“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. Provide proper supervision for two of 30 sampled patients (Patients 18 and 19), both of whom had a known history of aggression towards staff and other patients, to ensure that both patients (Patient 18 and Patient 19) did not physically attack Patient 17 twice, in accordance with the facility’s policy and procedure regarding supervision of patients. This deficient practice resulted in Patients 18 and 19 physically attacking Patient 17 for a second time within a 24-hour time frame. Patient 17 had to be transferred to a General Acute Care Hospital (GACH) Emergency Room (ER, responsible for the provision of medical care to patients arriving at the hospital in need of immediate treatment) for evaluation. Patient 17 suffered a laceration (wound produced by tearing of soft body tissue) to the forehead that required sutures (stitch made to join the open parts of the wound) after the first altercation and the laceration was re-opened after the second altercation. 2. Provide annual Abuse (any action or failure to act which causes unreasonable suffering, misery, or harm to the patient. Includes physical abuse, neglect, sexual abuse, emotional and financial abuse) Training for five of six staff (Charge Nurses [CN) 1, 2, and Mental Health Technicians [MHT] 1, 2, 4), in accordance with the facilities policies and procedures regarding abuse training. This deficient practice had the potential for staff not to be able to identify signs and symptoms of abuse or take appropriate actions in the event a patient is identified to be a victim of abuse, which may result in patient harm. Findings: 1. During a review of Patient 18’s face sheet (document that gives a patient’s information at a quick glance), the face sheet indicated that Patient 18 was admitted to the facility on 11/6/2023 at 3:45 p.m., with the diagnosis of oppositional defiant disorder (frequent and ongoing patter of anger, irritability, arguing and defiance toward parents and other authority figures). During a review of Patient 18’s Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation (first interview between physician and patient to help identify disorders and help to the treatment team develop a treatment plan), dated 11/6/2023, the evaluation indicated Patient 18 was admitted for danger to self and also meeting the criteria for danger to others as well. During a review of Patient 18’s psychiatric progress note (physician progress notes written by psychiatric doctor [physician who specializes in mental, emotional and behavioral disorders]), dated 11/11/2023, the progress report indicated Patient 18 remains unpredictable, has thoughts of self-harm and very aggressive. During a review of Patient 18’s progress notes dated for 11/11/2023 and 11/12/2023 timed at 11:00 p.m., and at 6:45 a.m., the progress notes indicated that Patient 18 was involved in two physical altercations involving Patient 17. During a review of Patient 19’s face sheet (document that gives a patient’s information at a quick glance), the face sheet indicated that Patient 19 was admitted to the facility on 11/3/2023 with the diagnosis of major depressive disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities). During a review of Patient 19’s psychiatric progress note (physician progress notes written by psychiatric doctor [physician who specializes in mental, emotional and behavioral disorders]) dated 11/11/2023, the progress note indicated that Patient 19 has anger management issues, very reckless, easily agitated and verbally aggressive. During a review of Patient 19’s progress note dated for 11/11/2023 and 11/12/2023 timed at 10:30 p.m., and 6:45 a.m., the progress note indicated that Patient 19 was involved in a physical altercation with Patient 17. During a review of Patient 19’s physician order (orders written by physicians to direct care and treatment), dated for 11/12/2023 and timed at 7:00 a.m., the physician order indicated Patient 19 had a 1:1 (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed) order (the 1:1 order was written after the second altercation involving Patient 17). During a review of Patient 17’s Face sheet (document that gives a patient’s information at a quick glance), the Face sheet indicated Patient 17 was admitted to the facility on 11/09/2023 at 3:30 p.m. with the diagnoses of major depressive disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities). During a review of Patient 17’s progress note dated 11/11/2023 and timed at 10:30 p.m., the progress note indicated that patient 17 was involved in an altercation (first physical altercation) that resulted in Patient 17 being transferred to the GACH (General Acute Care Hospital) ER (Emergency Room, responsible for the provision of medical care to patients arriving at the hospital in need of immediate treatment) for further evaluation. During a review of Patient 17’s Post (after) ER Visit Reassessment document, dated 11/12/2023 and timed at 1:23 a.m., the document indicated Patient 17 returned from the ER. Patient 17 suffered a laceration (wound produced by tearing of soft body tissue) to the forehead that required sutures (stitch made to join the open parts of the wound) after the first altercation on 11/11/2023 at 10:30 p.m. During a review of Patient 17’s Physician Order dated 11/12/2023 and timed at 7:00 a.m., the physician order indicated that patient 17 was to be transferred to the GACH ER for another evaluation (after the second altercation on 11/12/23 at 6:45 a.m.). During a review of Patient 17’s progress note dated 11/12/2023 and timed at 2:00 p.m., the progress noted indicated that patient 17 was transferred to another facility from the GACH ER. During an interview with Nurse Manager (NM) 3 on 7/11/2024 at 10:02 a.m., NM 3 stated that when an altercation occurs, a 1:1 order can be ordered by the physician, it depends on the “situation.” NM 3 stated that 1:1 is done for the safety of not only patients but for staff also. NM 3 stated if the aggressor had a history of previous 1:1 orders, then the aggressor would be put on a 1:1 after the altercation. During a record review on 7/12/2024 at 11:02 a.m., with Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Risk Management and performance improvement (DRPI) and NM 1 and 2, the facility’s video recording (no audio, recording of the second altercation) dated 11/12/2023 was reviewed, beginning at 6:27 a.m., the video captured Patient 18 and 19 walking into Patient 17’s room. Patient 17’s room was verified by NM 2 and Patients 18 and 19 were verified by NM 1. Approximately 25 seconds, roommate of Patient 17 was seen exiting the room with Patient 18 and 19 following shortly after. Staff was then seen running into Patient 17’s room. During a concurrent interview and record review on 7/12/2024 with NM 2 at 3:22 p.m., the medical charts for Patient’s 18 and 19 was reviewed. NM 2 stated that Patient 18 had a known history of being aggressive and having orders of 1:1 in the past. NM 2 stated that a Physician order for 1:1 was ordered on 11/10/2023 but only for Day time. NM 2 stated that is done because that is when patients “act out the most.” NM 2 stated that a 1:1 for all shifts was ordered for both Patients 18 and 19 after the physical altercation which happened the second time on 11/12/2023. NM 2 stated that after the first incident (on 11/11/2023) with Patient 17, both Patients 18 and 19 should have been put on a 1:1 in order to protect the safety of other patients and staff. NM 2 stated that safety is a priority for everyone. During a review of the facility’s policy and procedure (P&P) titled, “Patient Precautions,” revised 2/2022, the P&P indicated that it was the policy of the facility to identify and assess risk factors of all patients in order to provide care in a safe and therapeutic milieu. The P&P also indicated that patients would also be re-assessed for risk whenever there was an abrupt change in their behavior or mental status. During a review of the facility’s P&P titled, “Supervision of Patients/Patient Rounds,” revised 7/2021, the P&P indicated that patients be supervised to diminish the risk of harm and/or injury. The policy also indicated that patients who were assessed to be at imminent risk of harm to self or others, a 1:1 level of supervision may be assigned. During a review of the facility’s handbook titled “Rights for Individuals in Mental Health Facilities,” revised July 2018, the handbook (page 22) indicated that patients have the right to be free from abuse, neglect, or harm, including unnecessary or excessive restraint (devices that limit a patient’s movement), isolation (supervised confinement of a patient away from other patients) or medication. The handbook also indicated that patients have the right to be free from potentially harmful situations or conditions. 2. During a concurrent interview and personnel file review on 7/11/2024 at 4:29 p.m., with the Director of Human Resources (DHR), the DHR reviewed the personnel files and stated the following: Abuse (any action or failure to act which causes unreasonable suffering, misery, or harm to the patient. Includes physical abuse, neglect, sexual abuse, emotional and financial abuse) training should be provided upon hire and annually for staff, including Registered Nurses (RNs), and Mental Health Technicians (MHTs). The DHR stated the facility did not provide refresher abuse training last year (2023) during annual competencies (the application and demonstration of appropriate knowledge, skills and behavior in the clinical setting) for all staff including CN 2, MHT 1 and 2. During a second concurrent interview and personnel file review on 7/12/2024 at 10:54 a.m., the DHR stated CN 1 and MHT 4 did complete annual abuse training. During an interview on 7/12/2024 at 11:25 a.m. with the Director of Clinical Services (DCS), DCS stated she (DCS) provided abuse training to all staff upon hire and normally a refresher course was provided annually. The DCS stated that the facility did not ask her (DCS) to provide a refresher course in abuse training last year (2023) during the annual competency fair. The DCS stated abuse training should be provided annually to ensure staff are able to recognize signs and symptoms of abuse, and actions to take in the event abuse is identified. During a review of personnel files on 7/12/2024, the personnel files review indicated the following: RN 1 and MHT 4 did not have evidence of abuse training. CN 1’s last completed abuse training was on 11/6/2022. MHT 1’s last completed abuse training was on 10/25/2022. This was verified by the DHR during an interview. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reporting of Abuse and Neglect,” dated 10/2021, the P&P indicated the hospital treatment team will assess and reassess patients for signs and symptoms of abuse including: emotional, sexual, and fiduciary (financial) abuse, exploitation, neglect, and abandonment, upon intake, admission and throughout hospitalization. During a review of the facility’s policy and procedure (P&P) titled, “Staff Competency and Training,” dated 8/1/2020, the P&P indicated the following ...On an annual basis, each employee is required to complete refresher training on the following topics, including Abuse/Neglect Identification and Reporting.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(ii) Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior. This Standard is not met as evidenced by: 50515 Based on observation, interview, and record review, the facility failed to ensure that an age appropriate sleeping arrangement and therapeutic environment was provided for one of 30 sampled patients (Patient 21), in accordance with the facility’s policy and procedure regarding therapeutic environment when, Patient 21 was placed in a seclusion room (PRA - Private room Areas, a room used when a patient is being actively secluded/separated from other patients due to an aggressive behavior) at night to sleep. This deficient practice resulted in Patient 21 not having an age-appropriate room and furnishings which could negatively affect the patient’s emotional well-being and quality of care received. Findings: During a concurrent observation and interview, on 7/8/2024 at 2:05 p.m., with Nurse Manager 2 (NM 2), in Room 56, designated as one of the seclusion room (PRA - Private room Areas, a room used when a patient is being actively secluded/separated from other patients due to an aggressive behavior), was observed to have a bed with no fitted sheet or blanket on the mattress, there were no other furniture in the room. In addition, a camera was noted in the left corner of the room. NM 2 stated Patient 21 sleeps in the room (Room 56) at night to keep sleeping area separate from child (5-12 years old) and adolescent (13-17 years old) patients. During an interview on 7/9/2024 at 9:38 a.m. with the Director of Clinical Services and Regional Compliance (DRC), the DRC stated seclusion room should not be used for sleeping. During an interview on 7/9/2024 at 9:38 a.m. with the Chief Nursing Officer (CNO), the CNO stated Patient 21 sleeps in room 56 (seclusion room). The CNO agreed Room 56 was normally used for the patients needing to be separated from other patients for safety reasons. The CNO stated Patient 21 sleeps in Room 56 because the patient belongs to the child age group and should sleep in separate room from the adolescent patients. During an interview on 7/9/2024 at 10:58 a.m., with Patient 21, in the presence of the Regional Vice President (RVP), Patient 21 stated he was scared of being alone in the room, pointing to room 56. Patient 21 stated he sleeps in Room 56 at night and “they (staff) don’t check” on him (Patient 21). During an interview on 7/10/2024 at 3:55 p.m., with Registered Nurse 1 (RN 1), RN 1 stated the seclusion rooms (Room 55 and 56) were used when a patient is having behavioral problems. During a review of the facility’s “Patient Observation Record & Milieu Groups (rounding sheet),” dated 7/8/2024, the record indicated from 12:00 a.m. until 7:00 a.m., Patient 21 was sleeping in the seclusion room (PRA - Private room Areas, a room used when a patient is being actively secluded/separated from other patients due to an aggressive behavior)). During a concurrent interview and record review on 7/11/2024 at 2:21 p.m., with Nurse manager (NM) 2, the facility’s policy and procedure (P&P) titled, “Supervision of Patients/Patient Rounds,” dated 7/2021, was reviewed. The P&P indicated, “The Charge Nurse is responsible for ensuring the proper use of Private Room Areas (PRA’s/Seclusion room). These areas may ONLY be used when a patient is being actively secluded or restrained, during which time they will have a minimum of 1:1 supervision (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed) for the duration of emergency intervention.” NM 2 stated she was not aware of the P&P regarding the use of PRA room. During a review of the facility’s policy and procedure (P&P) titled, “Therapeutic Environment,” dated 3/2022, the P&P indicated, “It is the policy of facility that all patients are to have an appropriate environment in which to receive their treatment. This applies to privacy, personal space and age-appropriate furnishings. It is the responsibility of each Program Director to ensure that their unit meets the following: Space: adequate and separate personal area will be provided for patient belongings. Age-Appropriate Furnishings: each unit is to have furnishings, both indoor and outdoor, that are safe and encourage comfort and age-appropriate utilization.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 50515 Based on interview and record review, the facility failed to ensure that one of 30 sampled patients (Patient 21), was assessed and monitored, in accordance with the facility’s policy and procedure regarding Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion (confinement of a patient alone in a room in which the patient is physically prevented from leaving), when Patient 21 was placed on chemical restraints (a drug given to a person to control their behavior or restrict their movement). Patient 21 was administered Benadryl (medication used with sedation effects [a state of calmness or sleepiness]) and Thorazine (medication used to manage mental illness or behavior disorders). This deficient practice had the potential to cause a delay in determining Patient 21’s change of condition and/or provision of emergent treatment needed as a result of chemical restraint, which can lead to worsening of patient’s condition and/or death. Findings: During a review of Patient 21’s “Face Sheet (a document containing a patient’s medical and demographic information),” undated, the face sheet indicated Patient 21 was admitted to the facility on 6/28/2024. During a review of Patient 21’s “72 hour hold (5585, a law that allows for the involuntary detention of someone with a mental illness in a psychiatric [branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] hospital for up to 72 hours),” dated 6/28/2024, the hold indicated Patient 21 was a danger to himself and others. Patient 21 was agitated, violent and trying to jump out of a moving car. Patient 21 had an open case with Department of Children and Family Services (DCFS - agency that oversees Los Angeles County’s 24/7 child abuse [any action or failure to act which causes unreasonable suffering, misery, or harm to the patient. Includes physical abuse, neglect, sexual abuse, emotional and financial abuse] and neglect hotline and responds to the immediate needs of any child at risk). During a concurrent interview and record review on 7/11/2024 at 11:22 a.m., with Nurse Manager 2 (NM 2), Patient 21’s “Medication Administration Record (MAR),” indicated a physician order of Benadryl (medication used with sedation effects [a state of calmness or sleepiness]) 50 milligram (mg, a unit of measurement) to be given intramuscularly (IM-in the muscle) one time for agitated behavior/aggressive behavior towards staff. Furthermore, the MAR indicated Patient 21 was administered Benadryl 50 mg IM on 6/28/2024 at 11:45 p.m. NM 2 stated Patient 21 was held down for a couple of minutes to be given the medication thus “purple packet (Facility Seclusion/restraint order) was filled out. During a concurrent interview and record review on 7/11/2024 at 2:21 p.m. with NM 2, Patient 21’s “Facility Seclusion/Restrained order,” dated 6/28/2024, indicated Patient 21 was physically held down on 6/28/2024 at 11:45 p.m. until 11:47 p.m., and Benadryl 50 mg IM was given for improved mood/function. The assessment of patient range of motion, toileting/hygiene/food/vitals and assessment every 15 minutes after the administration of the Benadryl 50 mg IM was not completed with “n/a (not applicable)” written on the assessment record. NM 2 stated the assessment portion of the form was not necessary to fill out because physical hold was only for two minutes. NM 2 said medication used for the patient was considered a restraint, only if the patient falls sleep within an hour. During a concurrent interview and record review on 7/11/2024 at 2:21 p.m., with Nurse Manager 2 (NM 2), Patient 21’s MAR indicated a physician order of Thorazine (medication used to manage mental illness or behavior disorders) 25 mg to be given IM one time for agitation/aggression. Furthermore, the MAR indicated Patient 21 was administered Thorazine 25 mg IM on 6/29/2024 at 11:20 a.m. In the same record review on 7/11/2024 at 2:21 p.m., with NM 2, Patient 21’s “Facility Seclusion/Restrained order,” dated 6/29/2024 indicated Patient 21 was physically held down on 6/29/2024 at 11:20 a.m. until 11:21 a.m. and was given Thorazine 25 mg IM for improved mood/function, “patient (Patient 21) hit a peer, was running around the unit throwing items at staff and peers. The nursing graphics portion which included assessment of patient range of motion, toileting/hygiene/food/vitals and assessment every 15 minutes was not completed with “n/a” written on the assessment document. During a concurrent interview and record review on 7/11/2024 at 2:21 p.m. with NM 2, the facility’s policy and procedure (P&P) titled, “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion,” revised 3/2022, was reviewed. NM 2 stated she was unaware of the policy on chemical restraint that, “administration of a medication for the purpose of controlling an acute episodic behavior, with the intent to restrict the patient’s functioning or movement and/or to bring about sedation ...” required assessment and monitoring, and that was the reason the assessment and monitoring was not done. NM 2 agreed that the use of Benadryl and Thorazine for Patient 21’s behavior was a chemical restraint and required monitoring and reassessment per policy. During a review of the facility’s policy and procedure (P&P) titled, “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion,” revised in 3/2022, the P&P indicated the following: - Chemical (Medication) Restraint: The administration of a medication for the purpose of controlling an acute (severe and sudden in onset) episodic behavior, with the intent to restrict the patient’s functioning or movement and/or to bring about sedation (a state of calmness or sleepiness). - The RN immediately will assign a staff member, trained, and deemed competent in the usage and monitoring of seclusion and restraints to conduct continuous in person observation/monitoring for the duration of the seclusion/restraint episode. - Documentation of each episode of restraint/seclusion include 15-minute assessment of the patient status, continuous monitoring of patient and care provided.”

“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: 36206 Based on interview and record review, the facility failed to formulate and implement a corrective action plan or action, when the facility identified deficiencies in the staff’s responses when Patient 8 was found to be unresponsive (not reacting or unable to react in a normal way when touched, spoken to, etc.), pulseless, not breathing and subsequent death (refer to A-0144), as well as corrective action plan for follow-ups when issues were identified during Mock Codes (a simulation exercise with a mannequin/human patient simulator with no respiratory effort and/or no pulse), in accordance with the facility’s Quality Assurance & 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. This deficient practice had the potential for staff’s inability to respond appropriately during a medical emergency such as in cases of pulseless patients or patients who are not breathing. Findings: During an interview on 7/12/2024 at 4:30 p.m. with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Risk Management and Performance Improvement (DRPI), and Director of Clinical Services Regional Compliance (DRC), the CNO stated the following: A root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solutions) was performed for Patient 8’s death. The RCA identified there were concerns with rounding, delayed implementation of live-saving measures, delayed notification of licensed staff, and not applying the AED (automatic external defibrillator, delivers an electric shock through the chest to the heart when it detects an abnormal rhythm) during the code blue (hospital announcement means that someone is having a medical emergency, usually cardiac arrest [absent or abnormal heart activity] or respiratory arrest [absent breathing]). The facility implemented an action plan to correct the identified concerns, but the action plan (a document that lists what steps must be taken to correct identified concerns) was not documented. The CNO and DRPI confirmed the action plan was not documented and they were unable to provide a copy to the survey team. During a review of Patient 8’s “Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation,” dated 4/17/2024, the Psychiatric Evaluation indicated Patient 8 was admitted to the facility on a 5150 (an involuntary 72-hour hold for the treatment of a psychiatric condition), on 4/17/2024, with a diagnosis of schizoaffective disorder (a mood disorder where someone may experience depression [a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities], mania [extreme euphoria or irritability], and hallucinations [sensing things such as visions, sounds or smells that seem real but are not] or delusions [a fixed false belief based on an inaccurate interpretation of an external reality despite evidence to the contrary). During a review of Patient 8’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/18/2024, the H&P indicated Patient 8 had diagnosis of headaches, somatic complaints (an extreme focus on physical symptoms causing major emotional distress and problems functioning), obesity (weighing 100 pounds over the recommended weight) and tachycardia (increased heart rate). During a review of Patient 8’s “Code Blue/Medical Emergency Documentation,” dated 4/22/2024 at 8:04 a.m., the documentation indicated the following: Patient 8 was “found not breathing, pulseless, not responding.” A code blue was called at 8:04 a.m. The AED was not applied. Transferred care of Patient (8) to EMS (Emergency Medical Services) at 8:14 a.m. Patient (8) condition at departure or at the end of the code: Deceased. During a review of Patient 8’s “Discharge Summary (a narrative document for communicating clinical information about what happened to a patient in the hospital),” dated 5/4/2024 at 7:42 a.m., the Discharge Summary indicated the following: On March 22, 2024 at 8:14 a.m., Patient (8) was found unconscious and not responding ...Paramedics took over the emergency situation and Patient (8) didn’t make it. Outcome of hospitalization: Patient (8) expired. During an interview and record review on 7/12/2024 at 5:05 p.m. with Nurse Manager (NM) 2, NM 2 stated the following: Mock Codes (a simulation exercise with a mannequin/human patient simulator with no respiratory effort and/or no pulse) were conducted on 5/1/2024. The response of staff to the Mock code was analyzed and it was determined that the staff did not bring the AED and the staff was not able to utilize the equipment correctly. NM 2 verified there was no documentation of follow-up actions aimed at ensuring the staff would bring the AED and know how to utilize the AED during a Code (Code Blue, a medical emergency, usually cardiac [heart] or respiratory arrest). There should be follow up. During a review of a facility document titled, “Nursing Administration Evaluation and Analysis of Code Blue Response,” dated 5/1/2024 at 1:27 p.m., the document indicated the following: 3. Did staff bring the appropriate equipment (AED, oxygen tanks etc ...), No ... 6. Were the staff members able to utilize all equipment correctly? No ... If any “No” answers, describe: “Staff did not bring appropriate equipment to the code. Nursing Manager educated staff on necessary equipment to bring. During a review of a facility document titled, “Nursing Administration Evaluation and Analysis of Code Blue Response,” dated 5/1/2024at 10:30 p.m., indicated the following: 14. Were proper notifications completed (physician, Internist, family/support)? No. If any “No” answers, describe: “MOCK: Interventions Take to Correct: blank (no documentation of corrective interventions). During a review of the facility’s Quality Assurance & 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, dated 2024, the QAPI indicated the following: The QAPI program is designed to provide a coordinated, objective, and systemic approach to organization-wide performance improvement activities ...The Performance Improvement Committee ...is responsible to oversee and accomplish the following ...Ensure that a comprehensive assessment and root cause analysis is initiated when data analysis indicates undesirable variations in performance. Assure that appropriate actions are implemented to effectively resolve identified problems or improve existing processes.”

“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: 1. Perform a reassessment (reevaluation of a patient’s health status) for one of 30 sampled patients (Patient 8) within one hour after PRN (as needed) medications Vistaril (a medication used to relieve itching caused by allergic skin reactions with sedative [cause drowsiness or sleepiness] effects) and Trazodone (a medication used to treat depression and anxiety) were administered to Patient 8. This deficient practice had the potential to cause irregular heart rhythms, when Vistaril and Trazodone were taken together, resulting in patient harm or death. 2. Complete an admission assessment (a process where a nurse gathers, sorts, and analyzes a patient’s health information) for one of 30 sampled patients (Patient 8), in accordance with the facility’s policy and procedure regarding Assessment and reassessment. This deficient practice had the potential for delayed provision of medical care and treatment of identified concerns, resulting in patient harm and/or death. 3. Ensure two of 30 sampled patients (Patients 25 and 28) vital signs (VS, includes blood pressure, heart rate, respiration (breathing), and temperature) were assessed and documented in accordance with the physician’s order and the facility’s policy and procedure regarding Vital Signs assessment and documentation. This deficient practice had the potential to cause a delay in determining Patients’ 25 and 28’s change of condition and/or a delay in the provision of emergent treatment needed which could worsen the patients’ condition and may result in death. 4. Ensure that two of 30 sampled patients (Patients 29 and 30’s) Colombia Suicide Severity Rating Scale (CSSRS - suicidal risk assessment tool) assessment were completed daily in accordance with the facility’s policy and procedure regarding Nursing Assessment and Reassessment. This deficient practice had the potential for Patients’ 29 and 30’s assessment and reassessment to be inaccurate and may cause delay in the provision of medical care and treatment that could result in patient harm and or death. Findings: 1. During a review of Patient 8’s “Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation,” dated 4/17/2024, the Psychiatric Evaluation indicated Patient 8 was admitted to the facility on a 5150 (an involuntary 72-hour hold for the treatment of a psychiatric condition), on 4/17/2024, with a diagnosis of schizoaffective disorder (a mood disorder where someone may experience depression, mania [extreme euphoria- intense feeling of excitement/happiness or irritability]). During a review of Patient 8’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/18/2024, the H&P indicated Patient 8 had diagnosis of headaches, somatic complaints (an extreme focus on physical symptoms causing major emotional distress and problems functioning), obesity (weighing 100 pounds over the recommended weight) and tachycardia (increased heart rate). During a review of Patent 8’s “Physician Medication Orders,” dated 4/18/2024, the physician orders indicated an order for Trazodone (a medication used to treat depression and anxiety) 50 milligrams (mg, a unit of measurement) by mouth, as needed, at bedtime. During a review of Patent 8’s “Physician Medication Orders,” dated 4/18/2024, the physician orders indicated an order for Vistaril (a medication used to relieve itching caused by allergic skin reactions with sedative [cause drowsiness or sleepiness] effects) 50 mg by mouth, as needed, every 6 hours. During a concurrent interview and record review on 7/10/2024 at 3:48 p.m. with the Nurse Manager 2 (NM 2), Patient 8’s medical record titled “Medication Administration Record (MAR, a report detailing the drugs administered to a patient),” was reviewed. The MAR indicated on 4/22/2024 at 12:43 a.m., Patient 8 received as needed dose of Vistaril (a medication used to relieve itching caused by allergic skin reactions with sedative effects) 50 mg (milligram, a unit of measurement) by mouth for anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure). At 12:50 a.m. on 4/22/2024, Patient 8 received as needed dose of Trazodone (a medication used to treat depression and anxiety) 50 mg (milligram, a unit of measurement) by mouth for insomnia (inability to sleep). The NM 2 verified this was Patient 8’s first dose of Trazodone and Vistaril. The NM further verified the Vistaril and Trazodone were never reassessed and documented by the licensed nurse. The NM 2 said that all medications given required reassessment within an hour of administration, per policy. The NM 2 said that it was important to reassess Patient 8 to assess if the medication was effective and if there were any adverse side effects (unwanted undesirable effects that are possibly related to a medication). The NM 2 further stated that it was important to reassess Patient 8 after the first dose of medications because there was a likelihood the patient can have a reaction. During a review of the facility’s policy and procedure (P&P) titled, “Monitoring of Medication Effects on Patients,” revised 3/2022, the P&P indicated: “Policy: The effects of medications of patients will be monitored by appropriate clinical staff throughout the patient’s treatment ... members of the treatment team will document the patient’s response to medication therapy in progress notes. In addition to the clinician’s observations, notation will be made of the patient’s perception of the effectiveness of medications ... Procedure: ...2. The RN will record observations regarding patient behavior and symptoms in the daily nursing assessment. Response to PRN (as needed) medications will be recorded in the medical record, including the patient’s perception of effectiveness ... 3. The patient’s response to the first dose(s) of a medication new to the patient while he or she is under the direct care of the hospital will be recorded in the medical record.” 2. During a concurrent interview and record review on 7/9/2024 at 1:10 p.m. with the Nurse Manager 2 (NM 2), Patient 8’s medical record titled “Nursing Admission Assessment (a process where a nurse gathers, sorts, and analyzes a patient’s health information)- ADULTS (age 18+),” the NM 2 verified the following nursing assessment sections were incomplete and marked as not applicable (“N/A”): substance abuse assessment, potential for sexual victimization (being the recipient of a sexually aggressive act), sexually aggressive behavior (a person engaging in sexual behavior with someone who does not or cannot consent to engage in that behavior), homicidal/violence/aggression risk assessment (screens for someone who is dangerous because they are likely to harm or kill someone), psychological trauma (a person’s experience of emotional distress resulting) history, elopement (an act or instance of a patient in care leaving a hospital, care facility, or safe area independently without notifying anyone) risk assessment, and heightened risk associated with potential restraint (devices that limit a patient’s movement)/seclusion (confinement of a patient alone in a room in which the patient is physically prevented from leaving) intervention. During an interview on 7/9/2024 at 1:10 p.m. with the Nurse Manager (NM) 2, the NM 2 further verified that the admission assessment was not endorsed (to hand over) to the licensed nurse for completion. The NM 2 stated the following: The admission assessment should be completed on admission by a licensed nurse and signed off by a Registered Nurse (RN). If a licensed nurse is unable to complete the admission assessment prior to the end of their (8 hour) shift, incomplete sections of the admission assessment should be endorsed to the licensed nurse on the next shift. The number of attempts to complete the admission assessment should be documented on page one to include the date, time, reason unable to complete and RN initials. The RN can endorse the admission assessment up to three times. For Patient 8’s admission assessment, the incomplete sections should have not been marked “N/A,” instead, the RN should have documented the reason the assessment was incomplete or the patient’s refusal. It was important to complete the admission assessment to have a baseline of the Patient 8 on admission. Furthermore, Patient 8’s admission assessment should have been completed and relayed to the physician, so the physician knows the patient’s history to determine the course of treatment for their stay. During a review of the facility’s policy and procedure (P&P) titled “Nursing Assessment and Reassessment (reevaluation of a patient’s health status) of Patients,” revised 3/2022, the P&P indicated: “Assessment Policy: ...5. The Nursing Admission Assessment must be completed within eight (8) hours of admission by a Registered Nurse ... 6. The completion of the Nursing Admission Assessment is the responsibility of the shift during which the patient was admitted. If completion of the form is delayed because of the patient’s condition, a notation to this effect is to be documented in the “Attempts made for completion” section ...” 3.a. During a review of Patient 25’s “Face Sheet (a document containing a patient’s medical and demographic information),” undated, the face sheet indicated Patient 25 was admitted to the facility on 7/03/2024 with a medical diagnosis of Major depressive disorder (a serious mood disorder that can affect how people feel, think, and behave). During a concurrent interview and record review on 7/11/2024 at 8:57 a.m., with Nurse Manager 2 (NM 2), NM 2 stated Patient 25’s “Vital flowsheet” did not have Vital Signs (VS, includes blood pressure, heart rate, respiration, and temperature) documented on 7/8/2024. NM 2 stated Patient 25’s VS should be taken at least daily. During a review of the facility’s policy and procedure (P&P) titled, “Vital Signs”, revised 3/2022, the P&P indicated, “Vital signs (blood pressure, temperature, pulse, respirations) will be obtained at least once per day, documented, and evaluated by nursing staff in an appropriate manner to aid in diagnosis and treatment. All patients will have vital signs taken as part of the initial nursing assessment and daily thereafter until discharge, unless ordered more frequently by the physician...” 3.b. During a review of Patient 28’s “Face Sheet (a document containing a patient’s medical and demographic information),” undated, the face sheet indicated Patient 28 was admitted to the facility on 7/8/2024 with a medical diagnosis of major depressive disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities). During a review of Patient 28’s physician’s order, dated 7/8/2024, the Physician’s Order indicated Patient 28’s Vital Signs (VS, includes blood pressure, heart rate, respiration, and temperature) to be taken every four hours. During a concurrent interview and record review on 7/11/2024 at 10:01 a.m. with Nurse Manager (NM) 2, Patient 28’s “Vital flowsheet” indicated the following: - On 7/9/2014 at 6:30 a.m., Patient 28’s VS were completed, the next VS taken was taken at 2:01 p.m. (7 hours and 30 minutes since the last VS were taken); and, - On 7/10/2024 at 6:18 a.m. Patient 28’s VS were completed, the next VS taken was at 11:48 a.m. (5 hours and 30 minutes since last VS were taken). NM 2 stated Patient 28’s vital signs should be taken as ordered by the physician (every 4 hours). During a review of the facility’s policy and procedure (P&P) titled, “Vital Signs”, revised 3/2022, the P&P indicated, “Vital signs (blood pressure, temperature, pulse, respirations) will be obtained at least once per day, documented, and evaluated by nursing staff in an appropriate manner to aid in diagnosis and treatment. All patients will have vital signs taken as part of the initial nursing assessment and daily thereafter until discharge, unless ordered more frequently by the physician...” 4.a. During a review of Patient 29’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/23/2024, the H&P indicated Patient 29 was admitted to the facility for Major depressive disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities). During a concurrent interview and record review on 7/10/2024 at 11:18 a.m., with Nurse Manager 2 (NM 2), Patient 29’s “Colombia Suicide Severity Rating Scale (CSSRS - a suicidal assessment tool) documentation was reviewed and indicated the following: - Patient 29’s initial “Colombia Suicide Severity Rating Scale (CSSRS - a suicidal assessment tool),” assessment dated 4/23/2024, indicated Patient 29’s CSSRS was low risk for committing suicide (taking one’s own life). - Patient 29’s daily CSSRS was not completed on 4/24/2024 and 4/29/2024. On both dates, there was no documentation to indicate if Patient 29 was assessed to be a low risk or high risk for suicide) NM 2 verified Patient 29’s CSSRS assessment was not completed on 4/24/2024 and 4/29/2024. During a review of the facility’s policy and procedure (P&P) titled, “Nursing Assessment and Reassessment,” revised in 2/2024, the P&P indicated, “...each patient is assessed every 24 hours and as needed...RN will complete the CSSRS daily while patient remain on suicide precaution (interventions to prevent a patient from harming themselves such as frequent monitoring, etc.) ...” 4.b. During a review of Patient 30’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/23/2024, the H&P indicated Patient 30 was admitted to the facility on 4/23/2024 for Suicidal Ideations (SI, thoughts of ending one’s own life) with a plan to overdose (taking too much of a substance such as medications). Patient 30’s medical history included major depressive disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities) and substance abuse (a state of psychological and/or physical dependence on the use of drugs or other substances such as alcohol). During a concurrent interview and record review on 7/10/2024 at 11:18 a.m., with Nurse Manager 2 (NM 2) Patient 30’s “Colombia Suicide Severity Rating Scale (CSSRS - a suicidal assessment tool) documentation was reviewed and indicated the following: - Patient 30’s initial CSSRS assessment dated 4/23/2024, indicated Patient 30’s CSSRS was high risk for suicide (taking one’s own life); and, - Patient 30’s daily CSSRS was not completed on 4/24/2024 (3 p.m. to 11 p.m. shift) and 4/28/2024 (7 a.m. to 3 p.m. and 3 p.m. to 11 p.m. shift). During an interview on 7/10/2024 at 3:45 p.m., with the Nurse Manager (NM) 2, NM 2 stated the Initial CSSRS had to be completed on all the patients upon admission and a daily CSSRS would be done on the patients who were identified with SI. In the same interview, on 7/10/2024 at 3:45 p.m., NM 2 stated when the patients’ daily CSSRS was not completed, the patient would not be assessed if he/she was still suicidal and could cause to harm self. During a review of the facility’s policy and procedure (P&P) titled, “Nursing Assessment and Reassessment,” revised in 2/2024, the P&P indicated, “...each patient is assessed every 24 hours and as needed...RN will complete the CSSRS daily while patient remain on suicide precaution...””

“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 four of six sampled clinical staff (Registered Nurse (RN) 1, Mental Health Technicians [MHT] 1, 4, and Charge Nurse (CN) 1) were evaluated to ensure the staff were competent in their respective positions, in accordance with the facility’s policy and procedure regarding staff competency (the application and demonstration of appropriate knowledge, skills and behavior in the clinical setting) and training. This deficient practice had the potential for staff’s inability to perform the essential functions of their respective positions, which may compromise patient safety when necessary patient care interventions are not performed appropriately. Findings: During a concurrent interview and personnel file review on 7/11/2024 at 4:29 p.m. with the Director of Human Resources (DHR), the DHR reviewed the personnel files and stated the following: Competency (the application and demonstration of appropriate knowledge, skills and behavior in the clinical setting) evaluations should be performed annually to ensure staff are competent in their positions and should be documented in the “General/Unit/Program Specific Competency Checklist.” DHR verified Registered Nurse (RN) 1 did not have evidence of any competency evaluations in the file. Mental Health Technician (MHT) 1’s last competency was evaluated on 10/25/2022, was overdue for competency evaluation. During a second concurrent interview and personnel file review on 7/12/2024 at 10:54 a.m. the DHR stated Charge Nurse (CN) 1’s last competency was evaluated on 11/6/2022. Likewise, DHR verified Mental health Technician (MHT) 4 did not have evidence of any competency evaluation in the file. During a review of a checklist titled, “General/Unit/Program Specific Competency Checklist, undated, the Checklist indicated an area to document if a staff is competent (MET) or not competent (Not Met) in the following, including; Facilitates accurate communication between caregivers ...i.e ...critical patient care information. Can identify signs of decompensation (worsening of symptoms). Able to describe the admission and assessment ...Regularly surveys surroundings for safety hazards ...Assures adequate patient safety by timely rounding or supervision ...Identifies patients in crisis, offers appropriate interventions ...Assesses patient’s physical and emotional safety ...Assures that rounds are done and documented accurately. During a review of the facility’s policy and procedure (P&P) titled, “Staff Competency and Training,” dated 8/1/2020, the P&P indicated the following. It is the policy of the Facility to hire individuals who are qualified to perform the essential functions of the position with or without reasonable accommodation.”

“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: 50514 Based on interview and record review, the facility failed to ensure two of 30 sampled patients’ (Patient 29 and 30) nursing assessment (involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected) was completed in accordance with the facility’s guideline regarding Changes to Nursing Admit Assessment and Nursing Progress Notes when, Patient 29 and 30’s daily assessment, completed by the Licensed Psychiatric Technician (LPT), did not have a Registered Nurse (RN) co-signature to indicate the LPT’s assessment was verified by the RN. This deficient practice had the potential for Patients’ 29 and 30’s nursing assessment to be inaccurate and may cause delay in the provision of medical care and treatment that could result in patient harm and or death. Findings: 1. During a review of Patient 29’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/23/2024, the H&P indicated Patient 29 was admitted to the facility for Major depressive disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities). During a review of Patient 29’s nursing assessment (involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected) form dated, 4/29/2024 (3 p.m. to 11 p.m. shift), the form indicated the assessment was completed and signed by Licensed Psychiatric Technician (LPT) 1. The RN signature box beneath the LPT 1 signature box was blank. There was no RN signature in the assessment form completed by LPT 1. The form indicated, “Medical requires RN co-signature if completed by LVN (Licensed Vocational Nurse)/LPT.” During an interview on 7/12/2024 at 10:35 a.m., with Nurse Manager (NM) 2, the NM 2 verified Patient 29’s assessment on 4/29/2024 was completed by LPT 1. NM 2 stated an LVN/LPT should not do the patient’s initial assessments and reassessments alone, the assessment completed by the LVN/LPT must be co-signed by a RN. During a review of the facility’s document titled, “Changes to Nursing Admit Assessment and Nursing Progress Notes”, dated 9/5/2023, the documents indicated on page 2, “LVN/LPT’s completed training to assist w/completion of nursing progress notes, including narrative w/ (with) RN co-signature.” 2. During a review of Patient 30’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/23/2024, the H&P indicated Patient 30 was admitted to the facility on 4/23/2024 for Suicidal Ideations (SI, thoughts of causing one’s own death) with a plan to overdose (taking too much of a substance such as medications). Patient 30’s medical history included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities) and substance abuse (a state of psychological and/or physical dependence on the use of drugs or other substances such as alcohol). During a review of Patient 30’s daily nursing assessment (involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected) dated 4/28/2024 (3 p.m. to 11 p.m. shift), the form indicated the assessment was completed and signed by Licensed Psychiatric Technician (LPT) 1. The RN signature box beneath the LPT 1 signature box was blank. There was no RN signature in the assessment form completed by LPT 1. The form indicated, “Medical requires RN co-signature if completed by LVN (Licensed Vocational Nurse)/LPT.” During an interview on 7/12/2024 at 10:35 a.m., with Nurse Manager (NM) 2, the NM 2 verified Patient 30’s assessment on 4/28/2024 was completed by LPT 1. NM 2 stated an LVN/LPT should not do the patient’s initial assessments and reassessments alone, the assessment completed by the LVN/LPT must be co-signed by a RN. In the same interview on 7/12/2024 at 10:35 a.m., with NM 2, the NM 2 stated there was a change of practice in the facility regarding “Nursing Admission Assessment and Daily Nurse Progress Notes.” The NM 2 stated the change of practice allowed the LVN/Licensed Psychiatric Technician (LPT) to do assessments and RN to co-sign. During a review of the facility’s document titled, “Changes to Nursing Admit Assessment and Nursing Progress Notes”, dated 9/5/2023, the documents indicated on page 2, “LVN/LPT’s completed training to assist w/completion of nursing progress notes, including narrative w/ (with) RN co-signature.””