Aurora Charter Oak

“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 interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Governing Body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision making) was met, as evidenced by: 1. The facility’s Governing Body (the leadership group legally responsible for hospital operations, quality, and safety) failed to ensure oversight across hospital departments to ensure a safe environment, adequate monitoring, and adherence to hospital policies and procedures for one (1) of 34 sampled patients (Patient 1) and for other patients housed across the North, West, and East Units, by failing to prevent the addition and use of nine (9) unlicensed, unbolted, non?ligature?resistant “C beds (portable metal beds with removable metal springs and no tamper-proof hardware),” which were placed across three units (East: 4; West: 3; North: 2) without review, approval, fire?safety evaluation, or inclusion in emergency, fire, or evacuation plans. This deficient practice resulted in unaddressed environmental hazards, including unbolted metal C beds with removable metal parts that could be used for self-harm or to barricade doors, and that obstructed emergency-response space during CPR (cardiopulmonary resuscitation, a life-saving procedure used when a person’s breathing or heartbeat stops) for Patient 1. This deficient practice of not ensuring a safe environment and adequate monitoring also had the potential to result in patient harm for other patients in the facility (Refer to A-0063) 2. The facility’s Governing Body failed to ensure oversight across multiple hospital departments to ensure a safe environment, adequate monitoring, and adherence to hospital policies and procedures for one (1) of 34 sampled patients (Patient 1) and for all patients housed across the North, West, and East Units, by failing to Ensure environmental-risk assessments (systematic checks for hazards in the physical environment) were performed prior to adding “C beds” to patient rooms, including evaluation of fire-safety compliance (standards that determine whether materials resist ignition and reduce fire spread) and consideration of their impact during emergencies. This deficient practice resulted in a lack of fire-safety evaluation, leaving patients in rooms with furniture that had not been assessed for flame-spread or smoke-density compliance. Failure to integrate new equipment into emergency, fire, or evacuation plans, creating a risk that staff would be unprepared to safely respond during an emergency, which may result in patient harm for the facility’s 34 sampled patients and all other patients admitted to the facility. (Refer to A-0063) The cumulative effect of these systemic practices resulted in the facility’s inability to ensure the Governing Body maintained effective oversight and accountability for the hospital’s operations, including environmental safety, fire-safety compliance, licensing requirements, and protections designed to prevent patient harm.”

“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 uphold the patient right to “make informed decisions (involves gathering as much relevant information as possible and considering your options) regarding his or her care,” in accordance with the facility’s policy on patient rights pertaining to access to treatment, by not arranging the recommended orthopedic (the branch of medicine dealing with conditions affecting the bones or muscles) follow-up, for one of 34 sampled patients (Patient 15), nor documenting attempts, refusals, or communication efforts. Patient 15 had sustained a minimally displaced mid-calcaneal fracture (a break in the heel bone with slight movement of the bone fragments) after attempting to elope (a patient leaving a clinical unit or facility without authorization, proper discharge, or informing staff) from the facility by jumping over a fence. This deficient practice violated Patient 15’s right to be fully involved in the development and implementation of the treatment plan, including follow-up care needs. The failure to arrange or document the recommended orthopedic follow-up had the potential to delay necessary treatment and healing, which could result in increased pain, impaired mobility (conditions that limit a person’s ability to move, walk, stand, or use their limbs), improper bone healing (malunion), prolonged disability, and a risk of long-term functional impairment. (Refer to A-0129) 2. The facility failed to ensure that a police report was initiated for one of 34 sampled patients (Patient 31), when Patient 31 requested to press charges against a peer (another patient) who punched him (Patient 31) in the face, in accordance with the facility’s policy titled, “Identifying and reporting dependent adult/elder abuse (mistreatment causing physical or emotional harm),” regarding reporting of abuse to appropriate agencies including law enforcement. This deficient practice violated Patient 31’s right to have a reasonable care request addressed and had the potential for delay of an investigation by the local law enforcement, which may subject Patient 31 to episodes of further abuse or psychological distress. (Refer to A-0129) 3. The facility failed to ensure a safe environment and adequate monitoring for one (1) of 34 sampled patients (Patient 1), who had suicidal ideation (having thoughts of wanting to end one’s own life) and was considered high-acuity (having severe or complex medical or psychiatric needs), by: 3.a. Failing to conduct patient safety rounds (routine checks by staff to ensure patient well-being and safety), in accordance with the facility’s policies titled “Rounds for Patient Observation” (December 2025) and “Unit and Patio Rounds” (November 2025). This deficient practice resulted in incomplete observation of Patient 1 and other patients at risk and had the potential to result in delayed identification of patient distress (signs of suffering or medical problems) or medical emergencies (sudden, serious health problems requiring immediate attention), placing Patient 1 and other patients on the North, West, and East units-including high-acuity and suicide-risk patients-at risk for serious harm, injury, or death. (Refer to A-0144) 3.b. Adding nine (9) portable “C beds (extra beds with metal frames, removable metal springs, and no tamper-proof hardware [hardware that cannot be easily removed or altered] or safety anchors [anchoring devices used to secure equipment in place and prevent movement])” across three units (East: 4; West: 3; North: 2) that are unlicensed (not approved by regulatory authorities), unbolted (not securely attached to the floor or wall) “C beds” that were not ligature-resistant (not designed to prevent attachment of items that could be used for self-harm), and failing to evaluate the material composition of the “C beds” to ensure the materials met fire-safety requirements (standards that determine whether furniture materials resist ignition and reduce fire spread). The portable “C beds” were portable, unbolted, constructed with metal frames and removable metal springs, and not included in emergency, fire, or evacuation plans and documentation of flame-spread or smoke-density compliance was not provided. This deficient practice resulted in a delay in the emergency response (actions taken by staff to respond to urgent medical or safety needs) for Patient 1 and had the potential to expose patients to environmental hazards (dangerous objects or conditions in the environment) that could be used for self-harm (injuring oneself) or to harm others, and involve bed materials that were not evaluated for compliance with fire-safety requirements (standards that determine whether furniture materials resist ignition and reduce fire spread), placing patients at risk for serious injury, impairment (loss of physical or mental function), or death. (Refer to A-0144) 3.c. Failing to conduct environmental safety assessments (systematic checks for hazards in the physical environment) for added “C beds” (portable metal beds with foldable and removable components), including failure to evaluate the material composition of the “C beds” to ensure the materials met fire-safety requirements (standards that determine whether furniture materials resist ignition and reduce fire spread), and failure to include “C beds” in the facility’s emergency, fire, or evacuation plans (written procedures for responding to emergencies, fires, or relocation of patients to safety). No documentation was provided showing that a risk assessment or fire-safety evaluation was completed prior to placing these beds into patient rooms. This deficient practice resulted in unmitigated (unaddressed) environmental hazards, lack of evaluation of fire-safety compliance of the bed materials (standards that determine whether furniture materials resist ignition and reduce fire spread), and insufficient preparedness for emergencies, and had the potential to place Patient 1 and other patients at risk for serious harm or injury. (Refer to A-0144) 4. The facility failed to ensure that three (3) of 34 sampled patients (Patients 18, 29, and 30), were free from all forms of abuse (mistreatment causing physical or emotional harm), neglect (failure to provide necessary care), or harassment (behavior that intimidates or threatens ), when the facility did not implement effective mechanisms/interventions to protect patients from abuse and harassment by other patients, in accordance with the facility’s policy titled “Management of the disturbed/agitated patient,” regarding Patient Rights to ensure safety, when: 4.a. The facility failed to protect two (2) of 34 sampled patients (Patients 29 and 30) from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish), from another patient (Patient 28- the perpetrator), in accordance with the facility’s policy and procedure (P&P) titled “Patient Rights and Notification.” Patient 28 followed Patient 29, rushed into Patient 29’s room and assaulted him (Patient 29). Less than 24 hours later, Patient 28 punched another peer (Patient 30) in the face when they (Patient 28 and Patient 30) encountered each other in the hallway. Despite these incidents, Patient 28’s level of observation (refers to the set intensity and frequency of monitoring a patient to ensure safety based on their risk level) remained at every 15 minutes (often called Q15 or q15 checks- a high-level safety protocol, mainly in psychiatric care, requiring staff to physically check and confirm the location, safety, and breathing of a patient every 15 minutes), with no escalation of monitoring to the physician or implementation of a higher level of patient monitoring/observation. This deficient practice led to Patient 29 experiencing swelling on the left cheek/forehead, a lip laceration, and redness in the right eye. Patient30 suffered redness to the right side of face/nose and a bloody mouth. This deficient practice also placed other patients at risk for further abuse from Patient 28. (Refer to A-0145) 4.b. The facility failed to ensure a safe environment (free from physical abuse, the use of physical force that results in, or had the potential to result in, bodily injury, pain, or impairment) for one of 34 sampled patients (Patient 18), when Patient 18 was physically assaulted by Patient 33 (identified as high risk for aggressive behavior) who was not monitored. This deficient practice resulted in Patient 18 sustaining bruising on the right forehead and left eyelid (discoloration of the skin caused by bleeding underneath, typically due to trauma), an abrasion on the left eyelid (a superficial scrape or wearing away of the skin surface), and slight drooping of the left eyelid (partial sagging or lowering of the eyelid, medically referred to as ptosis). This deficient practice also violated Patient 18’s right (the fundamental entitlements guaranteed to patients, including the right to be treated with dignity, respect, and to be free from any form of abuse, neglect, or exploitation) to be free of any form of abuse. (Refer to A-0145) 5. The facility failed to ensure that appropriate agencies including CDPH (California Department of Public Health, a state government agency dedicated to protecting and improving the health, safety, and well-being of patients), was notified regarding incidents of abuse for four (4) of 34 sampled patients (Patients 18, 29, 30, and 31), in accordance with State and Federal Laws regarding reporting of suspected abuse involving patients to regulatory agencies and the facility’s policy pertaining to reporting of unusual occurrences that threatens patient safety. This deficient practice had the potential to delay an investigation by the Department into allegations of abuse involving Patients 18, Patient 29, Patient 30, and Patient 31, which may result in further incidents of patient abuse for Patients 18, 29, 30, and 31, as well as other patients in the facility and subjecting the patients to injuries (such as bruises) including psychological distress. (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.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 46333 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Quality Assurance and Performance Improvement (QAPI) was met, as evidenced by: 1. The facility’s QAPI (Quality Assessment and Performance Improvement- mandatory, comprehensive, and data-driven system designed to improve patient care, safety, and outcomes. It combines proactive performance improvement [PI] with reactive quality assurance [QA] to reduce medical errors, monitor adverse events, and ensure compliance) committee failed to collect and analyze required fire-safety data before placing nine (9) unlicensed “C beds (portable metal beds with foldable components and removable metal springs)” across three inpatient units, affecting all patients housed in rooms with these “C” beds, including but not limited to five (5) high?risk patients (Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5). The facility did not obtain or review information regarding material composition (what the bed and mattress were made of), flame-spread rating (how quickly fire travels across a material surface), or smoke-density rating (how much smoke a material produces when burning), [as required by facility policy and Life Safety Code]. This deficient practice had the potential to result in patients being exposed to furniture materials with unknown ignition and smoke-generation characteristics during a fire or evacuation, including risk of injury, smoke inhalation, or death, especially for patients with severe psychiatric symptoms who may be less able to respond to fire or evacuation instructions. (Refer to A-0273) 2. The facility’s QAPI committee failed to conduct a formal investigation to collect data and use it to monitor the effectiveness and safety of services and implement timely, measurable corrective actions following a serious elopement (a patient leaving a clinical unit or facility without authorization, proper discharge, or informing staff) event for one of 34 sampled patients (Patient 14). Specifically, the facility did not develop a formal, time-bound Plan of Correction (POC), failed to implement any interim safety measures, and did not establish or document monitoring processes to evaluate whether corrective actions were effective. In addition, the facility collected data on attempted and completed elopements but did not establish benchmarks, evaluation criteria, or documented follow-up to assess the success of the interventions outlined in the plan of action for elopements and did not reflect whether each elopement or attempted elopement had been evaluated against the required interventions This deficient practice had the potential to place Patient 14 and all facility patients (the universe of all individuals receiving care within the facility) at risk for elopement at continued risk of elopement-related harm by allowing patterns of elopement?related safety risks to remain unidentified and unaddressed (meaning patients could be exposed to dangers associated with leaving the hospital without authorization, including injury, exploitation, exposure to unsafe environments, or interruption of essential medical or psychiatric treatment). (Refer to A-0273) 3. The facility’s QAPI committee failed to evaluate the effectiveness of interventions, did not measure success, and did not audit compliance in response to repeated facility incidents of assault (refers to the act of causing physical harm to another person) in order to determine whether the interventions outlined in the quarterly plan of action were effective for three (3) of 34 sampled patients (Patients 18, 29 and 30) and which may impact all of the facility’s patients. Although the facility collected quarterly assault data (counts, injuries, ED [Emergency Department] transfers, shift/day), the QAPI team did not use these data to conduct trend analysis, identify contributing factors, or drive changes to interventions. Specifically, the QAPI team did not assess whether its preventive actions reduced incidents of assault, reduced severity, or improved patient safety, and there was no systematic analysis to determine whether the interventions lowered the risk of patient-to-patient assault or abuse (mistreatment causing physical or emotional harm). Additionally, not all assault-related outcomes were reported to the QAPI Committee, Medical Executive Committee (MEC, defined as the body of physician leaders responsible for oversight of clinical care quality and safety), or the Governing Body (defined as the entity legally responsible for the conduct of the hospital, including oversight of quality, safety, and compliance). This deficient practice had the potential to place Patients 18, 29 and 30, and all facility patients to ongoing assault-related risks, including patient-to-patient harm and physical abuse, and also increase staff injury risk (Refer to A-0273). 4. The facility failed to identify opportunities for improvement and take actions to mitigate environmental safety hazards associated with the addition of nine (9) unlicensed “C beds (portable metal beds with removable metal springs and foldable metal frames)” placed across three inpatient units, for five (5) high-risk patients (Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5) sampled from 34 patients, who were housed in rooms containing the added “C beds.” The hazards included obstruction of emergency response pathways (blocked physical space needed for care), ligature hazards (items that could be used for self-harm), and weaponization hazards (items that could be used to harm others). This deficient practice had the potential to result in delayed emergency treatment for Patient 1, increased risk of patient self-harm, and increased risk of physical harm to Patients 1, 2, 3, 4, and 5 and all other patients or staff at the facility due to unsecured and removable metal components. (Refer to A-0283) 5. The facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) program (defined as the hospital-wide, data-driven program required to monitor, analyze, and improve the quality and safety of patient care) established and maintained an effective system for identifying, tracking, analyzing, and reporting adverse patient events (An event in which care resulted in an undesirable clinical outcome) that included incidents of patient elopements (when a patient leaves a healthcare facility without authorization, discharge, or notifying staff, often posing severe safety risks) with or without injury for three (3) of 34 sampled patients (Patients 11, 15, and 16) and incidents of patient assault (the act of causing physical harm or unwanted physical contact to another person) with or without injury for three (3) of 34 sampled patients (Patients 18, 29 and 30). The QAPI committee did not maintain a log of patient-to-patient assaults, did not track adverse events (involving patient elopements or patient assault) resulting in patient harm (including injuries and Emergency Department transfers), and did not track or report abuse-related incidents, in accordance with regulatory requirements. This prevented the facility from demonstrating the ongoing monitoring required for compliance with patient-safety and quality improvement programs and from maintaining formal records of investigations in accordance with its QAPI plan (defined as the facility’s structured, data-driven method for reviewing adverse events, identifying causes, implementing corrective actions, and measuring improvement). In addition, the facility failed to report abuse-related events-including patient-to-patient assaults and injuries requiring Emergency Department evaluation-to the State regulatory authority as required, which can affect all patients at the facility. This deficient practice had the potential to place all patients at the facility, not just the six (6) sampled patients (Patients 11, 15, 16, 18, 29 and 30), at risk for unrecognized and unmitigated harm. The failure to report these events also had the potential to hinder external oversight, delay protective actions, and lead to repeated incidents of patient harm such as additional incidents of Patient elopement and/or patient abuse/assault. (Refer to A-0286) 6. The executive leadership (Governing Body, GB- defined as the entity legally responsible for the conduct of the hospital, including oversight of quality, safety, and compliance), responsible for defining, implementing, and maintaining hospital-wide programs that improve patient safety and reduce adverse events, failed to ensure that its QAPI (Quality Assessment and Performance Improvement, defined as the hospital-wide, data-driven program required to monitor, analyze, and improve the quality and safety of patient care) program addressed priorities for improved quality of care and patient safety as evidenced by a high number of ongoing patient-to-patient assault (the act of causing physical harm or unwanted physical contact to another person) events, as evidenced by patient-to-patient assault cases involving three (3) of 34 sampled patients (Patients 18, 29, and 30). Specifically, the Governing Body failed to ensure that the facility’s action plan for reducing assaults was evaluated for effectiveness and failed to ensure that systems were in place to track assaults, assess risk, determine whether corrective actions were effective, and ensure compliance with abuse-reporting mandates. This deficient practice had the potential to place Patients 18, 29 and 30 including all other patients admitted to the facility, at continued risk for harm due to continued patient assaults and unmitigated safety hazards. (Refer to A-0309) 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: 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 escalated monitoring and interventions (actions taken to keep the patient safe) and failed to notify the physician (the medical doctor responsible for the patient’s care) for one (1) of 34 sampled patients (Patient 1) after Patient 1 scored 6 (the highest possible risk of suicide) on the suicide risk assessment (a test to measure how likely a person is to try to end their own life) at 5:12 p.m. on 11/16/2025, as required by the facility’s “Precautions and Observation Levels” policy for imminent suicide risk (danger that someone may try to end their own life very soon). This deficient practice resulted in Patient 1 remaining in a room with a C bed (portable metal bed with removable components) with a metal frame and removable metal springs and was not placed under a higher level of observation (such as 1:1 level of observation [defined as continuous, one-to-one observation in which a staff member remains within arm’s reach of a patient at all times to ensure immediate intervention and prevent harm), leaving Patient 1 without required protective interventions for approximately 14 hours (from 5:12 p.m. on 11/16/2025 until found unresponsive [not awake and not responding] at 8:02 a.m. on 11/17/2025), placing the patient (Patient 1) at immediate risk for serious harm, injury, or death. (Refer to A-0395) 2. The facility failed to ensure nursing staff prepared and administered medications, in accordance with the practitioner’s orders and accepted standards of practice regarding medication preparation and administration, for one (1) of 34 sampled patients (Patient 5). Specifically, nursing staff did not obtain baseline vital signs (heart rate, blood pressure, temperature, and breathing rate) before administering STAT (immediate-use) medications (Ativan- a sedative medication, Benadryl 50 mg oral liquid- an antihistamine medication, and Haldol 5 mg oral concentration- an antipsychotic medication) for agitation (sudden episode of extreme restlessness, irritability, or aggressive behavior that poses a risk to the patient or others), and staff did not complete a post-administration reassessment as required by the practitioner’s orders and the facility’s policy titled “Administration and Documentation of Medications.” The only nursing documentation entered into the Medication Administration Record (MAR) was the single word “effective,” which did not include vital signs, physical assessment findings, mental status assessment, or any observable description of the patient’s (Patient 5) response to the medications. This deficient practice resulted in the facility not identifying the patient’s (Patient 5) physical condition before receiving medications that may lower blood pressure or cause sedation (the medical use of sedative medications to induce a state of relaxation, calmness, or sleepiness, reducing anxiety and discomfort), and not identifying the patient’s (Patient 5) physical or mental response after medication administration. (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.”

“LICENSURE OF HOSPITAL CFR(s): 482.11(b) The hospital must be - o Licensed; or o Approved as meeting standards for licensing established by the agency of the State or locality responsible for licensing hospitals. This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the hospital failed to operate within its licensed bed inventory by adding and using nine (9) unlicensed portable “C beds (portable metal beds with foldable and removable components)” across three units (East: 4; West: 3; North: 2) without licensure approval (authorization by the State licensing authority), environmental-risk assessment (systematic checks for hazards in the physical environment), fire-safety evaluation (assessment of flame-spread and smoke-density compliance), or inclusion in emergency, fire, or evacuation plans (written procedures for responding to emergencies, fires, or relocating patients to safety), which affects 34 of 34 sampled patients. This practice did not comply with 42 CFR §482.11(b) (hospital must be licensed or approved to State licensing standards). This deficient practice had the potential to result in delayed emergency response (actions taken by staff to respond to urgent medical or safety needs), obstructed access during CPR (cardiopulmonary resuscitation-a life-saving procedure used when a person’s heart or breathing stops) for Patient 1, and environmental hazards (dangerous objects or conditions in the environment) caused by unbolted metal frames and removable metal springs that could be used for self-harm (injuring oneself), to harm others, or to block doorways, placing patients at risk for serious harm, injury, impairment (loss of physical or mental function), or death. Findings: During a review of surveillance video dated 11/17/2025, conducted on 2/4/2026 at 11:02 a.m. with the Chief Executive Officer (CEO), the video showed that at 8:05 a.m., staff pushed a “C bed (a portable metal bed with foldable and removable components)” from Patient 1’s room into the hallway to create space to perform CPR (cardiopulmonary resuscitation-a life?saving procedure used when a person’s heart or breathing stops). During an observation on 2/3/2026 at 12:10 p.m. in the West Unit in rooms 220 and 221, portable “C beds (portable metal bed frames with foldable components)” were present in each patient room. The beds were unbolted (not attached to the floor or wall), constructed of metal frames (solid metal structures), and contained removable metal springs (detachable metal components). The beds lacked tamper-proof hardware (hardware resistant to removal or alteration) and safety straps (devices used to secure equipment). The folded beds were easily movable. Additional “C beds” were observed in North Unit rooms 232 and 238. During an interview on 2/3/2026 at 12:20 p.m. with the Director of Nursing (DON), the DON stated the facility used the same portable beds throughout the units and confirmed the beds were light enough for one person to move. The DON stated there were nine (9) “C beds” added across three units: four (4) in East, three (3) in West, and two (2) in North. The DON stated they were unsure when the facility began adding “C beds” to patient rooms and unsure whether the beds went through the licensing body for approval. During an interview on 2/4/2026 at 9:10 a.m. with the CEO, the CEO stated the “C beds (portable metal beds with foldable components)” were not listed on the facility’s license (state-issued authorization identifying approved bed types) and the facility did not have a flex path (regulatory process allowing temporary or alternative licensed bed use) for the “C beds.” The CEO did not provide an answer regarding when the “C beds” were added to patient rooms and did not recall whether the addition was reviewed in a safety meeting. The CEO did not provide evidence that the safety considerations for the “C beds” were discussed with the Governing Body (leadership group legally responsible for hospital operations, quality, and safety). During a concurrent interview and review of surveillance video on 2/4/2026 at 11:02 a.m. with the CEO, footage dated 11/17/2025 showed that at 8:05 a.m., staff moved a portable “C bed” from Patient 1’s room into the hallway to create space to perform CPR. During an interview on 2/4/2026 at 1:55 p.m. with Charge Nurse (CN 1), CN 1 confirmed there were two “C beds” in North Unit rooms 238 and 240. CN 1 stated patients housed in the North Unit were high acuity (having severe or complex medical or psychiatric needs) and may be detoxing or a danger to self or others. During an interview on 2/4/2026 at 3:05 p.m. with the Director of Quality (DQ), the DQ stated no environmental?risk assessment (systematic check for hazards in the physical environment), no flame?spread evaluation, and no smoke?density or material?composition review, were completed before or after placing “C beds” in patient rooms. During an interview on 2/4/2026 at 3:08 p.m. with the Plant Operations/Safety Officer (SO 1), SO 1 stated the “C beds” had a metal frame (a solid metal structural base) with removable metal springs (metal components providing support and tension) that could be removed by hand. SO 1 stated they were unsure what material the mattress was made of and did not know who verified whether the mattress material met fire?safety requirements (standards that determine whether materials resist ignition and reduce fire spread). SO 1 stated there was no documentation showing Purchasing Department approval for acquiring the “C beds.” During a concurrent interview and record review on 2/4/2026 at 3:20 p.m. with SO 1, the facility’s Emergency, Fire, and Evacuation Plans (written procedures for responding to emergencies, fires, or relocating patients to safety), were reviewed. The plans did not reference the “C beds,” their placement in patient rooms, or instructions for managing them during an emergency, fire, or evacuation. SO 1 stated the removable metal springs could be used as a weapon (an object used to strike or cause injury) and stated the unbolted bed frame could be used to block a doorway. During a review of the facility’s policy and procedure (P&P) titled “Quality Management Program and Performance Improvement Plan,” dated January 2026, the P&P indicated “Membership in the Quality Improvement Council shall include, but not be limited to: the CEO, Medical Director, CNO, DON, Director of Quality Improvement, Director of Clinical Services and Service Directors. The CEO shall serve as the chairperson. The Council shall meet not less than quarterly to meet its responsibilities. The committee shall record its activities and report to the Governing Body at least quarterly. In addition, the Quality Council shall have the following responsibilities: Ensure compliance with standards and regulations governing the accreditation, licensure and certification of the hospital.” During a review of the facility’s policy and procedure (P&P) titled “Fire Safety management Plan,” undated, the P&P indicated the hospital was responsible for maintaining a fire-safe environment and ensuring furnishings complied with applicable safety standards. During a review of the facility’s policy and procedure (P&P) titled “Policy for Acquisition of Furnishings,” undated, the P&P indicated hospital furnishings must comply with Life Safety Code flame-spread and smoke-density rating and that the Purchasing Department was responsible for ensuring materials met required standards and maintaining documentation. During a review of the facility’s policy and procedure (P&P) titled “Quality Management Program and Performance Improvement Plan,” dated 2026, the P&P indicated the Governing Body had the ultimate responsibility for establishing, maintaining, and supporting the ongoing quality- improvement program and for reviewing and evaluating activities related to the safety and quality of patient care.”

“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 leadership group legally responsible for hospital operations, quality, and safety) failed to ensure oversight across hospital departments to ensure a safe environment, adequate monitoring, and adherence to hospital policies and procedures for one (1) of 34 sampled patients (Patient 1) and for all patients housed across the North, West, and East Units, by failing to: 1.Prevent the addition and use of nine (9) unlicensed, unbolted, nonligature-resistant “C beds (portable metal beds with removable metal springs and no tamper-proof hardware),” which were placed across three units (East: 4; West: 3; North: 2) without review, approval, fire-safety evaluation, or inclusion in emergency, fire, or evacuation plans. This deficient practice resulted in unaddressed environmental hazards, including unbolted metal C beds with removable metal parts that could be used for self-harm or to barricade doors, and that obstructed emergency-response space during CPR (cardiopulmonary resuscitation, a life-saving procedure used when a person’s breathing or heartbeat stops) for Patient 1. This deficient practice of not ensuring a safe environment and adequate monitoring also had the potential to result in patient harm for other patients in the facility 2. Ensure environmental-risk assessments (systematic checks for hazards in the physical environment) were performed prior to adding “C beds” to patient rooms, including evaluation of fire-safety compliance (standards that determine whether materials resist ignition and reduce fire spread) and consideration of their impact during emergencies. This deficient practice resulted in a lack of fire-safety evaluation, leaving patients in rooms with furniture that had not been assessed for flame-spread or smoke-density compliance. Failure to integrate new equipment into emergency, fire, or evacuation plans, creating a risk that staff would be unprepared to safely respond during an emergency, which may result in patient harm for the facility’s 34 sampled patients and all other patients admitted to the facility. Findings: 1. During a concurrent observation and interview on 2/3/2026 at 12:10 p.m. with the Director of Nursing (DON), in the West Unit in rooms 220 and 221, an additional “C bed (a portable metal bed frame with foldable components)” was observed positioned in each patient room. The “C beds” in both rooms (220 and 221) were identical. The DON stated the facility utilized the same portable beds throughout the facility. The “C bed” in room 220 was unbolted (not attached to the floor or wall), constructed with metal frames (solid metal structures), and contained removable metal springs (metal components that could be detached). The beds lacked tamper-proof hardware (hardware resistant to removal or alteration) and safety straps (devices used to secure equipment). When the bed was folded, it was easily movable (able to be pushed or repositioned with little effort). The DON confirmed the “C beds” were light enough to be moved by one person and stated that all “C beds” used in the facility were portable and not bolted or made unremovable. It was also observed with the DON, in the North unit, there were additional “C” beds in room 232 and room 238. During the same interview on 2/3/2026 at 12:20 p.m. with DON, the assignments board for East, West, and North units, was reviewed. The DON stated, “There are Nine (9) C beds added across three units: - East Unit: Licensed for 16 beds; 4 C beds added. - West Unit: Licensed for 14 beds; 3 C beds added. - North Unit: Licensed for 20 beds; 2 C beds added. -The DON stated she was unsure when the facility started adding the C beds in patients’ rooms. DON also said she was unsure if the C bed went through the appropriate licensing body for approval. During an interview on 2/4/2026 at 9:10 a.m. with the Chief Executive Officer (CEO, the highest?ranking executive responsible for the overall management and daily operations of an organization and for executing the Governing Body’s strategic vision), the CEO stated that the “C beds (portable metal beds with foldable components)” were not listed on the facility’s license (the state-issued authorization identifying approved bed types) and that the facility did not have a flex path (a regulatory process that allows temporary or alternative licensed bed use) for the “C beds.” The CEO stated the addition of the “C beds” did not exceed the facility’s census (the number of patients present in the facility). The CEO did not provide an answer regarding when the facility began adding the “C beds” to patient rooms. The CEO did not recall if there was a safety meeting to discuss adding the “C beds” prior to placing them in patient-care areas. The CEO did not provide evidence that the safety plan for the “C beds” was discussed with the Governing Body. During an interview on 2/4/2026 at 1:15 p.m. with the Director of Quality (DQ), DQ stated adding new beds should go through licensing first; if approved, required steps must be completed before expansion. During a concurrent observation, interview and surveillance?video review on 2/4/2026 at 11:02 a.m. with the Chief Executive Officer (CEO), the surveillance video of the North Unit hallway, with a view of Patient 1’s room doorway, dated 11/17/2025, was reviewed. The video showed that at 8:05 a.m., during the emergency response for Patient 1, staff pushed a “C bed (a portable metal bed with foldable and removable components)” from Patient 1’s room into the hallway to create physical space for CPR (cardiopulmonary resuscitation-a life?saving procedure used when a person’s heart or breathing stops). The CEO confirmed that at 8:05 a.m. staff moved a portable “C bed” from Patient 1’s room into the hallway to create space for CPR. During an interview on 2/4/2026 at 1:55 p.m. with Charge Nurse (CN 1), CN 1 confirmed the presence of two C beds in North Unit (Rooms 238 and 240). CN 1 stated patients housed in this unit were high acuity, meaning they are danger to self or others, maybe detoxing (patients requiring medical and non-medical treatments to help manage withdrawal symptoms when abstaining from drugs or alcohol) and were not safe to house with other patients. During an interview on 2/4/2026 at 3:08 p.m. with the Plant Operations/Safety Officer (SO 1), SO 1 stated they were aware of the composition of the “C bed.” SO 1 stated the bed had a metal frame (a solid metal structural base) with metal spring parts (metal components that provide support and tension) that could be removed by hand. SO 1 stated they were unsure what material the mattress was made of and did not know who verified whether the mattress material met fire-safety requirements (standards that determine whether furniture materials resist ignition and reduce fire spread). SO 1 stated that when new items were needed, the Safety Department presented the items to the Purchasing Department, which determined whether it was appropriate to purchase them. SO 1 stated the facility did not have documentation showing Purchasing Department approval for acquiring the “C beds.” During a concurrent interview and record review on 2/4/2026 at 3:20 p.m. with SO 1, the facility’s “Fire Safety Management Plans (written procedures for responding to emergencies, fires, and relocation of patients to safety),” were reviewed. SO 1 confirmed the plans did not include the “C beds,” and Environmental Rounding (routine physical-environment checks to identify hazards) did not address the presence or safety characteristics of the “C beds.” No documentation referenced the “C beds,” their placement in patient rooms, or instructions for managing them during an emergency, fire event, or evacuation. SO 1 confirmed that the facility’s Emergency Safety Plans indicated no reference to C beds in: Emergency Plans, Fire Safety, Evacuation Procedures, or Environmental Rounding Logs. SO 1 also confirmed the “C” beds could be used to block a doorway or create hazards during evacuation. During a review of the facility’s policy and procedure (P&P) titled, “Quality Management Program and Performance Improvement Plan,” dated 2026, the P&P indicated, “The Board of Trustees, as the governing body of the hospital, has the ultimate responsibility and authority to establish, maintain, and support the ongoing quality-improvement program ... The Board will review and evaluate activities to assess and continually improve the overall quality and efficiency of patient care ... and will update the plan annually in response to changes in the internal or external environment.” During a review of the facility’s policy and procedure (P&P) titled, “Fire Safety management Plan,” undated, the P&P indicated, Fire Evacuation: The policy of the Hospital to maintain a fire evacuation procedure to assure that all staff can proceed with an organized evacuation in the event of a fire ...In case of needed evacuation due to fire, flood, bomb threat, earthquake or hurricane ... All patients and employees will evacuate through the nearest safe exit while closing all windows and doors behind them ... Compartmentalization in the event of fire and/or smoke works ONLY if all doors in the building are closed.” The policies did not include the C beds addition that are occupied by patients. 2. During an interview on 2/4/2026 at 3:08 p.m. with the Plant Operating/Safety Officer (SO 1), SO 1 confirmed the “C” beds had metal frames and removable metal springs, which could be pulled out by hand and used as weapons. SO 1 could not identify the mattress material or whether it met fire-safety requirements. No documentation showed Purchasing Department approval prior to acquiring the “C” beds. During a concurrent interview and record review on 2/4/2026 at 3:20 p.m. with SO 1, the facility’s “Fire Safety Management Plans (written procedures for responding to emergencies, fires, and relocation of patients to safety),” were reviewed. SO 1 confirmed the plans did not include the “C beds,” and Environmental Rounding (routine physical?environment checks to identify hazards) did not address the presence or safety characteristics of the “C beds.” No documentation referenced the “C beds,” their placement in patient rooms, or instructions for managing them during an emergency, fire event, or evacuation. SO 1 confirmed that the facility’s Emergency Safety Plans indicated no reference to C beds in: Emergency Plans, Fire Safety, Evacuation Procedures, or Environmental Rounding Logs. SO 1 also confirmed the “C” beds could be used to block a doorway or create hazards during evacuation. During an interview on 2/4/2026 at 3:05 p.m. with the Director of Quality (DQ), Director of Quality confirmed no environmental-risk assessment was conducted before or after placing C beds in patient rooms. No flame-spread, smoke-density, or material-composition evaluation was completed. During a review of the facility’s policy and procedure (P&P) titled, “Quality Management Program and Performance Improvement Plan,” dated 2026, the P&P indicated, “The Board of Trustees, as the governing body of the hospital, has the ultimate responsibility and authority to establish, maintain, and support the ongoing quality-improvement program ... The Board will review and evaluate activities to assess and continually improve the overall quality and efficiency of patient care ... and will update the plan annually in response to changes in the internal or external environment.” During a review of the facility’s policy and procedure (P&P) titled, “Fire Safety management Plan,” undated, the P&P indicated, “The Fire Safety Management Plan defines the mechanisms for interaction and oversight for the primary functions involved with Fire Safety ... The administration and oversight of fire safety management is primarily the responsibility of the maintenance department and the Safety Officer ...Maintenance is responsible for keeping the flame ratings requirements for acquisitions of bedding, window draperies/curtains, :furnishings, decorations, wastebaskets and other equipment. Purchasing Services is responsible to ensure that all materials purchased meet these requirements and standards.” During a review of the facility’s policy and procedure (P&P) titled, “Policy for Acquisition of Furnishing,” undated, the P&P indicated, “To provide materials for hospital furnishings that comply with Life Safety Code flame spread and smoke density ratings. To provide flame spread and smoke density ratings on all furnishing type products that are purchased for use at the hospital. The purchase of materials should by in large be purchased through corporate approved vendors. When purchases are to be made, the corporate purchasing department should be contacted for samples, and the name of corporate approved vendors. The corporate purchasing department will ensure that materials comply with necessary standards and provide necessary documentation of flame spread and smoke density should the purchased made through corporate purchasing ...The Purchasing Department will ensure that these products meet with the appropriate Class rating for smoke density, and flame spread per the 1997 Life Safety Code. In ·a11 cases the corporate purchasing department should be contacted to assist in verifying the safety of a product to be placed in the facility.””

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 46238 Based on interviews and record reviews, the facility failed to ensure that patient care requirements are met, when the facility failed to: 1. Uphold the patient right to “make informed decisions (involves gathering as much relevant information as possible and considering your options) regarding his or her care,” in accordance with the facility’s policy on patient rights pertaining to access to treatment, by not arranging the recommended orthopedic (the branch of medicine dealing with conditions affecting the bones or muscles) follow-up for one of 34 sampled patients (Patient 15), nor documenting attempts, refusals, or communication efforts. Patient 15 had sustained a minimally displaced mid?calcaneal fracture (a break in the heel bone with slight movement of the bone fragments) after attempting to elope (a patient leaving a clinical unit or facility without authorization, proper discharge, or informing staff) from the facility by jumping over a fence. This deficient practice violated Patient 15’s right to be fully involved in the development and implementation of the treatment plan, including follow-up care needs. The failure to arrange or document the recommended orthopedic follow-up had the potential to delay necessary treatment and healing, which could result in increased pain, impaired mobility (conditions that limit a person’s ability to move, walk, stand, or use their limbs), improper bone healing (malunion), prolonged disability, and a risk of long-term functional impairment. 2. Ensure that a police report was initiated for one of 34 sampled patients (Patient 31), when Patient 31 requested to press charges against a peer (another patient) who punched him (Patient 31) in the face, in accordance with the facility’s policy titled, “Identifying and reporting dependent adult/elder abuse (mistreatment causing physical or emotional harm),” regarding reporting of abuse to appropriate agencies including law enforcement. This deficient practice violated Patient 31’s right to have a reasonable care request addressed and had the potential for delay of an investigation by the local law enforcement, which may subject Patient 31 to episodes of further abuse or psychological distress. Findings: 1. During a review of Patient 15’s “Psychiatric Evaluation (a mental health assessment used to diagnose emotional, behavior, and cognitive conditions),” dated 7/31/2026, the record indicated that Patient 15 was admitted to the facility with a diagnosis of unspecified psychosis (a mental condition characterized by disorganized thinking, impaired perception of reality, and disturbances in behavior or cognition [the mental process of acquiring knowledge and understanding through thought, experience, and the senses]) and was placed on an involuntary hold (a legal detention for evaluation and treatment when a patient is deemed a danger to self, danger to others, or gravely disabled due to mental illness) due to being a danger to others (DTO). During a concurrent interview and record review on 2/5/2026 at 9:50 a.m. with the Director of Nursing (DON), Patient 15’s Nurse Progress Note, dated 8/7/2026, was reviewed. The note indicated that Patient 15 was sent to the Emergency Department (ED, a hospital unit that provides immediate evaluation and treatment for urgent or emergent medical conditions) after he (Patient 15) sustained a right heel fracture (broken bone). The note also indicated that Patient 15 would be placed in a right posterior long leg splint (a type of immobilization device that supports the leg from the thigh to the foot along the back side, allowing swelling while stabilizing the fracture), with a recommendation to follow up with orthopedics (a medical specialty focused on diagnosing and treating conditions involving the bones, joints, and musculoskeletal system) in 3-4 days. The DON stated that nursing and/or case management (CM) was responsible for arranging a follow-up appointment if one was necessary. During a review of Patient 15’s “Medical Doctor Follow?up Progress Note,” dated 8/8/2025, the note indicated that on 8/7/2025, Patient 15 attempted to elope (to leave or escape the facility without authorization) and jumped over a fence. The note also indicated that Patient 15 was diagnosed with a minimally displaced mid-calcaneal fracture (a break in the heel bone with slight shifting of the bone fragments, located in the middle portion of the calcaneus) and was sent back (from the ED) to the facility with an ACE wrap (an elastic compression bandage used to reduce swelling and provide support) to the right foot and a recommendation to follow up with an orthopedic surgeon. The note also indicated that Patient 15 was referred to an orthopedic doctor, with the physician’s name and phone number documented in the note. This record was reviewed with the Director of Nursing (DON) on 2/5/2026. During a concurrent interview and record review on 2/5/2026 at 9:55 a.m. with the Director of Nursing (DON), Patient 15’s record titled “MD Follow-up Progress Notes,” dated 8/8/2025, was reviewed. The DON stated that based on the record, Patient 15 was referred to an orthopedic doctor (a medical doctor who specializes in diagnosing and treating injuries and disorders of the bones, joints, and musculoskeletal system) by internal medicine (a primary care medical specialty focused on the comprehensive, non-surgical diagnosis, treatment, and prevention of complex, chronic, and acute diseases in adults), and the surgeon’s phone number was documented in the note. The DON confirmed that no further follow?up was documented in Patient 15’s medical chart and that no documentation could be found indicating that this follow-up appointment was attempted to be arranged for Patient 15. The DON also stated that nursing staff could have documented if the patient refused the follow?up appointment but did not confirm nor deny whether documenting follow?up arrangements or refusals was mandatory. During the same interview on 2/5/2026 at 9:55 a.m. with the Director of Nursing (DON), the DON confirmed that, potentially, the lack of follow?up with the orthopedic doctor could have caused a delay in treatment, but did not confirm whether the failure to arrange a timely follow-up actually resulted in a delay of treatment for Patient 15. During a concurrent interview and record review on 2/5/2026 at 10:15 a.m. with the Director of Nursing (DON), Patient 15’s Nursing Progress Note, dated 8/19/2025, was reviewed. The note indicated that on 8/19/2025 (11 days after Patient 15 sustained the fracture to the right heel), Patient 15 was offered (per internal medicine recommendation) to obtain a repeat X-ray (imaging) to evaluate how the right heel fracture was healing. Patient 15 refused the repeat X-ray and agreed to follow up with an orthopedic physician after discharge, which the case manager (CM) arranged. The DON stated that Patient 15 was “probably” refusing to see orthopedic before 8/19/2025 but confirmed that there were no documented attempts to arrange an orthopedic follow-up or a repeat X-ray for Patient 15 prior to the documentation on 8/19/2025. During a review of the facility’s policy and procedure (P&P) titled “Patient Rights and Notifications,” dated 11/2025, the P&P indicated that, “Each patient shall have access to treatment ...and shall have the right to be involved fully in the development and implementation of their treatment plan...” 2. During a review of Patient 31’s “Psychiatric Evaluation (Psych eval, a mental health assessment used to diagnose emotional, behavior, and cognitive conditions),” dated 9/7/2025, the Psych eval indicated Patient 31 was admitted to the facility with chief complaint of “I fight with the staff.” During a concurrent interview and record review on 2/9/2026 at 11:14 a.m. with the House Supervisor (HS) 1, Patient 31’s “Acute Progress Notes (Night),” dated 9/8/2025, was reviewed. The progress notes indicated, (on 9/8/2025) Patient 31 was pacing in the hallway and became confrontational with a peer (another patient) who was also pacing. The peer then struck Patient 31 in the face, pushed Patient 31 to the ground, and was then observed to have blood dripping from the mouth (Patient 31). HS 1 stated that Patient 31 would like to press charges towards the peer. During the same concurrent interview and record review on 2/9/2026 at 11:14 a.m. with HS 1, HS 1 stated the patient (Patient 31) had the right to contact law enforcement if Patient 31 wished to file a police report. HS 1 said that the expectation for the staff was to provide Patient 31 with the police contact number upon request. During an interview on 2/9/2026 at 11:58 a.m. with the Director of Quality Assessment and Performance Improvement Risk Management (QA), QA stated that for Patient 31, no police report was filed. QA stated that it was important for Patient 31 to be provided the opportunity to file a police report, as this was a part of the patient’s rights. During a review of the facility’s policy and procedure (P&P) titled, “Identifying and reporting dependent adult/elder abuse,” revised 4/2025, the P&P indicated, “The staff is trained to recognize the following indicators. While not signifying abuse or neglect per se, the indicators are clues to staff for further assessment in this area and determination of need to file a report. A Physical Indicators -MD or RN only ...Any injury incompatible with history ...cuts, lacerations, puncture wounds ...The California Abuse Reporting laws cover adult patients at [facility name]. Any events or allegations of abuse may be reported to one of the appropriate regulatory agencies (e.g. law enforcement, CDPH, APS, etc). Abuse may include, but is not limited to the following: 1. Physical (patient-to-patient, patient-staff, staff-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: 46333 Based on observation, interview, and record review, the facility failed to ensure a safe environment and adequate monitoring for 1 (one) of 34 sampled patients (Patient 1), who had suicidal ideation (having thoughts of wanting to end one’s own life) and was considered high-acuity (having severe or complex medical or psychiatric needs), by: 1. Failing to conduct patient safety rounds (routine checks by staff to ensure patient well-being and safety), in accordance with the facility’s policies titled “Rounds for Patient Observation” (December 2025) and “Unit and Patio Rounds” (November 2025). This deficient practice resulted in incomplete observation of Patient 1 and other patients at risk and had the potential to result in delayed identification of patient distress (signs of suffering or medical problems) or medical emergencies (sudden, serious health problems requiring immediate attention), placing Patient 1 and other patients on the North, West, and East units-including high-acuity and suicide-risk patients-at risk for serious harm, injury, or death. 2. Adding nine (9) portable “C beds (extra beds with metal frames, removable metal springs, and no tamper-proof hardware [hardware that cannot be easily removed or altered] or safety anchors [anchoring devices used to secure equipment in place and prevent movement])” across three units (East: 4; West: 3; North: 2) that are unlicensed (not approved by regulatory authorities), unbolted (not securely attached to the floor or wall) “C beds” that were not ligature-resistant (not designed to prevent attachment of items that could be used for self-harm), and failing to evaluate the material composition of the “C beds” to ensure the materials met fire-safety requirements (standards that determine whether furniture materials resist ignition and reduce fire spread). The portable “C beds” were portable, unbolted, constructed with metal frames and removable metal springs, and not included in emergency, fire, or evacuation plans and documentation of flame-spread or smoke-density compliance was not provided. This deficient practice resulted in a delay in the emergency response (actions taken by staff to respond to urgent medical or safety needs) for Patient 1 and had the potential to expose patients to environmental hazards (dangerous objects or conditions in the environment) that could be used for self-harm (injuring oneself) or to harm others, and involve bed materials that were not evaluated for compliance with fire?safety requirements (standards that determine whether furniture materials resist ignition and reduce fire spread), placing patients at risk for serious injury, impairment (loss of physical or mental function), or death. 3. Failing to conduct environmental safety assessments (systematic checks for hazards in the physical environment) for added “C beds” (portable metal beds with foldable and removable components), including failure to evaluate the material composition of the “C beds” to ensure the materials met fire-safety requirements (standards that determine whether furniture materials resist ignition and reduce fire spread), and failure to include “C beds” in the facility’s emergency, fire, or evacuation plans (written procedures for responding to emergencies, fires, or relocation of patients to safety). No documentation was provided showing that a risk assessment or fire-safety evaluation was completed prior to placing these beds into patient rooms. This deficient practice resulted in unmitigated (unaddressed) environmental hazards, lack of evaluation of fire-safety compliance of the bed materials (standards that determine whether furniture materials resist ignition and reduce fire spread), and insufficient preparedness for emergencies, and had the potential to place Patient 1 and other patients at risk for serious harm or injury. On 2/5/2026 at 4:54 p.m. the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the Chief Executive Officer (CEO), Executive Administrator (EA), Director of Quality Assessment and Performance Improvement/Risk Management (QA), Chief Nursing Officer (CNO), Director of Pharmacy (DIR 2), House Supervisor (HS 1), and Director of Intake (DIR 3). The IJ was called due to the facility’s failure to ensure complete patient observation rounds (scheduled bedside checks to verify breathing and well-being), failure to maintain a ligature-resistant environment (furniture and fixtures designed to reduce the risk of self-harm) for Patient 1 and other high-acuity behavioral-health patients (patients with severe, unstable, or complex medical or mental health condition requiring intense, frequent monitoring and specialized care), and failure to conduct environmental safety assessments (systematic checks for hazards in the physical environment) for the added “C beds” (portable metal beds with foldable and removable components). The environmental-safety failures included the facility’s failure to evaluate the material composition of the “C beds” to determine whether the materials met fire-safety requirements (standards that determine whether furniture materials resist ignition and reduce fire spread), and failure to include the “C beds” in the facility’s emergency, fire, or evacuation plans (written procedures for responding to emergencies, fires, or relocation of patients to safety). No documentation was provided showing that a risk assessment or fire-safety evaluation had been completed prior to placing these “C beds” into patient rooms. During a concurrent interview and Surveillance video review on 02/04/2026 at 11:02 a.m. with the Chief Executive Officer (CEO, highest-ranking executive responsible for the overall management and daily operations of an organization and responsible for executing the GB’s strategic vision and managing daily operations) and the House Supervisor (HS 1, a registered nurse who provides facility-wide operational oversight for a hospital during assigned shifts), HS 1 confirmed that on 11/17/2025, staff conducted patient rounds (a structured, proactive practice involving regular checks on patients to enhance safety) by standing at the doorway for less than five seconds, failing to observe the required three respirations (visible chest rise and fall counted at least three times). Patient 1 was found unresponsive (not awake and not responding) at 8:02 a.m. and pronounced deceased at 8:20 a.m. This failure had the potential to delay recognition of Patient 1’s deterioration and initiation of timely emergency care, placing patients at risk for harm, and the potential outcome of incomplete rounding which includes failure to identify critical conditions such as apnea (not breathing) or cardiac arrest (sudden and unexpected stop in the heart’s pumping function). Additionally, during CPR (cardiopulmonary resuscitation, a life-saving procedure to restore breathing and circulation) for Patient 1, staff were observed on surveillance video pushing an unbolted C bed (a metal bed frame with removable metal springs, lacking tamper-proof hardware and safety straps) out of the room (where Patient 1 was located on 11/17/2025) to create space for emergency equipment and personnel. During the same interview on 02/04/2026 at 11:02 a.m. with the CEO, the CEO confirmed that the C bed was moved to make room for staff to perform first aid and CPR (on Patient 1). The presence of unbolted, non-ligature-free C beds created the potential to delay emergency care and posed additional hazards. The potential outcomes include patients using C beds to barricade themselves inside a room by blocking the door or breaking off the metal spring to use as a weapon, creating a risk of harm to self or others. On 2/10/2026 at 5:33 p.m., the IJ was removed in the presence of the Chief Executive Officer (CEO), Executive Administrator (EA), Director of Quality Assessment and Performance Improvement/Risk Management (QA), Chief Nursing Officer (CNO), Director of Nursing services (DON), Director of Clinical Services (DIR 4), Director of Intake (DIR 3), Nurse Educator (RN 6), 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 included the following: 1. Patient Observation Rounds: Education & Tools: On 2/5/2026, leadership provided a “Patient Observation Rounds” handout and conducted in-services covering proper rounding techniques: timely 15-minute checks, direct visualization of breathing (e.g., chest rise three times, snoring), and documentation of patient location and behaviors. Policy 100.32 requires use of a flashlight (available on the electronic rounding device) for darkened rooms. Communication: Handout emailed to all nursing staff on 2/5/2026. Coverage: In-services began 2/5/2026 PM shift and continued every shift (including weekends) until all staff trained; new hires receive training during orientation. Staff not yet trained must meet with a supervisor before their shift for just-in-time education. Monitoring: CNO/designee conducts daily video surveillance reviews, focusing on night shift, to verify rounding compliance and reeducate noncompliant staff immediately. Completion Goal: 100% of active nursing staff educated by 2/13/2026. Evidence: Handout, email notification, sign-in sheets, and video review logs. 2. Non-Ligature-Free, Unbolted C Beds: Cease Unsafe Practice: Effective 2/5/2026 at 5:15 p.m., overflow “C” beds were removed from use. Census Control: Admissions from transferring facilities reduced immediately; law enforcement notified on 2/5/2026 at 6:31 p.m. to limit PD (Police Department) drop-offs due to capacity constraints. Real-Time Tracking & Transfers: Implemented a log for patients presenting without a licensed bed; actively pursue outbound transfers and document all attempts. Interim Holding Plan: Patients awaiting placement remain in intake under observation, admitted to EMR (Electronic Medical Record) for safety monitoring, q15 (every 15 minutes) rounding, physician orders, and medication administration. Policy Development: Hospital drafting policy to formalize capacity communication, over-capacity procedures, and safety measures in interim holding areas. Evidence: PD communication records, capacity logs, patient logs, EMR documentation, and transfer attempt records. Findings: 1. During a review of Patient 1’s Psychiatric Evaluation report dated 11/16/2025, the report indicated Patient 1 was admitted voluntarily after reporting suicidal ideation (having thoughts of wanting to end one’s own life), stating he (Patient 1) wanted “to drive my car off the cliff.” The report indicated Patient 1 also reported paranoia (an unfounded belief that others intend to harm or follow someone), stating that someone was following him (Patient 1) and that they had an air gun. During a review of Patient 1’s Psychiatric Evaluation report, dated 11/17/2025, at 8:30 a.m., the report indicated: “I tried to interview him (Patient 1), but the patient (Patient 1) was not answering any of my questions, and he (Patient 1) was not responding, lying on his bed. I asked the staff who was accompanying me to try to wake up the patient and check his pulse. CPR (Cardiopulmonary Resuscitation, a life-saving procedure used when a person’s heart or breathing stops) was started and 911 was called.” During a concurrent observation, interview and record review of surveillance video of the North Unit hallway, on 2/4/2026 at 11:02 a.m. with the Chief Executive Officer (CEO, highest-ranking executive responsible for the overall management and daily operations of an organization and responsible for executing the GB’s strategic vision and managing daily operations), the surveillance footage with a view of Patient 1’s room door, dated 11/17/2025, beginning at 6:40 a.m., was reviewed. Video review showed doorway checks conducted by facility staff without entering the room (Patient 1’s room) at 6:42 a.m., 6:59 a.m., and 7:47 a.m. and for less than five seconds, which did not allow time to count three respirations as required by the “Rounds for Patient Observation” policy (December 2025). The CEO confirmed that two other roommates of Patient 1 were in the room at the time. During a concurrent interview and record review on 2/4/2026 at 1:15 p.m. with the Director of Quality (QA 1) and the Executive Assistant Administrator (EA 1), surveillance video for the night-shift patient rounds (routine checks by staff to ensure patient well-being and safety) on 2/4/2026, at 1:43 a.m., was reviewed. The video showed two Behavioral Health Specialists (BHS) conducting rounds on opposite sides of the hallway. The BHS on the left side entered each patient room. The BHS on the right side briefly popped their head into multiple rooms for less than five seconds. QA 1 confirmed that staff conducted rounds while standing at the doorway, holding a phone, and entering information, and that the BHS on the right side was not in the patient rooms long enough to visually confirm all one to three patients present. During an interview on 2/4/2026 at 2:00 p.m. with Behavioral Health Staff (BHS 1), BHS 1 stated that during patient rounding, staff must knock, say “room check,” ensure patient breathing by observing chest rise or movement, and enter if patient was not visible. During an interview on 2/4/2026 at 2:06 p.m. with Charge Nurse (CN 2), CN 2 stated that patient rounds required visual confirmation; if a patient was sleeping, staff must get close to the patient to observe chest rise or movement before leaving the patient room. CN 2 added that the North Unit (where Patient 1 was located) housed high-acuity (having severe or complex medical or psychiatric needs) and suicidal patients. During an interview on 2/4/2026 at 2:34 p.m. with RN 3, RN 3 stated detox patients (patients requiring medical and non-medical treatments to help manage withdrawal symptoms when abstaining from drugs or alcohol) required staff to attempt to wake the patient three times and observe at least three chest rises. During an interview on 2/4/2026 at 2:50 p.m. with Behavioral Health Staff (BHS 2), BHS 2 stated they (facility staff) did not attempt to wake Patient 1 on 11/17/2025, for vital signs at 7:37 a.m. (approximately 25 minutes before the patient was found unresponsive (not awake and not responding), after calling the patient’s name twice and hearing snoring. BHS 2 stated they left and planned to return later to complete the vital signs check on Patient 1. During a review of the facility’s policy and procedure (P&P) titled “Rounds for Patient Observation,” dated December 2025, the P&P indicated: “To monitor for the safety of each individual patient by visualizing and intervening when any potential hazard is present. To ensure that each individual patient is monitored in a timely manner for their status and safety. MHW to observe patients are in bed or sleeping by: Looking for the rise and the fall of the chest. Counting at least three respirations and then documenting ‘Yes’ in the ‘Location/Activity Comment Code’ column of the Patient Observation Record.” During a review of the facility’s policy and procedure (P&P) titled “Unit and Patio Rounds,” dated November 2025, the P&P indicated: “Rounds will be made and documented at designated intervals on all units of the hospital to evaluate condition of patients, assess the therapeutic environment, assess the physical environment for any high-risk sentinel event/close call opportunities (e.g., elopement, ligature, assault, etc.) and observe safety measures. Patients who are sleeping or in bed will be observed for the rise and fall of their chest as well as overall well-being.” 2. During a concurrent observation and interview on 2/3/2026 at 12:10 p.m. with the Director of Nursing (DON), in the West Unit in rooms 220 and 221, an additional “C bed (a portable metal bed frame with foldable components),” was observed positioned in each patient room. Two pillows were found jammed underneath the empty space below the bed, which functions like a foldable stretcher. The DON confirmed that during rounds, staff should ensure that nothing was stored underneath the bed. The “C beds” in both rooms were identical. The DON stated the facility utilized the same portable beds throughout the facility. The “C bed” in room 220 was unbolted (not attached to the floor or wall), constructed with metal frames (solid metal structures), and contained removable metal springs (metal components that could be detached). The beds lacked tamper-proof hardware (hardware resistant to removal or alteration) and safety straps (devices used to secure equipment). When the bed was folded, it was easily movable (able to be pushed or repositioned with little effort). The DON confirmed the “C beds” were light enough to be moved by one person and stated that all “C beds” used in the facility were portable and not bolted or made unremovable. There were also additional C beds in room 232 and room 238 that were observed and verified by the DON during observation in the North Unit. During the same concurrent interview and record review on 2/3/2026 at 12:20 p.m. with DON, the assignments board for East, West, and North units, was reviewed. The DON stated, “There are Nine (9) C beds added across three units:” - East Unit: Licensed for 16 beds; 4 C beds added. - West Unit: Licensed for 14 beds; 3 C beds added. - North Unit: Licensed for 20 beds; 2 C beds added. During a concurrent observation, interview and surveillance video review on 2/4/2026 at 11:02 a.m. conducted with the Chief Executive Officer (CEO), the surveillance video of the North Unit hallway, with a view of Patient 1’s room doorway, dated 11/17/2025, was reviewed. The video showed that at 8:05 a.m., during the emergency response for Patient 1, staff pushed a “C bed (a portable metal bed with foldable and removable components)” from Patient 1’s room into the hallway to create physical space for CPR (cardiopulmonary resuscitation, a life-saving procedure used when a person’s heart or breathing stops). The CEO confirmed that at 8:05 a.m. staff moved a portable “C bed” from Patient 1’s room into the hallway to create space for CPR. During a concurrent interview and record review on 2/4/2026 starting at 10:04 a.m. until 3:49 p.m., with the Director of Intake (DIR 3), the electronic medical records (EMR, digital patient medical files) of patients who had been placed in “C beds (portable metal beds with foldable and removable components),” were reviewed as follows: -At 10:04 a.m., Patient 2’s “Psychiatric Evaluation (a clinical assessment of mental health status),” dated 2/2/2026, was reviewed with DIR 3. The report indicated Patient 2 was brought into the hospital on a 5150 hold (a California law allowing temporary involuntary detention of an adult for danger to self, danger to others, or grave disability). The report indicated Patient 2 reported hearing voices (auditory hallucinations, hearing sounds or voices that are not present). -At 10:05 a.m., Patient 2’s “Acute Nursing Progress Note (a nursing documentation record of patient condition),” dated 2/3/2026, was reviewed with DIR 3. The note indicated that for the suicide assessment (a structured evaluation of a patient’s risk of self-harm), Patient 2 scored a total of 3. DIR 3 stated, “A score of 3 means the patient is at high risk for suicide.” -At 3:41 p.m., Patient 3’s “Psychiatric Evaluation,” dated 2/2/2026, was reviewed with DIR 3. The report indicated Patient 3 was brought in after walking in traffic (a behavior indicating possible unsafe judgment). The report indicated Patient 3 reported seeing guns everywhere (visual hallucinations-seeing objects that are not present) and hearing voices telling them to hurt self (auditory hallucinations with self-harm commands). -At 3:42 p.m., Patient 3’s “High Risk Alert” form (a document used to notify staff of elevated safety concerns), dated 2/3/2026, was reviewed with DIR 3. The form indicated, “Suicide ideation with intent or plan in past month. Danger to others due to concern of substance abuse history, psychotic symptoms; and self-injury due to cutting.” DIR 3 stated Patient 3 was at high risk of danger to self and stated the form was used to keep staff aware of precautions when monitoring the patient. -At 3:46 p.m., Patient 4’s “Psychiatric Evaluation,” dated 2/2/2026, was reviewed with DIR 3. The report indicated Patient 4 arrived by ambulance on a 5585 hold (a California law allowing temporary involuntary detention of a minor for a mental health crisis). The report indicated Patient 4 was using alcohol and marijuana (MJ) intermittently to cope, and was documented as depressed (persistently low mood) and suicidal (having thoughts of ending one’s own life) with a plan to overdose (OD; taking an excessive amount of a substance). The report also indicated Patient 4 had a recent SA (suicide attempt-an act of trying to end one’s life). The report indicated Patient 4 was on precautions, including suicide precautions (enhanced monitoring to prevent self-harm), aggression/assault precautions (increased observation due to risk of physical aggression), elopement precautions (measures to prevent leaving the unit without authorization), and self-harm precautions (monitoring to prevent injury to self). -At 3:48 p.m., Patient 5’s “Psychiatric Evaluation,” dated 2/2/2026, was reviewed with DIR 3. The report indicated Patient 5 was brought in on a 5150 hold for danger to self. The report indicated Patient 5 reported suicide ideation (thoughts of wanting to end one’s own life). Patient 5 reported, “He wish to be dead.” In the report, Patient 5 stated, “I want to hurt the people who did this to me.” The report indicated Patient 5 also reported psychosis (a mental state involving loss of contact with reality) and A/H (auditory hallucinations-hearing voices or sounds that are not present) that were command in nature (“They tell me to kill myself”). -At 3:49 p.m., Patient 5’s “Acute Nursing Progress Note,” dated 2/3/2026, was reviewed with DIR 3. The note indicated that for the suicide assessment, Patient 5 scored a total of 3. DIR 3 stated a score of 3 meant Patient 5 was at high risk for suicide. During an interview on 2/4/2026 at 9:10 a.m. with the Chief Executive Officer (CEO), the CEO stated the “C beds (portable metal beds with foldable components)” were not listed on the facility’s license (the state-issued authorization identifying approved bed types) and that the facility did not have a flex path (a regulatory process that allows temporary or alternative licensed bed use) for the “C beds.” The CEO stated the addition of the “C beds” did not exceed the facility’s census (the number of patients present in the facility). The CEO did not provide an answer regarding when the facility began adding the “C beds” to patient rooms. During an interview on 2/4/2026 at 1:15 p.m. with the Director of Quality (DQ), DQ stated adding new beds should go through licensing first; if approved, required steps must be completed before expansion. During an interview on 2/4/2026 at 1:55 p.m. with Charge Nurse (CN 1), CN 1 confirmed presence of two C beds in North Unit (Rooms 238 and 240). CN 1 stated patients housed in this unit were high acuity, meaning the patients were a danger to self or others, maybe detoxing (patients requiring medical and non-medical treatments to help manage withdrawal symptoms when abstaining from drugs or alcohol) and were not safe to house with other patients. During an interview on 2/4/2026 at 2:00 p.m. with BHS 1, BHS 1 stated the C beds were light enough to be moved by one person and were not secured to the floor; the C bed could be closed quickly. During an interview on 2/4/2026 at 3:08 p.m. with the Plant Operations/Safety Officer (SO 1), SO 1 stated they were aware of the composition of the “C bed (a portable metal bed with foldable and removable components).” SO 1 stated the C bed had a metal frame (a solid metal structural base) with metal spring parts (metal components that provide support and tension) that could be removed by hand. SO 1 stated the removable metal parts could be used as a weapon (an object used to strike or cause injury) or used to harm self (inflict injury on oneself). During a concurrent interview and record review on 2/4/2026 at 3:05 p.m. with the Director of Quality (QA), the Quality Assessment and Performance Improvement (QAPI) documents was reviewed. QA confirmed that no environmental risk assessment (systematic check for hazards in the physical environment) had been conducted for the “C beds,” and they had not been included in any environmental safety evaluations, fire safety plans, or emergency evacuation procedures. During a review of the facility’s policy and procedure (P&P) titled, “Managing Suicidal Patients - Risk Reduction Guidelines,” revised 1/2022 and reviewed 11/2025, the P&P indicated, “Patients exhibiting behavior indicating that they are a danger to themselves will be managed in such a way as to minimize the threat of injury or harm through providing a safe environment ... Environmental hazards must be minimized.” During a review of the facility’s policy and procedure (P&P) titled, “Unit and Patio Rounds,” the P&P indicated that rounds were to be conducted to assess the therapeutic environment and the physical environment for any high-risk safety concerns, including ligature (items that could be used for self-harm), elopement (a patient leaving a clinical unit or facility without authorization, proper discharge, or informing staff), or assault (an intentional act causing reasonable fear of imminent harmful or offensive contact, or the actual physical attack itself) hazards, and that sleeping patients must be observed for the rise and fall of their chest as well as overall well-being. During a review of the facility’s policy and procedure (P&P) titled, “Quality Management Program and Performance Improvement,” the P&P indicated the hospital was responsible for identifying, monitoring, and evaluating safety risks and implementing corrective actions to ensure a safe environment of care for all patients. 3. During an observation of patient care units on 2/3/2026 at 12:10 p.m. with the Director of Nursing (DON), “C beds” were observed present in multiple patient rooms, including rooms 220 and 221 in the West Unit and rooms 232 and 238 in the North Unit. The C beds were unbolted (not attached to the floor or wall), constructed of metal frames (solid metal structures), and contained removable metal springs (metal components that could be detached). No documentation was provided showing these C beds had undergone a material or fire-safety evaluation prior to use. During an interview on 2/4/2026 at 3:05 p.m. with the Director of Quality (DQ), DQ stated they were not working at the facility when the “C beds” (portable metal beds with foldable and removable components) were implemented. DQ stated they could not find evidence that any environmental risk assessment (a systematic check for hazards in the physical environment) had been completed for the “C beds,” and stated they did not find documentation showing the beds were evaluated for inclusion in emergency, evacuation, or fire-safety planning (written procedures for responding to emergencies, fires, or relocating patients to safety). During an interview on 2/4/2026 at 3:08 p.m. with the Plant Operations/Safety Officer (SO 1), SO 1 stated they were aware of the composition of the “C bed.” SO 1 stated the C bed had a metal frame (a solid metal structural base) with metal spring parts (metal components that provide support and tension) that could be removed by hand. SO 1 stated they were unsure what material the mattress was made of and did not know who verified whether the mattress material met fire-safety requirements (standards that determine whether furniture materials resist ignition and reduce fire spread). During the same interview on 2/4/2026 at 3:08 p.m. with the Plant Operations/Safety Officer (SO 1), SO 1 stated that when new items were needed, the Safety Department presents the items to the Purchasing Department, which determines whether it was appropriate to purchase them. SO 1 stated the facility did not have documentation showing Purchasing Department approval for acquiring the “C beds.” During a concurrent interview and record review on 2/4/2026 at 3:20 p.m. with SO 1, the facility’s Emergency, Fire, and Evacuation Plans (written procedures for responding to emergencies, fires, and relocation of patients to safety), were reviewed. SO 1 confirmed the plans did not include the “C beds,” and Environmental Rounding (routine physical environment checks to identify hazards) did not address the presence or safety characteristics of the “C beds.” No documentation referenced the “C beds,” their placement in patient rooms, or instructions for managing them during an emergency, fire event, or evacuation. SO 1 confirmed the removable metal spring could be pulled out and used as a weapon (an object used to strike or cause injury) and stated the unbolted bed frame could be used to block a doorway. During an interview on 2/4/2026 at 9:10 a.m. with the Chief Executive Officer (CEO), the CEO stated the “C beds” were not included in the facility’s licensed bed count (the state-approved number and type of beds) and confirmed the facility did not have a flex path (a regulatory process to approve non-licensed bed use). The CEO confirmed the C beds were added without updating fire-safety or evacuation procedures to reflect their presence. During surveillance video review on 2/4/2026 at 11:02 a.m. with the CEO, video dated 11/17/2025 showed that at 8:05 a.m., staff had to push a “C bed” out of Patient 1’s room into the hallway during the emergency response to create space to perform CPR (cardiopulmonary resuscitation-a life-saving procedure used when a person’s heart or breathing stops). No document was provided demonstrating that the facility had assessed or planned for emergency response clearance involving unbolted beds. During a review of the facility’s policy and procedure (P&P) titled, “Fire Safety Management Plan,” undated, the P&P indicated the plan’s objective was to “provide a plan that complies with all local, state and federal guidelines/regulations,” “provide a fire safe environment for patients, staff and visitors,” and “reduce Haz/Mat (dangerous substances that pose risks to patients, the staff, or the environment) risks through pro?active inspections & processes for identifying fire safety issues in the patient care setting.” The P&P indicated the plan would “correct/address any deficiencies in a timely manner,” and that “buildings are designed and equipped with fire protection features that will minimize the effects of fire, smoke, and heat ... inspected, maintained and repaired/replaced in accordance with approved standards, procedures, and materials,” in accordance with “Life Safety Code NFPA 101,” “CA Building Code; Fire Prevention Code,” and “NFPA Standards 99, 72, 13.” During a review of the facility’s policy and procedure (P&P) titled, “Policy for Acquisition of Furnishings,” undated, the P&P indicated, “materials for hospital furnishings must comply with Life Safety Code flame spread and smoke density ratings.” The P&P indicated the Purchasing Department is responsible for “ensuring that materials comply with the necessary standards, and provide necessary documentation of flame spread and smoke density should the purchased [items be] made through corporate purchasing ...the Purchasing Department is responsible for “review of California Codes for flame retardancy” for draperies and “California technical bulletin #117 requirements” for upholstered fabrics and furniture ... the Purchasing Department must “provide documentation regarding these products to the Integrated Service Leader for file.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Management Program & Performance Improvement Plan,” dated January 2026, the P&P indicated the purpose of the program was to “provide an objective and systematic approach for performance improvement related to the quality of care and services provided.” The P&P indicated the program was based on “an interdisciplinary and collaborative approach to increase the probability of desired patient outcomes by assessing and improving those governance, managerial, clinical and support processes that most affect patient outcomes ...the goal of the quality improvement program was to assure continuous and incremental performance improvement toward the delivery of quality health care that is efficient and cost effective and consistent with the hospital mission.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Management Program & Performance Improvement Plan,” dated January 2026, the P&P indicated the program “provides surveillance of health care delivery involving the qualifications and performance of those managing and delivering the services; the outcome of care and services delivered; the availability and utilization of support resources, facilities, staff, equipment, assistance and environment.” The P&P indicated the objectives include “an effective, planned, systematic mechanism to design, measure, assess and improve the performance of the hospital,” and “to identify opportunities for improvement with a focus of continuous quality improvement and monitoring of actions taken ...the program provides an ongoing system for monitoring and evaluating important aspects of patient care.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Management Program & Performance Improvement Plan,” dated January 2026, the P&P indicated that data may include reports from “Riskonnect, leadership meetings, administrator-on-call (AOC) reports, etc.” and that data are “utilized to assess the hospital’s performance in providing safe, quality care, treatment, and services to patients.””

“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: 50594 Based on interviews and record review, the facility failed to: 1. Ensure that three (3) of 34 sampled patients (Patients 18, 29, and 30), were free from all forms of abuse (mistreatment causing physical or emotional harm), neglect (failure to provide necessary care ), or harassment (behavior that intimidates or threatens) , when the facility did not implement effective mechanisms/interventions to protect patients from abuse and harassment by other patients, in accordance with the facility’s policy titled “Management of the disturbed/agitated patient,” regarding Patient Rights to ensure safety, when: 1.a. The facility failed to protect two (2) of 34 sampled patients (Patients 29 and 30) from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish), from another patient (Patient 28- the perpetrator), in accordance with the facility’s policy and procedure (P&P) titled “Patient Rights and Notification.” Patient 28 followed Patient 29, rushed into Patient 29’s room and assaulted him (Patient 29). Less than 24 hours later, Patient 28 punched another peer (Patient 30) in the face when they (Patient 28 and Patient 30) encountered each other in the hallway. Despite these incidents, Patient 28’s level of observation (refers to the set intensity and frequency of monitoring a patient to ensure safety based on their risk level) remained at every 15 minutes (often called Q15 or q15 checks- a high-level safety protocol, mainly in psychiatric care, requiring staff to physically check and confirm the location, safety, and breathing of a patient every 15 minutes), with no escalation of monitoring to the physician or implementation of a higher level of patient monitoring/observation. This deficient practice led to Patient 29 experiencing swelling on the left cheek/forehead, a lip laceration, and redness in the right eye. Patient30 suffered redness to the right side of face/nose and a bloody mouth. This deficient practice also placed other patients at risk for further abuse from Patient 28. 1.b. The facility failed to ensure a safe environment (free from physical abuse, the use of physical force that results in, or had the potential to result in, bodily injury, pain, or impairment) for one of 34 sampled patients (Patient 18), when Patient 18 was physically assaulted by Patient 33 (identified as high risk for aggressive behavior) who was not monitored by staff. This deficient practice resulted in Patient 18 sustaining bruising on the right forehead and left eyelid (discoloration of the skin caused by bleeding underneath, typically due to trauma), an abrasion on the left eyelid (a superficial scrape or wearing away of the skin surface), and slight drooping of the left eyelid (partial sagging or lowering of the eyelid, medically referred to as ptosis). This deficient practice also violated Patient 18’s right (the fundamental entitlements guaranteed to patients, including the right to be treated with dignity, respect, and to be free from any form of abuse, neglect, or exploitation) to be free of any form of abuse. 2. The facility failed to ensure that appropriate agencies including CDPH (California Department of Public Health, a state government agency dedicated to protecting and improving the health, safety, and well-being of patients), was notified regarding incidents of abuse for four (4) (4) of 34 sampled patients (Patients 18, 29, 30, and 31), in accordance with State and Federal Laws regarding reporting of suspected abuse involving patients to regulatory agencies and the facility’s policy pertaining to reporting of unusual occurrences that threatens patient safety. This deficient practice had the potential to delay an investigation by the Department into allegations of abuse involving Patient 18, Patient 29, Patient 30, and Patient 31, which may result in further incidents of patient abuse for Patients 18, 29, 30, and 31, as well as other patients in the facility and subjecting the patients to injuries (such as bruises) including psychological distress. On 2/9/2026 at 10:29 a.m., the survey team called a 2nd Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have cause, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Executive Officer (CEO), Executive Administrator (EA), and Vice President, Clinical and Regulatory Compliance (VPCR). The IJ was called due to the facility’s failure to ensure that patients were free from all forms of abuse (mistreatment causing physical or emotional harm), neglect (failure to provide necessary care), or harassment (behavior that intimidates or threatens). Specifically, the facility did not implement effective mechanisms (systems or processes) to protect patients (Patient 18, Patient 29, and Patient 30) from abuse and harassment by other patients. This deficient practice resulted in three patients (Patient 18, Patient 29, and Patient 30) being exposed to unsafe conditions, including sexual acting out behaviors (SAO-engaging in sexually inappropriate actions such as exposing oneself or touching others without consent) and physical assaults (intentional acts causing bodily harm), without escalation (increasing the level of monitoring or intervention) to prevent further harm. Patient 28 (perpetrator) repeatedly engaged in aggressive and sexually inappropriate behaviors and, due to lack of escalation to the physician or to higher nursing leadership in observation level, assaulted two other patients (Patient 29 and Patient 30, first and second victim of assault by Patient 28) on separate occasions (SAO, Sexually Acting Out), dated 5/25/2025 and physical assault (5/31/2025 and 6/1/2025), causing facial injuries and exposing other patients and staff to ongoing risk of harm. During a concurrent interview and record review on 02/04/2026 at 1:40 p.m. with Registered Nurse (RN 6), Patient 28’s “Progress Notes,” dated 05/25/2025, were reviewed. The notes indicated Patient 28 (perpetrator) engaged in sexually inappropriate behavior toward female staff and a housekeeper by following her (the housekeeper) into a room and masturbating (sexual act performed in front of another person without consent). RN 6 confirmed that Patient 28’s observation level remained at Q15 (every 15 minutes) despite being identified as SAO (Sexually Acting Out). During a concurrent interview and record review on 02/04/2026 at 3:05 p.m. with RN 6, Patient 28’s “Progress Notes,” dated 05/31/2025 and 06/01/2025, were reviewed. The notes indicated Patient 28 assaulted Patient 29 (first victim on 5/31/2025) and Patient 30 (second victim on 6/1/2025), causing facial injuries. RN 6 confirmed that despite high DASA scores (Dynamic Appraisal of Situational Aggression, a clinical tool used to predict aggression by scoring each item as present (1) or absent (0) within the previous 24 hours, moderate 1-3, high risk 4-7) observation level remained unchanged and no physician consultation occurred. RN 6 confirmed Patient 28’s DASA score of 7 (considered High Risk) on 5/31/2025 was completed later to reflect the risk. During a concurrent interview and record review on 02/04/2026 at 11:29 a.m. with Behavioral Health Specialist (BHS 3), Patient 33’s (perpetrator) “Violence Risk Assessment,” dated 10/19/2025, was reviewed. The assessment indicated a Danger to Others (DTO) score of 20 (high risk for aggression) and a high DASA score (Score of 5). BHS 3 confirmed Patient 33 was not placed on increased observation and subsequently assaulted Patient 18 (victim of Patient 33), causing a laceration (deep cut) to the left eye. On 2/10/2026 at 5:34 p.m., the IJ was removed in the presence of the Chief Executive Officer (CEO), Executive Administrator (EA), Director of Quality Assessment and Performance Improvement/Risk Management (QA), Chief Nursing Officer (CNO), Director of Nursing services (DON), Director of Clinical Services (DIR 4), Director of Intake (DIR 3), Nurse Educator (RN 6), 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 included the following: 1. Staff Education: -all nursing staff will be immediately re-educated to the following facility policies and procedures: Policy # 700.17: Precautions and Observation Levels, Policy # 700.04: “Close Monitoring: 1-ON-1/LINE OF SIGHT/EVERY 5-MINUTE, and Policy # 100.32: Unit and Patio Round (DRAFT) -All licensed nursing staff will be re-educated to the use of the “High Risk Alert” form when patients screen “high risk” for possible unsafe behavior. This form is completed at intake and for the next 3 shifts to screen patients for changes in behavior during the first 24 hours of their admission. The current violence risk assessment tool (DASA) will continue to be completed every shift by nursing as policy requires. When there is an increase in any risk score to “High” the nurse will notify the provider and complete the new form. -Any change to the risk screen post 3 shifts from admission will be documented on the new form titled “High Risk Alert-Change in Status or Post Adverse Event.” -A new form was created titled “High Risk Alert-Change in Status or Post Adverse Event.” The draft form will be implemented effective 2/9/2026 PM shift and will be completed by the unit charge nurse when a patient’s level of risk increases to “High” or after any adverse event that involves high risk behaviors (such as assault, sexual acting out, or self-harm). 2. Notifications: If a patient’s level of risk increases to “High” or after any event that involves high risk behaviors, the staff will implement the following interventions: -Notification to MDs (psychiatric and internist) -Notification to guardian / law enforcement a. Orders Obtained: i. PRN (as needed) medication ii. Medical / nursing intervention iii. Change in precaution level iv. Change in level of Observation order v. Other: ________________________ b. A comment section requiring staff to describe rationale if precaution orders or level of observation remain unchanged by MD. 3. Completion Goal: CNO and/or designee will ensure 100% of nursing staff members (active status) will be educated on the policies and form by 2/16/2026. 4. Monitoring: -House Supervisors will ensure that a High-risk form is completed for each adverse event on their shift. -The nurse educator will audit 30 random records a month to review compliance with patient observation rounding / documentation of patient behavior. -The Risk manager, or designee, will monitor for completion of the high-risk form daily M-F (Monday to Friday) by reviewing all relevant incident reports for subsequent “High Risk Alert form- Change in Status / Post Adverse Event” form. Noncompliance will be documented on a log and the DON (Director of Nursing) notified for follow up education. Noncompliance by a staff member will be documented on the “Staff Education / Re-education” form. The form included employee name, summary of education/education, 1st attempt date to 3rd attempt date, employee signature, and supervisor/educator. Continued noncompliance by the same staff member will be referred to HR (Human Resources) for possible progressive discipline, per facility policy and procedure. Findings: 1.a. During a review of Patient 28’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 5/23/2025, the Psych Eval indicated Patient 28 was admitted to the facility when Patient 28 sought assessment for inpatient admission with chief complaint of “Bad Voices” and continuing to hear voices, “They keep telling me to jump in front of a train.” During a review of Patient 29’s “Psychiatric Evaluation (Psych Eval),” dated 5/30/2025, the Psych Eval indicated Patient 29 was admitted to the facility on 5150 hold (a paperwork, a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [GD, unable to take care of themselves]). The 5150-hold form indicated Patient 29 held his (Patient 29) mother’s neck to choke her (Patient 29’s mother) and stated, “I want to kill you.” During a review of Patient 30’s “Psychiatric Evaluation (Psych Eval),” dated 5/23/2025, the Psych Eval indicated Patient 30 was admitted to the facility on 5150 hold for GD (Grave Disability), non-compliance with medication at home, and on admission appeared disheveled, bizarre, with poor hygiene, hyperverbal (talk excessively, rapidly), tangential (communication pattern where a speaker wanders away from the main topic), agitated (feeling anxious, restless, or troubled), with threats of self-harm and delusional ideation (the presence of firmly held, false beliefs that are resistant to reason or contrary evidence). During a review of Patient 28’s “Acute Nursing Progress Note,” dated 5/31/2025, the progress note indicated Patient 28 (perpetrator) rushed into another patient’s room (Patient 29’s room) on 5/31/2025 at 9:10 p.m. and assaulted him (Patient 29- first victim) and physician ordered medications including Zyprexa (antipsychotic medication used to treat mental health condition) 10 milligram (mg, unit of measure) and Benadryl (treats symptoms of allergies also can act as a sedative) 50 mg and the medications were administered to Patient 28 (perpetrator) via IM (Intramuscular- into the muscles) injection. The progress notes further indicated Patient 28 “will continue to be monitored q15mins (every 15 minutes) for safety.” During a review of Patient 28’s “Acute Nursing Progress Note,” dated 6/1/2025, the progress note indicated Patient 28 (perpetrator) was pacing the hallway and made eye contact with a peer in the unit, the peer (Patient 30, second victim) was punched on the right side of the face by Patient 28. The progress note further indicated STAT (right away) medication was administered to Patient 28 per physician orders at 12:35 p.m. (on 6/1/2025) given via IM (intramuscular) and that for Patient 28 “will continue to monitor him (Patient 28) Q15 (every 15) min for patient safety...” During an interview on 2/4/2026 at 9:45 a.m. with Registered Nurse (RN) 6, RN 6 stated if there was a pattern of assault behavior (more than one incident) exhibited by the same patient (such as the case with Patient 28), this would trigger an evaluation to determine the need for 1:1 observation (a high-level safety intervention where a dedicated staff member [sitter] remains within arm’s length or continuous eyesight of a patient 24/7 ) as patient was a risk for assaultive behavior to staff and other patients. RN 6 further stated if a patient had a history of continued assaultive behavior, this may warrant the need for a 1:1 level of observation. However, this was not done in the case of Patient 28 thus resulting to the assault on two patients (Patients 29 and 30) within a span of 24 hours. During an interview on 2/4/2026 at 11:29 a.m. with Behavioral Health Specialist (BHS) 3. BHS 3 stated (on 6/1/2025) he (BHS 3) was relieving the 1:1 sitter assigned to Patient 30 (Second victim of Patient 28) and was arms-length away slightly behind Patient 30 (Second victim of Patient 28 ) when he (BHS 3) observed another patient (Patient 28- perpetrator) pacing the hallway. When Patient 28 (perpetrator) met up with Patient 30 (second victim) in the hallway, Patient 28 (the perpetrator) punched Patient 30 (the second victim) in the face, causing Patient 30’s glasses to fall to the floor. BHS 3 stated that he separated Patient 28 (perpetrator) and told him (Patient 28) to return to his room. The med nurse then administered medication to Patient 28. Patient 30 (second victim) was taken to the observation room for nurses to assess Patient 30’s injury. During a concurrent interview and record review on 2/4/2026 at 1:40 p.m. with Registered Nurse Educator (RN) 6, Patient 28’s (perpetrator), “Progress Notes,” dated 5/25/2025, was reviewed. Patient 28’s progress notes indicated Patient 28 (perpetrator) followed a housekeeper in his (Patient 28) room when the housekeeper was cleaning (on 5/25/2025) and began masturbating in front of the housekeeper. Housekeeper removed herself from the room and he (Patient 28) continued to expose himself to the housekeeper. RN 6 confirmed Patient 28 was placed on SAO precaution (Sexually Acting Out, 0-5 low risk, 6-14 moderate risk, 15+ high) due to a SAO score which was 20 (considered high). RN 6 confirmed Patient 28’s regular rounding sheet (colored white) was changed to blue sheet as an indication identifying Patient 28 (perpetrator) as SAO (Sexually Acting Out). RN 6 clarified there was no documentation that the RN assigned to Patient 28 on the date of the incident (5/25/2025) consulted and informed the physician regarding Patient 28’s SAO high score of 20. RN 6 stated that it was a standard nursing practice to consult with the provider in order to determine the appropriate interventions. RN 6 confirmed that the observation level monitoring for Patient 28 continued to be every 15 minutes. During the same interview on 2/4/2026 at 1:40 p.m. with RN 6. Patient 28’s (perpetrator), “Progress Notes,” dated 5/26/2025, was reviewed. Patient 28’s progress notes indicated, Patient 28 (perpetrator) was being verbally aggressive with staff and Patient 28 threatened another peer and stating “Get him the F*** out of my face. I’m gonna F*** him up.” The progress notes further indicated verbal de-escalation (the strategic use of communication-both spoken words and tone-to calm an agitated, angry, or distressed individual, reducing the risk of conflict or violence) was done but did not indicate if it (referring to the verbal de-escalation) was effective. However, the note indicated PRN (As needed) medications (Haldol- medication to treat severe behavioral problems, 5 mg [milligrams, a unit of measure]; Ativan- used to treat anxiety disorders, 2 mg; and Benadryl- used for agitation, 50 mg) were administered and Patient 28 had a DASA (Dynamic Appraisal of Situational Aggression, moderate 1-3, high risk 4-7), score of 7 (indicates high risk for aggressive or violent behavior). During a concurrent interview and record review on 2/4/2026 at 3:05 p.m. with Registered Nurse Educator (RN 6), Patient 28’s (perpetrator) Progress Note, dated 5/31/2025 - 6/1/2025, were reviewed. The Progress Note indicated Patient 28 (perpetrator) rushed into Patient 29’s (first victim) room and assaulted (punched in the face) Patient 29. RN 6 confirmed Patient 28’s (perpetrator) Progress notes also indicated that there was no change in the level of monitoring, RN 6 confirmed they (the staff) continued to monitor Patient 28 (perpetrator) every 15 minutes following the incident involving Patients 28 and 29. RN 6 confirmed that there was no documented evidence that a discussion with a physician regarding increasing Patient 28’s level of monitoring as necessary (higher level of observation such as LOS [Line of Sight, the direct, unobstructed visual] or 1:1). During the same concurrent interview and record review on 2/4/2026 at 3:05 p.m. with RN 6, RN 6 confirmed that there was no escalation to consulting psychiatrist or nursing leadership for higher observation precautions. RN 6 stated that either 1:1 observation or LOS (Line of Sight monitoring) as higher levels of observation, should have been considered for Patient 28 (perpetrator) because Patient 28 was a safety risk for other patients and staff. RN 6 also stated that the second incident involving the second victim (Patient 30) of Patient 28 could have been prevented if a staff member had been assigned to watch Patient 28 either LOS or 1:1 for prevention of aggressive behavior. RN 6 confirmed that this was not done. During the same interview and record review on 2/4/2026 at 3:05 p.m. with RN 6, RN 6 stated that after Patient 28 (perpetrator) assaulted Patient 29 (first victim) on 5/31/2025, Patient 28’s DASA (Dynamic Appraisal of Situational Aggression) score was 7 (High Risk). RN 6 stated that she would have consulted the psychiatrist and nursing supervisor to determine appropriate level of observation monitoring when Patient 28 presented a high DASA score. RN 6 confirmed that this was not done. During a concurrent interview and record review on 2/5/2026 at 9:38 a.m. with RN 6, Patient 28’s (perpetrator) “Progress Note,” dated 5/31/2025, was reviewed. The record indicated DASA high risk intervention included but not limited to “consider level of observation, monitor patient closely without appearing overly watchful or suspicious,” RN 6 stated Patient 28’s (perpetrator) progress notes did not reflect that there was an escalation or consideration to increase the level of observation monitoring (either LOS or 1:1 observation). During an interview on 2/5/2026 at 10:37 a.m. with Registered Nurse (RN) 6, RN 6 stated that for Patient 28 (perpetrator), time-out (a time-out is a therapeutic, voluntary behavioral management technique where a patient temporarily removes themselves from a stressful situation, activity, or social interaction to de-escalate, calm down, or manage sensory overload. It is considered a positive coping strategy designed to help patients gain control of their emotions in a safe environment) was not part of the intervention but would have been appropriate in other circumstances. During a concurrent interview and record review on 2/5/2026 at 1:43 p.m. with House Supervisor (HS) 1, Patient 28’s (perpetrator) Progress Note, dated 5/31/2025 -6/1/2025, were reviewed. HS 1 confirmed that nursing staff intervention for Patient 28’s (perpetrator) assaultive behavior towards Patient 29 (first victim) and Patient 30 (second victim) included administration of emergency medication, talking to Patient 28 about distraction technique and continued monitoring of Patient 28 every 15 minutes for safety. HS 1 confirmed 1:1 sitter criteria was indicated for someone who was a danger to others or self, not contracting for safety, and not positively responding to medication. HS 1 confirmed Patient 28 remained with Q15 level of monitoring. HS 1 confirmed monitoring frequency did not change. During a concurrent interview and record review on 2/5/2026 at 1:43 p.m. with House Supervisor (HS) 1, Patient 28’s (perpetrator) Progress Note, dated 5/31/2025 -6/1/2025, were reviewed. The progress notes indicated, on 5/31/2025 (after Patient 29 was assaulted), intervention for Patient 28 included administration of emergency medication, talking to Patient 28 about distraction technique and continued monitoring of Patient 28 every 15 minutes for safety. The progress notes further indicated, on 6/1/2025 (after Patient 30 was assaulted), the intervention for Patient 28 included administration of emergency medication, talking to Patient 28 about distraction technique and continued monitoring of Patient 28 every 15 minutes for safety. HS 1 confirmed that interventions for Patient 28 remained the same without any escalation of observation level despite the incidents with Patient 29 and Patient 30. During an interview on 2/6/2026 at 12:14 p.m. with BHS 3, BHS 3 stated that an aggressive patient can be sent to a room but would be escorted by staff, who were to stay with the patient and evaluate whether medication was needed. BHS 3 added that other interventions, such as consulting a specialist, providing 1:1 therapy, or involving a case manager or social worker, may also be considered. During a review of the facility’s policy and procedure (P&P) titled, “Identifying and reporting dependent adult/elder abuse,” revised 4/2025, the P&P indicated, “The clinical staff at [facility name] will be able to recognize and identify the key indicators and dynamics of elder and dependent adult abuse.” During a review of the facility’s policy and procedure (P&P) titled, “Patients’ Rights and Notification,” reviewed 11/2025, the P&P indicated, “Patients have a right to personal safety. Staff provides safety checks q15 min., q5 min (as needed), 1:1/line-of-sight close monitoring (as needed), and room/contraband checks every shift.” During a review of the facility’s policy and procedure (P&P) titled, “Close Monitoring: 1-ON-1/LINE OF SIGHT/EVERY 5-MINUTE,” dated December 2025, the P&P indicated, “Criteria for a patient to be placed on a “one-on-one,” “line-of-sight” or every 5-minute close monitoring may be the following instances: a. Patient is a high suicidal / self-harm risk. The patient has made a significant suicidal attempt while in the hospital. The patient has made a significant suicidal attempt prior to admission to the hospital. The patient’s Intake Assessment’s SAFE-T Protocol with C-SSRS - Recent Suicide Risk Screen score of fifteen (15) and above. The patient is highly psychotic, under the influence of substance use, highly anxious and/or presents as a danger to themselves... Patient is a high assault risk. The patient has made significant assaultive behaviors while in the hospital. The patient has made significant assaultive behaviors prior to admission to the hospital.” During a review of the facility’s policy and procedure (P&P) titled, “Management of the Disturbed/Agitated Patient,” dated 12/2025, the P&P indicated, “The DASA will be conducted each shift and interventions followed dependent on patient’s score ...A “timeout” period may be offered to the patient. “Time-out” is a procedure used to assist the patient to regain emotional control by he/she voluntarily going to a quiet area or unlocked quiet room. The DASA will be conducted each shift and intervention followed dependent on patient’s score ... Remove the patient from situation if it appears that escalating behavior has been triggered by other patient or environmental stimuli.” During a review of the facility’s Policy and Procedure (P&P) titled Management of the Disturbed/Agitated Patient, dated 12/2025, the P&P indicated... “All nursing staff are responsible for recognizing and observing signs of potential violent behavior, reporting it to appropriate staff and acting within the limits of their position description to protect with the least restrictive method, all other patients, visitors and staff...” 1.b. During a review of Patient 18’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 10/14/2025, the H&P indicated that Patient 18 was admitted on a 5150 hold for danger to self and others. During a review of Patient 18’s Acute Nursing Progress Note, dated 10/19/2025, the note indicated that on 10/19/2025, Patient 18 was asleep in her (Patient 18) room after receiving medications (Haldol- medication to treat severe behavioral problems, 5 mg [milligrams, a unit of measure] by mouth; Ativan- used to treat anxiety disorders, 2 mg by mouth; and Benadryl- used for agitation, 50 mg by mouth), after complaining of severe agitation (is a sudden episode of extreme restlessness, irritability, or aggressive behavior that poses a risk to the patient or others), a few hours prior to the incident of assault (committed by intentionally acting to cause reasonable apprehension of imminent harmful or offensive contact in another person, or by attempting to commit physical violence). The note further indicated that Patient 18 stated that Patient 33 assaulted her (Patient 18), unprovoked. During a review of Patent 18’s Internal Medicine Progress Note, dated 10/20/2025 (after the incident of assault by Patient 33), the note indicated that Patient 18 was hit by Patient 33 in the middle of the night and sustained slight bruising on the right forehead and left eyelid (a minor, superficial injury where small blood vessels under the skin have broken, causing blood to leak into the surrounding tissue), a small abrasion on the left eyelid (a superficial scratch or scrape on the skin of the eyelid, often caused by friction, trauma, or foreign objects), and slight drooping of the left eyelid (occurs when the trauma damages, stretches, or tears the muscles responsible for lifting the eyelid). During an interview on 2/5/2026 at 9:30 a.m. with the House Supervisor (HS 1), HS 1 stated that on 10/19/2025, he (HS 1) assisted Patient 18 with filing a police report. HS 1 said that he was unsure what had occurred between the two patients (Patient 18 and Patient 33), but confirmed that Patient 33 (the perpetrator) was not physically harmed, while Patient 18 (victim) sustained a laceration to the left eye. During a concurrent interview and record review on 2/5/2026 at 9:30 a.m. with HS 1, Patient 33’s Acute Nursing Progress Note, dated 10/19/2025, was reviewed. The note indicated that Patient 33 admitted to hitting her roommate (Patient 18) because she (Patient 18) touched her (Patient 33) while she (Patient 33) was sleeping. The note also indicated that the RN contacted the attending physician and obtained an order for PRN (As needed) Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg, emergency medications (refers to a drug that is ordered and administered only when a specific condition occurs [not on a fixed schedule]), to be administered by mouth to Patient 33 for acute agitation (is a sudden episode of extreme restlessness, irritability, or aggressive behavior that poses a risk to the patient or others). During a record review on 2/5/2026 at 3:13 p.m. with the Nurse Educator (RN 6), Patient 33’s “Intake Assessment (intake assessment: a comprehensive evaluation conducted upon admission to gather medical, psychiatric, and behavioral history),” dated 10/19/2025, was reviewed. The Intake assessment indicated that Patient 33 had a documented history of physical assaults (physical assaults: intentional acts of physical force against another person causing or intended to cause harm) during previous inpatient psychiatric admissions and was assessed as high risk for aggressive behavior (Danger to Others [DTO]: a clinical designation indicating the patient poses a potential threat of harm to others). Patient 33 received a DTO score of 20 (a high score indicating significant risk for aggression), and also scored 5 (High Risk for aggression towards others) on the Violence Risk Assessment (DASA: Dynamic Appraisal of Situational Aggression, a tool used to assess the risk of aggression by scoring each item as present [1] or absent [0] within the previous 24 hours). Patient 33 scored 1 for each of the following indicators: -Impulsivity -Unwillingness to follow directions -Sensitivity to perceived provocation (the patient has become angry or aggressive she was asked to adhere to some aspect of her treatment or to the ward’s routine in the last 24 hour) -Easily angered when requests are denied -Negative attitudes (the patient has tended to become angry when her requests have not been granted immediately) -The total score (for Patient 33) was 5, indicating a high risk of aggression toward others. During the same record review on 2/5/2026 at 3:13 p.m. with the Nurse Educator (RN 6), the intake assessment further indicated that Patient 33 was admitted to the facility for voluntary services for SI (suicidal ideations: thoughts or plans of self-harm or suicide). Additional observations documented in the intake assessment record of Patient 33 included: “ ... During evaluation - restless, easily irritable, became agitated, screaming at writer, stated ‘I just do not feel good! I want to kill myself,’ guarded with plan. Guarded with psychosis (psychosis: a mental state characterized by loss of contact with reality, including hallucinations or delusions) observed preoccupied and suspicious, paranoid (paranoid: exhibiting irrational distrust or belief that others intend harm), believes being followed, also delusional (holding false, unrealistic, or irrational beliefs that persist despite evidence to the contrary) state ...” During an interview on 2/5/2026 at 10:35 a.m. with the Chief Executive Officer (CEO), the CEO stated that the scope of service (the range and type of healthcare services a facility or unit is authorized and equipped to provide) was the same for all units. The CEO also said that the reason some of the facility’s units (A, B, C, and D) were considered high acuity (measures the severity, complexity, and urgency of a patient’s mental health condition, determining the necessary intensity of care) was due to, “Grouping like with like... (referring to grouping of patients based on the severity of condition).” The CEO also said that safety precautions would typically begin with Q15 checks (patient observation every 15 minutes to monitor safety and behavior), and there were more Behavioral Health Specialists (BHS, trained professionals who provide behavioral health support, crisis intervention, and therapeutic care, but do not perform licensed nursing tasks) in high-acuity units to keep patients as safe as possible because increasing the number of licensed staff (such as Registered Nurses and Licensed Vocational Nurses) as opposed to BHS workers was not going to create a safer environment. The CEO stated that the first step in the de-escalation process (a strategic, multi-step approach designed to reduce the intensity of conflict, aggression, or distress, allowing a person to return to a calm baseline), for aggressive behavior, involved moving patients (to other units) and attempting verbal de-escalation. During an interview on 2/5/2026 at 3:15 p.m. with the Nurse Educator (RN 6), RN 6 explained the facility’s protocol for admitting patients with high assault risk scores: “Clients admitted to the unit with a high DTO (Danger to Others) score are not automatically placed in separate rooms because there are multiple clients with high acuity (patients with severe, complex, or unstable psychiatric conditions that require intensive, around-the-clock monitoring, specialized care, and frequent, often immediate, interventions to ensure safety) in the unit.” RN 6 also stated that when Patient 33 (perpetrator) was admitted, Patient 33 was placed on the high acuity unit and was placed on physical aggression precautions (special safety measures implemented in healthcare settings to protect staff, patients, and visitors from individuals who may exhibit aggressive or violent behavior). RN 6 said that typically staff would provide observation every 15 minutes (a standard safety protocol where mental health staff members (technicians or nurses) check on each patient at irregular intervals (within every 15-minute timeframe) to monitor for signs of violence during rounds. RN 6 did not provide an explanation of how monitoring for signs of violence during rounds was implemented. During an interview on 2/6/2026 at 11:00 a.m. with RN 6, RN 6 stated the following regarding the level of monitoring for Patient 33 due to high risk for assault and being placed on High-Risk Assault Protocol: RN 6 stated that observation levels which may be implemented included Q15-minute checks, 1:1 observation (a high-level safety intervention where a trained staff member is assigned to a single patient to monitor them continuously, usually within arm’s length, to prevent suicide, self-harm, elopement, or to manage severe aggression), and Line of Sight (LOS, a safety protocol where a staff member maintains direct, unobstructed visual contact with one or more patients at all times). RN 6 also said that the level or type of observation was determined by physician orders in collaboration with nursing staff. RN 6 stated that the patient (Patient 33) was placed in a high-acuity unit, and assault precautions were based on intake assessments (DASA and DTO). Behavioral Health Specialists (BHS) were responsible for monitoring, and they (the facility) typically had more BHS staff on high-acuity units. RN 6 said that registered nurses were responsible for ongoing assessment of patients and implementation of interventions, as well as contacting the physician if observation levels needed adjustment based on the clinical presentation of the patient. However, Patient 33, who had documented history of physical assaults, was not placed on either line-of-sight observation or 1:1 observation. During an interview on 2/6/2026 at 11:43 a.m. with the Director of Quality (QA), QA stated that the incident (Patient 18’s assault by Patient 33) was unwitnessed. QA then said, that “Patients admitted with a high risk for assault should be monitored every 15 minutes and if closer observation was needed (based on their observed behavior), they were placed on 1:1 observation (a high-level safety intervention where a dedicated staff member is assigned to monitor a single patient at all times) or Line-of-Sight observation (a high-level safety protocol requiring a staff member to have the patient in direct, uninterrupted view at all times, even in the bathroom). QA stated that the assault incident could have been prevented by blocking (no roommate) Patient 33’s room so that she (Patient 33, the perpetrator) did not have a roommate. During a review of Patient 33’s “Patient Observation and Monitoring (Observation Round Sheets, are critical documentation tools, typically recording patient checks every 15 minutes to monitor safety, mood, and behavior),” dated 10/19/2025, the record indicated the following: -On 10/19/2025 from 8:00 p.m. to 9:00 p.m., Patient 33 was identified as R2 (R = bedroom, 2 = lying/sitting), which reflected comments regarding the patient’s activity. However, the record lacked documentation of the patient’s behavior. This was verified with the Director of Nursing (DON 1) on 2/6/2026 at 3:15p.m. During an interview on 2/6/2026 at 3:26 p.m. with the Behavioral Health Services Lead (BHS 4) and the Director of Nursing (DON), BHS 4 said that the behavior part (whether the patient is calm or agitated, anxious or confused, isolative or socializing) on the observation rounds was only recommended to be recorded. BHS 4 stated that staff typically documented the location of the patient and their activity, such as whether the patient was sleeping or walking, lying or sitting. BHS 4 added that it was only required for nurses to document behavior in their acute notes. BHS 4 then said that while the patient’s behavior could be documented on the observation round sheets, it was not mandatory for BHS staff to do it. The DON confirmed that there was no policy indicating how to record the patient observation record and monitoring. During a review of the Facility’s Policy and Procedure (P&P)titled Precautions and Observation Levels, dated 7/2021, the P&P indicated “ ... j. Precautions ...Danger to others/ Assault (DTO)-Patients who have a history of aggressive or assault, are threatening violence or are identified at risk of violence may be placed on precaution ... Patient will not be assigned a roommate who is an assault victim ... d. Sexual Acting Out (SAO)- Patient who have a history of sexually acting or sexual assault, or are identified at risk for sexual aggression, sexualized behavior or accusations will be placed on precautions based on the level of risk assessed. -Placement in a blocked room/ no roommate -Implementation of prescribed distance from peers -Increased observation levels beyond Q15s -Assigned a room close to the nursing station ...” During a review of the facility’s Policy and Procedure (P&P) titled Management of the Disturbed/Agitated Patient, dated 12/2025, the P&P indicated... “All nursing staff are responsible for recognizing and observing signs of potential violent behavior, reporting it to appropriate staff and acting within the limits of their position description to protect with the least restrictive method, all other patients, visitors and staff...” 2.a. During a review of Patient 18’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 10/14/2025, the H&P indicated that Patient 18 was admitted on a 5150 hold (a law allowing temporary involuntary detention of an adult for danger to self, danger to others, or grave disability [unable to provide for one’s own basic needs such as food, hygiene, shelter]) for danger to self and others. During a review of Patient 18’s Acute Nursing Progress Note, dated 10/19/2025, the note indicated that on 10/19/2025, Patient 18 (victim) was asleep in her room after receiving Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg, all administered by mouth, after complaining of severe agitation, a few hours prior to the incident. The note further indicated that Patient 18 stated that Patient 33 (perpetrator) assaulted her (Patient 18), unprovoked. During a review Patent 18’s Internal Medicine Progress Note, dated 10/20/2025, the note indicated that Patient 18 had slight bruising on the right forehead and left eyelid (a minor, superficial injury where small blood vessels under the skin have broken, causing blood to leak into the surrounding tissue), a small abrasion on the left eyelid (a superficial scratch or scrape on the skin of the eyelid, often caused by friction, trauma, or foreign objects), and slight drooping of the left eyelid (occurs when the trauma damages, stretches, or tears the muscles responsible for lifting the eyelid). During an interview on 2/5/2026 at 9:30 a.m. with the House Supervisor (HS 1), HS 1 stated that on 10/19/2025, he (HS 1) assisted Patient 18 with filing a police report. HS 1 said that he (HS 1) was unsure what had occurred between the two patients (Patient 18 [victim] and Patient 33 [perpetrator]), but confirmed that Patient 33 was not physically harmed, while Patient 18 sustained a laceration (deep cut) to the left eye. During an interview on 2/9/2026 at 3:07 p.m. with Director of Quality Assessment and Performance Improvement Risk Management (QA), QA stated that the facility reported abuse to either law enforcement, APS (Adult Protective Services, 24 hour service program to investigate all situation involving senior [age 65 and older and dependent adults 18-59 who are physically and /or mentally impaired]), or CDPH (California Department of Pubmic Health). QA also stated that reporting to CDPH was mandated if there was a death involved. During an interview on 2/10/2026 at 11:31 a.m. with QA, QA stated that since the patient-to-patient assault (involving Patients 18 and 33) was considered a physical abuse, the incident should have been reported to CDPH. During a review of facility’s policy and procedures (P&P) titled, “Reporting of “Unusual Occurrences” to local regulatory agencies,” revised 11/2025, the P&P indicated, “To ensure the safety and welfare of patients and employees to report to licensing California Department of Public Health (CDPH) ...any occurrence which threatens the welfare, safety and health of patient (s), personnel and visitors ...The following are considered critical incidents: ...8. Major altercations or threat between patients or between staff and patient (s) 9. Physical harm to others ...11. Any other serious adverse event ...Reporting of the process must occur “as soon as possible” including weekends and holidays ...The Risk Manager or designee will conduct all investigation and reporting ...” During a review of “Title 22 California Code of Regulations 715657 Adverse Event Reporting Requirements (set of rules and regulations established by the California Department of Social Services that governs community care facilities),” the California Code of Regulations indicated, “Adverse events that are ongoing urgent or emergent, threatening the welfare, health, or safety of patients, personnel, or visitors, shall be reported within 24 hours after the adverse event is detected...All other adverse events shall be reported to the Department no later than five (5) calendar days after the adverse event is detected...when reporting adverse events, the hospital shall provide to the Department the following information: ...Date and time the adverse event occurred and was detected, if known...” 2.b. During a review of Patient 28’s “Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 5/23/2025, the Psych Eval indicated Patient 28 was admitted to the facility when Patient 28 sought assessment for inpatient admission with chief complaint of “Bad Voices” and continuing to hear voices, “They keep telling me to jump in front of a train.” During a review of Patient 29’s “Psychiatric Evaluation (Psych Eval),” dated 5/30/2025, the Psych Eval indicated Patient 29 was admitted to the facility on 5150 hold (a paperwork, a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [GD, unable to take care of themselves]). The 5150-hold form indicated Patient 29 held his (Patient 29) mother’s neck to choke her and stated, “I want to kill you.” During a review of Patient 30’s “Psychiatric Evaluation (Psych Eval),” dated 5/23/2025, the Psych Eval indicated Patient 30 was admitted to the facility on 5150 hold for GD (Grave Disability), non-compliance with medication at home, and on admission appeared disheveled, bizarre, with poor hygiene, hyperverbal (talk excessively, rapidly), tangential (communication pattern where a speaker wanders away from the main topic), agitated (feeling anxious, restless, or troubled), with threats of self-harm and delusional ideation (the presence of firmly held, false beliefs that are resistant to reason or contrary evidence). During a review of Patient 31’s, “Psychiatric Evaluation,” dated 9/7/2025, the psych eval indicated Patient 31 was admitted to the facility with chief complaint of “I fight with the staff.” During a review of Patient 28’s “Acute Nursing Progress Note,” dated 5/31/2025, the progress note indicated Patient 28 (perpetrator) rushed into another patient’s room (Patient 29’s room) on 5/31/2025 at 9:10 p.m. and assaulted him (Patient 29- first victim) and Zyprexa (a prescription medication used to treat serious mental health conditions by balancing chemicals in the brain) and Benadryl (used for agitation [a sudden episode of extreme restlessness, irritability, or aggressive behavior that poses a risk to the patient or others]) medications were administered to Patient 28 (perpetrator) via IM (Intramuscular- into the muscles) injection. The progress notes further indicated Patient 28 “will continue to be monitored every 15 minutes.” During a review of Patient 28’s “Acute Nursing Progress Note,” dated 6/1/2025, the progress note indicated Patient 28 (perpetrator) was pacing the hallway and made eye contact with a peer in the unit, the peer (Patient 30, second victim) was punched on the right side of the face. The progress note further indicated STAT (right away) medication was administered to Patient 28 per physician orders at 12:35 p.m. (on 6/1/2025) given via IM (intramuscular) and that Patient 28 “will continue to be monitored every 15 minutes.” During a concurrent interview and record review on 2/9/2026 at 11:14 a.m. with the House Supervisor (HS) 1, Patient 31’s “Acute Progress Notes (Night),” dated 9/8/2025, was reviewed. The progress notes indicated, (on 9/8/2025) Patient 31 was pacing in the hallway and became confrontational with a peer (another patient) who was also pacing. The peer then struck Patient 31 in the face, pushed Patient 31 to the ground, and was then observed to have blood dripping from the mouth (Patient 31). HS 1 stated that Patient 31 would like to press charges towards the peer. During an interview on 2/5/2026 at 2:47 p.m. with the Director of Quality Assessment and Performance Improvement Risk Management (QA), QA stated that they (QA) were responsible for reporting abuse, death, and any of the “never 27 events (list of 27 serous, preventable, and reportable medical errors)” to California State authorities. QA stated that for abuse cases, reports may be made to either one of the agencies identified as CDPH, APS (Adult Protective Services, 24 hour service program to investigate all situation involving senior [age 65 and older and dependent adults 18-59 who are physically and /or mentally impaired]) or law enforcement per facility’s policy. During an interview on 2/6/2026 at 12:37 p.m. with QA, the QA confirmed that patient-to-patient abuse involving Patients 29, 30, and 31 was not reported to CDPH. During an interview on 2/9/2026 at 3:06 p.m. with QA, the QA stated that the facility followed Title 22 of the Code of Regulations, which governed hospital operations. The QA emphasized reporting abuse to CDPH for patient safety, noting that CDPH offered an independent review of abuse cases. During an interview on 2/10/2026 at 11:27 a.m. with the QA, the QA stated that physical assault, such as the incidents involving Patients 29, 30, and 31, was considered abuse and should have been reported to CDPH for patient protection. During a concurrent interview and record review on 2/9/2026 at 3:35 p.m. with the QA, the facility’s policy and procedure titled, “Reporting of ‘Unusual Occurrences’ to local regulatory agencies,” revised 11/2025, was reviewed. QA stated the incident involving Patients 29, 30, and 31 would be considered as unusual occurrences and should have been reported to CDPH. During an interview on 2/10/2026 at 11:27 a.m. with QA, the QA stated physical assault (refers to the act of causing physical harm to another person) was considered an abuse and should have been reported to CDPH to protect the patients. During a review of facility’s policy and procedures (P&P) titled, “Reporting of “Unusual Occurrences” to local regulatory agencies,” revised 11/2025, the P&P indicated, “To ensure the safety and welfare of patients and employees to report to licensing California Department of Public Health (CDPH) ...any occurrence which threatens the welfare, safety and health of patient (s), personnel and visitors ...The following are considered critical incidents: ...8. Major altercations or threat between patients or between staff and patient (s) 9. Physical harm to others ...11. Any other serious adverse event ...Reporting of the process must occur “as soon as possible” including weekends and holidays ...The Risk Manager or designee will conduct all investigation and reporting ...” During a review of “Title 22 California Code of Regulations 715657 Adverse Event Reporting Requirements (set of rules and regulations established by the California Department of Social Services that governs community care facilities),” the California Code of Regulations indicated, “Adverse events that are ongoing urgent or emergent, threatening the welfare, health, or safety of patients, personnel, or visitors, shall be reported within 24 hours after the adverse event is detected ...All other adverse events shall be reported to the Department no later than five (5) calendar days after the adverse event is detected ...when reporting adverse events, the hospital shall provide to the Department the following information: ...Date and time the adverse event occurred and was detected, if known...””

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility’s QAPI (Quality Assessment and Performance Improvement- mandatory, comprehensive, and data-driven system designed to improve patient care, safety, and outcomes. It combines proactive performance improvement [PI] with reactive quality assurance [QA] to reduce medical errors, monitor adverse events, and ensure compliance) committee failed to: 1. Collect and analyze required fire-safety data before placing nine (9) unlicensed “C beds (portable metal beds with foldable components and removable metal springs)” across three inpatient units, affecting all patients housed in rooms with these “C” beds, including but not limited to five (5) high-risk patients (Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5). The facility did not obtain or review information regarding material composition (what the bed and mattress were made of), flame-spread rating (how quickly fire travels across a material surface), or smoke-density rating (how much smoke a material produces when burning), [as required by facility policy and Life Safety Code]. This deficient practice had the potential to result in patients being exposed to furniture materials with unknown ignition and smoke-generation characteristics during a fire or evacuation, including risk of injury, smoke inhalation, or death, especially for patients with severe psychiatric symptoms who may be less able to respond to fire or evacuation instructions. 2. Conduct a formal investigation to collect data and use it to monitor the effectiveness and safety of services and implement timely, measurable corrective actions following a serious elopement (a patient leaving a clinical unit or facility without authorization, proper discharge, or informing staff) event for one of 34 sampled patients (Patient 14). Specifically, the facility did not develop a formal, time-bound Plan of Correction (POC), failed to implement any interim safety measures, and did not establish or document monitoring processes to evaluate whether corrective actions were effective. In addition, the facility collected data on attempted and completed elopements but did not establish benchmarks, evaluation criteria, or documented follow-up to assess the success of the interventions outlined in the plan of action for elopements and did not reflect whether each elopement or attempted elopement had been evaluated against the required interventions This deficient practice had the potential to place all facility patients (the universe of all individuals receiving care within the facility) at risk for elopement at continued risk of elopement-related harm by allowing patterns of elopement-related safety risks to remain unidentified and unaddressed (meaning patients could be exposed to dangers associated with leaving the hospital without authorization, including injury, exploitation, exposure to unsafe environments, or interruption of essential medical or psychiatric treatment). 3. Evaluate the effectiveness of interventions, did not measure success, and did not audit compliance in response to repeated facility incidents of assault (refers to the act of causing physical harm to another person) in order to determine whether the interventions outlined in the quarterly plan of action were effective for three (3) of 34 sampled patients (Patients 18, 29 and 30) and which may impact all of the facility’s patients. Although the facility collected quarterly assault data (counts, injuries, ED [Emergency Department] transfers, shift/day), the QAPI team did not use these data to conduct trend analysis, identify contributing factors, or drive changes to interventions. Specifically, the QAPI team did not assess whether its preventive actions reduced incidents of assault, reduced severity, or improved patient safety, and there was no systematic analysis to determine whether the interventions lowered the risk of patient-to-patient assault or abuse (mistreatment causing physical or emotional harm). Additionally, not all assault-related outcomes were reported to the QAPI Committee, Medical Executive Committee (MEC, defined as the body of physician leaders responsible for oversight of clinical care quality and safety), or the Governing Body (defined as the entity legally responsible for the conduct of the hospital, including oversight of quality, safety, and compliance). This deficient practice had the potential to place Patients 18, 29 and 30, and all facility patients to ongoing assault-related risks, including patient-to-patient harm and physical abuse, and also increase staff injury risk. Findings: 1. During a review of Patient 1’s Psychiatric Evaluation report (a mental health assessment used to diagnose emotional, behavior, and cognitive conditions), dated 11/16/2025, the report indicated Patient 1 was admitted voluntarily after reporting suicidal ideation (thoughts of self-harm), stating he (Patient 1) wanted “to drive my car off the cliff.” The report indicated paranoia (an unfounded belief that others intend to harm or follow someone), stating that someone was following him and that they had an air gun. During a review of Patient 2’s “Psychiatric Evaluation,” dated 2/2/2026, the report indicated Patient 2 was brought into the hospital on a 5150 hold (a California law allowing temporary involuntary detention of an adult for danger to self, danger to others, or grave disability). The report indicated Patient 2 reported hearing voices (auditory hallucinations, hearing sounds or voices that are not present). During a review of Patient 2’s “Acute Nursing Progress Note,” dated 2/3/2026, the note indicated that for the suicide assessment (a structured evaluation of a patient’s risk of self-harm), Patient 2 scored a total of 3. DIR 3 stated, “A score of 3 means the patient is at high risk for suicide.” During a review of Patient 3’s “Psychiatric Evaluation,” dated 2/2/2026, the report indicated Patient 3 was brought in after walking in traffic (a behavior indicating possible unsafe judgment). The report indicated Patient 3 reported seeing guns everywhere (visual hallucinations-seeing objects that are not present) and hearing voices telling them to hurt self (auditory hallucinations with self-harm commands). During a review of Patient 4’s “Psychiatric Evaluation,” dated 2/2/2026, the report indicated Patient 4 arrived by ambulance on a 5585 hold (a California law allowing temporary involuntary detention of a minor for a mental health crisis). The report indicated Patient 4 was using alcohol and marijuana (MJ) intermittently to cope, and was documented as depressed (persistently low mood) and suicidal (having thoughts of ending one’s own life) with a plan to overdose (OD; taking an excessive amount of a substance). The report also indicated Patient 4 had a recent SA (suicide attempt-an act of trying to end one’s life). During a review of Patient 5’s “Psychiatric Evaluation,” dated 2/2/2026, the report indicated Patient 5 was brought in on a 5150 hold for danger to self. The report indicated Patient 5 reported suicide ideation (thoughts of wanting to end one’s own life). Patient 5 reported, “He wish to be dead.” Patient 5 stated, “I want to hurt the people who did this to me.” The report indicated Patient 5 also reported psychosis (a mental state involving loss of contact with reality) and A/H (auditory hallucinations-hearing voices or sounds that are not present) that were command in nature (“They tell me to kill myself”). During a concurrent observation and interview on 2/3/2026 at 12:10 p.m. with the Director of Nursing (DON) in the West Unit (rooms 220 and 221), two additional “C beds (portable metal bed frames with foldable components)” were observed positioned in patient rooms. The beds were unbolted (not attached to the floor or wall), constructed with metal frames (solid metal structural bases), and contained removable metal springs (detachable metal components). The DON stated the facility used the same portable beds throughout all units. During a concurrent observation and interview on 2/3/2026 at 12:20 p.m. with the DON, in the North Unit, additional “C beds” were observed in room 232 and room 238. The DON reviewed the assignment board (a posted list showing patient and bed placement) and identified that nine total “C beds” were placed across units: East Unit-4; West Unit-3; North Unit-2. During an interview on 2/4/2026 at 9:10 a.m. with the Chief Executive Officer (CEO, the highest-ranking executive responsible for the overall management and daily operations of an organization), the CEO stated the “C beds” were not listed on the facility’s license (state?issued authorization specifying approved bed types) and that the facility did not have a flex path (a regulatory process allowing alternative or temporary bed types). The CEO did not provide the date when the “C beds” were introduced into the facility. During an interview on 2/4/2026 at 3:08 p.m. with Plant Operations/Safety Officer (SO 1), SO 1 stated the “C bed” consisted of a metal frame (solid metal structural base) and metal spring parts (removable metal components). SO 1 stated they did not know the mattress material (the type of material inside the mattress) and did not know who verified the bed for fire?safety requirements (standards used to determine resistance to ignition and fire?spread). SO 1 stated the facility had no documentation showing Purchasing Department approval for acquiring the “C beds.” During an interview on 2/4/2026 at 3:05 p.m. with the Director of Quality (DQ), the DQ stated the facility had no environmental risk assessment (a systematic evaluation of hazards in the physical environment) related to the “C beds” and no documentation showing the beds had been evaluated for fire?safety planning (procedures for preventing or responding to fire). During a review of the facility’s policy and procedure (P&P) titled “Policy for Acquisition of Furnishings,” (undated), the P&P indicated all furnishings must comply with Life Safety Code documentation for flame-spread and smoke-density ratings and that the Purchasing Department must ensure compliance and maintain documentation. During a review of the facility’s policy and procedure (P&P) titled, “Quality Management Program and performance Improvement Plan,” dated January 2026, the P&P indicated, “The program provides surveillance of health care delivery involving the qualifications and performance of those managing and delivering the services; the outcome of care and services delivered; the availability and utilization of support resources, facilities, staff, equipment, assistance and environment ... The quality management program will provide an ongoing system for monitoring evaluating important aspects of patient care. The Board of Trustees, as the governing body of the hospital, has the ultimate responsibility and authority to establish, maintain and support the ongoing quality improvement program.The Board will require review and evaluation of activities to assess and continually improve the overall quality and efficiency of patient care. The Board will receive and act upon recommendations regarding quality assessment and improvement activities. The Board will review the plan at least annually and update the plan to reflect any changes in strategic priorities and in response to changes in the internal or external environment.” 2. During a review of the facility’s elopement log (defined as the facility’s record of all attempts or incidents in which a patient leaves or attempts to leave the facility without authorization), dated 2026, the log indicated that on 1/26/2026, one patient (Patient 14) eloped (a patient leaving a clinical unit or facility without authorization, proper discharge, or informing staff) from the facility by climbing the wall outside the facility building, during a patio break and “AWOL’ed (defined as leaving the facility without authorization)” at 12:50 p.m. on 1/26/2026. During a review of Patient 14’s psychiatric evaluation (Psych Eval, defined as a formal and comprehensive assessment conducted by a psychiatrist to determine the patient’s mental status, diagnosis, and treatment needs), dated 1/23/2026, the Psych Eval indicated that Patient 14 was admitted to the facility with a diagnosis of psychosis (a mental state involving loss of contact with reality), described by Patient 14 as “demons terrorizing the patient (Patient 14) and serpents in the heart causing the patient to want to stab self in the heart.” The record also indicated that Patient 14 was placed on a legal hold for danger to self (defined as an involuntary detention, such as a 5150-hold initiated when a patient is determined to present a risk of self-harm and requires evaluation and treatment in a secured facility). The record further indicated that Patient 14 required self-harm and elopement precautions (defined as heightened safety monitoring and interventions implemented to prevent a patient from engaging in self-injurious behavior or leaving the facility without authorization). During an interview on 2/4/2026 at 2:36 p.m. with the Director of Quality (QA), QA stated that no official Root Cause Analysis (RCA, defined as a structured method used to identify underlying system causes of an adverse event and develop corrective actions to prevent recurrence) had been conducted for the incident involving Patient 14. QA explained that an informal investigation was performed, during which staff were debriefed, interviewed involved personnel, and inspected the area where the elopement occurred. During the same interview on 2/4/2026 at 2:36 p.m. with the Director of Quality (QA), QA stated that the facility had identified that the elopement occurred because Patient 14 was able to place his (Patient 14) foot on the fence handle, push upward, grab the aluminum section at the top of the fence, and leverage himself over it to climb and jump over. QA stated that the vendor had been contacted to “cover the aluminum cover [that] Patient 14 used to grab onto to leverage himself over the fence and jump over.” QA stated, “we are in the process of correcting the identified issue with the identified risk,” and confirmed that, as of 2/4/2026, the risk for other elopement incidents continued to prevail. During a follow-up interview on 2/4/2026 at 3:45 p.m. with the Director of Plant Operations and Safety (SO), SO stated that they conducted an assessment of the area (where the elopement incident occurred). SO explained that, typically, the Quality Director would review the footage of the incident and notify the SO about what happened to aid in the investigation. SO stated that the plan of action was to install a steel plate to reinforce the area and cover the aluminum plate to prevent patients from grabbing onto it. SO said they had contacted the vendor, but there was no confirmation regarding when the vendor would come out to repair the area, adding, “Possibly next week.” During an interview on 2/5/2026 at 9:29 a.m. with Behavioral Health Specialist (BHS 4), who investigated the incident of elopement involving Patient 14, BHS 4 stated that staff had been interviewed by the facility’s supervisor. BHS 4 explained that there was one staff member outside with Patient 14 and other patients at the time of the incident. BHS 4 further said that the staff member witnessed Patient 14 holding onto the door before Patient 14 proceeded to climb the fence and jump over, successfully eloping from the facility. During a concurrent interview and record review on 2/5/2026 at 11:15 a.m. with the Director of Quality (QA), the facility’s elopement data for the past 12 months, was reviewed. The QA stated that no additional data were collected for the elopement incident involving Patient 14 and QA did not confirm or deny whether the fence had been previously identified as a potential elopement risk, whether staffing had been an issue (since only one staff member was present outside at the time of the elopement incident of Patient 14), or whether the patient (Patient 14) had required different elopement precautions. The QA did not provide a formal RCA (Root Cause Analysis, a structured, team-based investigation used to identify the underlying system failures that caused a sentinel event [serious harm] or near miss. It focuses on why a mistake occurred-examining processes, technology, and communication-rather than who made it, with the ultimate goal of preventing future recurrences) report for the incident, and the discussed plan of correction which involved contacting the vendor to address the aluminum plate (that Patient 14 was able to grab onto to raise himself up and over the fence), with no specified date for when the repairs would occur and did not confirm that there was an immediate mitigation plan (a proactive, documented strategy designed to identify potential hazards, and implement measures to reduce or eliminate their impact on patient safety) in place to prevent future elopement occurrences. Review of the facility’s elopement data for the past 12 months indicated no documented trending, analysis, or identification of contributing factors such as structural vulnerabilities or staffing inadequacy. During a review of the facility’s Elopement 2025-2026 Log (the facility’s tracking tool used to record all attempted and completed elopements, including dates, patient identifiers, locations, and adverse outcomes), the log indicated that across January 2025 through January 2026, the facility experienced a total of 34 attempted elopements and eight (8) completed elopements. During a concurrent interview and record review on 2/4/2026 at 1:40 p.m. with the Director of Quality Assessment and Performance (QA), the facility’s elopement log, dated January 2025 through January 2026, was reviewed. Six out of eight sampled patients’ (Patient 9, Patient 10, Patient 11, Patient 14, Patient 15, and Patient 16) records, which indicated attempted or completed elopements from the facility, were reviewed from the elopement log: -Patient 9 (4/26/2025): Patient 9 dialed 911 from the intake lobby telephone, stating he (Patient 9) had medical problems. Patient 9 was transported to the Emergency Department (ED, defined as the hospital’s emergency medical treatment unit), from which the patient (Patient 9) eloped before being seen by a physician. Police were notified. Patient 9 was not found. -Patient 16 (3/7/2025): Patient 16 ran to the patio fence and jumped over. Police were notified. Patient 16 did not return to the facility and was discharged. - Patient 11 (3/10/2025): Patient 11 began complaining of chest pain. Staff called 911, and the patient (Patient 11) was transported to the ED, from which the patient (Patient 11) eloped and did not return to the facility. - Patient 10 (3/29/2025): Patient 10 attempted to elope by jumping through the half door in the nurse’s station and attempting to climb over the counter in an attempt to AWOL. Patient 10 was stopped. - QA confirmed that although elopement data had been collected and the elopement log contained details of each event (whether attempted or completed), the elopement log did not include the actions taken to reduce attempts or prevent elopements, nor did it include any immediate action plans. QA stated that informal investigations had been conducted for all attempted and completed elopements. QA also verified that there had been no official evaluation conducted to review each incident of elopement or attempted elopement against the interventions identified in the facility’s plan of action for elopement (defined as the set of corrective strategies, preventive measures, and follow-up steps developed by the facility) to reduce elopement risk, to ensure staff adhered to required interventions, and to evaluate whether the implemented measures to address elopement risks, were effective. During a review of Patient 9’s Intake Assessment (an initial clinical evaluation used to determine the patient’s symptoms, risks, and need for psychiatric treatment), dated 4/26/2025, the Assessment indicated that Patient 9 was seeking evaluation due to severe paranoia (an unfounded belief that others intend to harm or follow someone), admitted to having access to firearms, and stated that he (Patient 9) “will hurt someone to defend self ...,” and was placed on a legal hold (an involuntary, short-term detention-typically 72 hours-of an individual experiencing a mental health crisis) due to danger to others (meaning the patient’s statements or behaviors indicated a likelihood of harming another person because of a mental health disorder). During a review of Patient 14’s psychiatric evaluation (Psych Eval, defined as a formal and comprehensive assessment conducted by a psychiatrist to determine the patient’s mental status, diagnosis, and treatment needs), dated 1/23/2026, the Psych Eval indicated that Patient 14 was admitted due to psychosis (a severe mental condition in which the patient loses touch with reality, including hallucinations [hearing voices or sounds that are not present] or delusions [the presence of firmly held, false beliefs that are resistant to reason or contrary evidence]) and paranoid delusions, described by Patient 14 as “demons terrorizing the patient (Patient 14) and serpents in the heart causing the patient (Patient 14) to want to stab self,” and was placed on a legal hold for danger to self (an involuntary psychiatric detention applied when a patient is at risk of self-harm and requires evaluation in a secure facility). During a review of Patient 15’s psychiatric evaluation (Psych Eval), dated 8/1/2025, the Psych Eval indicated that Patient 15 was admitted to the facility due to being paranoid (meaning the patient exhibited irrational distrust or suspicion of others), psychotic (experiencing a loss of contact with reality, such as delusions or hallucinations), hostile, and aggressive, and was placed on a legal hold due to being a danger to self (meaning the patient’s behaviors or statements indicated a risk of self-harm) and gravely disabled (meaning the patient was unable to provide for basic needs such as food, clothing, or shelter due to a mental health disorder). During a review of Patient 16’s psychiatric evaluation (Psych Eval), dated 3/7/2025, the Psych Eval indicated that Patient 16 was admitted to the facility voluntarily, admitting that Patient 16 was suicidal (meaning the patient expressed thoughts, intentions, or desires to harm or kill themself). During a review of Patient 11’s psychiatric evaluation (Psych Eval), dated 3/10/2025, the Psych Eval indicated that Patient 11 was suicidal, admitted to wanting to end their (Patient 11) life, and requested to be voluntarily admitted (voluntary admission means the patient is seeking inpatient psychiatric treatment of their own choice and is willing to remain in the hospital for evaluation and care). During a review of Patient 10’s psychiatric evaluation (Psych Eval), dated 3/28/2025, the Psych Eval indicated that Patient 10 was placed on an involuntary hold (legally being admitted to a psychiatric unit for care of a severe mental health condition against your wishes) due to danger to self (meaning the patient’s thoughts or behaviors demonstrated a likelihood of self-harm), admitting that Patient 10’s “grandfather was plotting against them and trying to kill them ...” During an interview on 2/4/2026 at 3:05 p.m. with the Director of Quality (QA), the QA verified that there were no formal documents demonstrating that a root-cause analysis (RCA, defined as a structured method used to identify contributing factors and underlying causes of an adverse event) had been conducted for each of the elopement events. The QA stated that investigations had been conducted informally, with supervisors debriefing the staff, interviewing involved personnel, and inspecting the relevant areas (where the incidents of elopement occurred). The QA stated, “We do investigations by supervisors who will initiate the investigations because sometimes Risk [personnel] is not here. A lot of events happen on the evening or night shift. The following day we look at the video surveillance and bring safety officer and behavioral health staff lead to analyze what happened. We evaluate that. We don’t keep records, but we put it in the risk incident report. Our RCA is more informal; we do it more as an investigation. When we report it, I let them know what the plans are moving forward. I verbalize the events, such as a patient, who used the table to get over the fence... but we do not document the action plan in the report; it is verbally discussed.” The QA also stated that there had been no tracking of measures implemented to reduce elopements or of whether the identified interventions were effective. During a concurrent interview and record review on 2/5/2026 at 11:00 a.m. with the Director of Quality (QA), Risk Management Reports, dated 2025, were reviewed. QA stated that the reports were presented to the QAPI Committee, Governing Body (GB, defined as the entity legally responsible for the conduct of the hospital, including oversight of quality, safety, and compliance) quarterly. QA explained the data demonstrated in a graph, stating that the number of attempted and completed elopements fluctuated, with 3 completed elopements in Quarter 4 of 2024 and 3 completed elopements in the 2nd quarter of 2025. However, QA indicated that there were no completed elopements from October 2025 through December 2025, which had been reported as a decrease in incidents of elopement compared to the 3rd quarter of 2025, but there had been no set benchmark for elopements (defined as a predetermined performance target or threshold established by the facility to evaluate whether the number of elopements was improving, worsening, or remaining stable over time), for comparison purposes. During a concurrent interview and record review on 2/5/2026 at 11:00 a.m. with the Director of Quality (QA), the Risk Management report also indicated that QA had collected data on location, shift, identified and assessed elopement risks, status (voluntary versus involuntary), days in treatment, staffing adequacy, and population. However, the report also reflected that there were no adverse events (An event in which care resulted in an undesirable clinical outcome) reported when, in fact, Patient 15 had been documented to have sustained a right heel fracture (break in the bone) after attempting to jump over the fence. QA stated that this (incident involving Patient 15) had been an oversight (the unintentional failure to notice, document, or include required information or findings in the report). During a concurrent interview and record review on 2/5/2026 at 11:15 a.m. with the Director of Quality (QA), the plan of action for elopement, presented in the Risk Management 4th quarter 2025 Report back in January 2026, was reviewed. The plan of action identified several measures intended to prevent elopements on the unit; however, there were no evaluation criteria established to verify whether the measures were successful, and there was no evidence that compliance with the measures had been monitored or evaluated. QA stated that success was measured only by the number of elopements and stated that the facility had no completed elopements during the last quarter of 2025, which QA attributed to the measures identified in the plan of action for elopements. However, QA could not demonstrate how the facility monitored the effectiveness of the implemented actions, as there was no documented evaluation or follow-up to determine whether the interventions worked, whether staff followed the required preventive steps, whether each intervention identified in the plan of action had been carried out, whether the interventions were effective, or whether modifications were needed. During an interview on 2/9/2026 at 1:33 p.m. with the Director of Quality (QA), the QA stated that data on elopement was collected because it related to patient safety. QA explained that the data was collected monthly by the departments and then quantified. If the data fell below the benchmark, QA would notify the department that a Plan of Correction (POC) was required and would request that the department provide the POC. QA also said that the Nurse Educator was responsible for conducting all necessary in?services. The QA further stated that during QAPI meetings, the team would review details of any fallouts related to not meeting benchmarks, evaluate the causes, and continue tracking the data until the goal was sustained. During an interview on 2/10/2026 at 10:08 a.m. with the Chief Executive Officer (CEO), the CEO was asked whether elopements were considered a high-risk or problem-prone area for the facility based on what QAPI had been reporting. The CEO stated that elopements were a high-risk issue “in addition to other risks in the psychiatric setting.” The CEO explained that involuntary admissions presented challenges because patients might disagree with treatment and attempt to leave, and that elopement prevention, therefore, required continuous evaluation of the physical plant (the facility environment). The CEO stated that elopements would “always be a priority,” and emphasized that the challenge for the facility was determining what safeguards could be put in place and whether elopement risks could be mitigated, given that the facility could not control what happened once a patient left the grounds. During a review of the facility’s Quality Assessment and Performance Improvement (QAPI) plan, dated 2026, the plan indicated that “the purpose of the QAPI program was to provide an objective and systematic approach to performance improvement related to the quality of care and services provided, with the goal of ensuring continuous performance improvement through effective leadership involvement in quality assessment and improvement activities. The program emphasizes analysis of the appropriateness of care, as well as the evaluation of problems, concerns, and opportunities for improvement in services and patient care. The QAPI plan also indicated the following: -The QAPI program will provide an ongoing system for monitoring and evaluating important aspects of patient care. The data compiled is analyzed according to the performance improvement plan on quality measurement and performance improvement activities, using methodologies such as Plan-Do-Check-Act (PDCA) and Plan-Do-Study-Act (PDSA). The hospital improves performance and takes action when improvement priorities are identified or when it does not achieve or sustain planned improvements according to established performance goals. -In determining the priority of a study, consideration must be given to the scope of patients affected, the effect on patient care, and the overall impact on the quality and safety of services provided. -Data is collected for each indicator and evaluated on an ongoing basis by departments, services, and programs. The findings from monitoring activities are analyzed to identify problems or opportunities to improve care. When an issue is identified, action is taken to resolve the problem. Reports of monitoring and evaluation activities are submitted to the Director of Quality Improvement, and these reports include the specific actions and follow?up necessary to prevent or correct the problem and improve patient care. -The monitoring and evaluation process is designed to assist the facility in identifying potential areas for performance improvement in patient care. This process includes a proactive and preventive approach to continually improving the processes and systems required to meet the needs of patients. The program establishes thresholds for each indicator, monitors important aspects of care by collecting and organizing data, evaluates care when thresholds are reached, takes action to improve performance, and assesses the effectiveness of the interventions to determine whether the improvements have been sustained. -An informal approach is used when the cause of the problem is likely to be obvious once identified, and corrective action can be taken based on preliminary findings without collecting additional data. This method is most appropriate when statistical data alone is sufficient to support the corrective action. -A formal approach is used when the defined problem may have multiple variables, when those variables involve clinical judgment or skills, or when there is no agreement regarding the attribution or cause. A formal evaluation involves establishing predetermined criteria that are clinically valid and stated in measurable terms, measuring actual practice against the criteria, and analyzing the differences between the expected criteria and actual practice.” 3. During a review of facility incidents of abuse on 2/4/2026 at 1:40 p.m., the surveyor reviewed the first sampled incident of patient abuse which involved Patient 28’s medical records that indicated Patient 28 (perpetrator) repeatedly engaged in aggressive and sexually inappropriate behaviors on 5/25/2025 and, due to lack of escalation to the physician or to higher nursing leadership with regards to Patient 28’s observation level, Patient 28 physically assaulted two other patients (Patient 29 and Patient 30, first and second victim of assault by Patient 28) on separate occasions (5/31/2025 and 6/1/2025, respectively), causing facial injuries and exposing other patients and staff to ongoing risk of harm. The reviewed medical records further indicated the following: -Patient 29 had swelling to the left cheek and forehead (swelling defined as enlargement of the tissue due to injury), a cut on the lip (a break in the skin caused by trauma), and redness in the right eye (irritation or bleeding under the surface of the eye). -Patient 30 had redness on the right side of the face and nose (skin irritation related to impact) and a bloody mouth (bleeding inside or around the mouth caused by trauma). During a review on 2/5/2026 at 9:30 a.m. regarding the second incident of abuse which involved Patient 33, who had been identified as high risk for assault (meaning the patient had a known history or behavior pattern that indicated a likelihood of harming others), the records indicated that Patient 33 assaulted Patient 18 without provocation (meaning Patient 18 did nothing to trigger the incident) while Patient 18 was asleep in Patient 18’s room. Patient 18 had bruising on the right forehead and left eyelid (bruising defined as discoloration caused by broken blood vessels under the skin), a small abrasion on the left eyelid (a superficial scrape on the skin), and slight drooping of the eyelid (drooping defined as the eyelid sitting lower than normal due to swelling or muscle injury) after being assaulted by Patient 33. During a concurrent interview and record review on 2/9/2026 at 1:38 p.m. with the Director of Quality (QA), the Assaults Report for the 1st quarter through 4th quarter (Q1, Q2, Q3, and Q4) of 2025, were reviewed. The report indicated that: -In the first quarter of 2025 (Q1), there were 70 assaults during that period, representing an 89% increase compared to the 4th quarter of 2024. The data showed a total of 25 patient-to-patient assaults with 8 patients sustaining injuries. The report also indicated that the following data had been collected: shift, day of the week, days in treatment, and staffing adequacy. The report further indicated that two patients, one with a closed head injury (a type of traumatic brain injury [TBI] where the skull remains intact and is not penetrated, often caused by rapid shaking, falls, or blows to the head) and another with head, neck, and back pain, had been sent to the Emergency Department. -In the second quarter of 2025 (Q2), there was an 8% increase in assaults, with 76 documented total assaults. Of these, 33were patient-to-patient assaults. Additionally, 12 patients sustained injuries that did not require transfer to the emergency department. -In the third quarter of 2025 (Q3), there were 87 total documented assaults. Of these, 36 were patient to patient assaults. 10 patients were documented to have sustained injuries and two (2) patients required transfer to the Emergency department due to nasal fracture (a crack or break in the bone or cartilage of the nose, often resulting from traumatic impact) and closed fracture (a broken bone that does not pierce the skin, leaving the surrounding skin intact) of the nasal bone. -In the fourth quarter of 2025 (Q4), there were 85 assaults, representing a 2% decrease compared to Q3 2025. Nine patients sustained injuries, while 33 patients had no injuries reported from Q3. One patient requested transfer to the emergency department after being hit in the eye and was diagnosed with bacterial conjunctivitis (an infection of the eye’s transparent outer membrane [conjunctiva] caused by bacteria, resulting in red, irritated eyes with thick yellow or green discharge) related to the trauma. -QA stated that the facility collected quarterly assault data (counts, injuries, ED transfers, shift/day), there was no log to track patient-to-patient assaults for monitoring or trending purposes. QA was unable to provide information regarding patients who had been sent to the Emergency Department after sustaining injuries and confirmed that no data were available for review pertaining to the injured patients. QA reported that the facility did not maintain a specific log documenting assault incident, including whether injuries occurred, no stratification by unit/location, nor any analysis correlating observation levels, staffing adequacy, or DASA (Dynamic Appraisal of Situational Aggression, a tool used to assess the risk of aggression by scoring each item as present [1] or absent [0] within the previous 24 hours)/DTO (Danger to Others) scores with each assault occurrence. During a concurrent interview and record review on 02/09/2026 at 2:48 p.m. with the Director of Quality (QA), QA stated that the facility did not have an established benchmark for assaults and that the facility “tries to decrease it by a certain percentage per year.” QA added that from 2024 to 2025, the goal was to achieve a 5% decrease, but the QA “had not reviewed the full year yet.” QA explained that a team was created to evaluate assault incidents involving staff injuries. QA reported that in the first quarter (Q1) of 2025, events were monitored and staff received education. In quarter 2 (Q2) of 2025, the facility evaluated whether patients had drug history, legal history, prior assaults, incarceration history, developmental delays, special needs, or were conserved (an adult whom a court has deemed unable to manage their own care or finances due to severe impairment). During the same concurrent interview and record review on 02/09/2026 at 2:48 p.m. with the Director of Quality (QA), QA referred to the documented additional interventions implemented during Q2 of 2025, including: -Seeking Safety (an evidence-based, present-focused counseling model designed to help individuals attain safety from trauma and substance use by strengthening coping skills and grounding techniques). -Crisis Stabilization (short-term, intensive intervention aimed at reducing acute psychiatric distress, restoring behavioral control, and stabilizing the patient through assessment, medication management, monitoring, and therapeutic support). -Early medication interventions to prevent escalation of aggressive or assaultive behavior. 1:1 monitoring (defined as continuous, one-to-one observation in which a staff member remains within arm’s reach of a patient at all times to ensure immediate intervention and prevent harm) or line-of-sight observation(keeps a patient within direct, unobstructed view at all times, including while the patient uses the bathroom or sleeps) for patients assessed as high risk for assaultive behavior. -Ongoing staff in-services and Therapeutic Options Training (Therapeutic Options Training defined as a structured, competency-based program that teaches staff de-escalation, crisis intervention, and assault-prevention techniques). The facility did not provide documentation of any staff in-services conducted during 2025. -Use of hospital video surveillance to analyze assault incidents and incorporate findings into Therapeutic Options Training curricula. The facility did not provide any video footage for review; videos were not available. -Utilization of the DASA tool (DASA defined as the Dynamic Appraisal of Situational Aggression, a standardized, evidence?based screening tool used to assess patients’ short-term risk for violence and trigger early intervention measures). -Continued review of staffing adequacy to ensure appropriate coverage and supervision. -QA stated that in Quarter 3 and Quarter 4 of 2025, the facility added a PRN (As needed) Medication Protocol (defined as a structured process outlining the criteria, indications, assessment steps, documentation, and monitoring required when administering medications “as needed” to manage acute agitation or aggression). -QA said that additional measures implemented in Q3-Q4 included the following: -A high-assault risk screening assessment -The Yellow Observation Rounding Form, defined as a high-risk patient-monitoring tool used to document enhanced observation, patient behavior, and staff rounding frequency for individuals identified as having elevated assault risk -New case scenarios incorporated into staff training -More timely and frequent staff rounds to ensure patient safety on the unit During the same concurrent interview and record review on 02/09/2026 at 2:48 p.m. with the Director of Quality (QA), QA verified that there was no documentation demonstrating that QAPI evaluated the effectiveness of the interventions and stated that the program relied solely on the decreased percentage in annual assault data as its measure of success. QA also stated that audits were not conducted to verify and evaluate intervention compliance or effectiveness (including 1:1 or Line-of-Sight [LOS] timeliness, DASA completion, observation-documentation quality, and PRN [as needed] medication-protocol adherence). QA confirmed that QAPI did not document follow-up to validate whether these actions reduced assaults or injuries, involving either patient-to-patient or patient-to-staff. During a review of QAPI Committee materials for 2025, the record indicated that no documented trend analysis, measurable goals, or re-evaluation of assault-prevention interventions had been conducted to verify whether the actions taken throughout 2025 resulted in sustained improvement. During a review of the facility’s Quality Assessment and Performance Improvement (QAPI) plan, dated 2026, the plan indicated that the purpose of the QAPI program was to provide an objective and systematic approach to performance improvement related to the quality of care and services provided, with the goal of ensuring continuous performance improvement through effective leadership involvement in quality assessment and improvement activities. The program emphasizes analysis of the appropriateness of care, as well as the evaluation of problems, concerns, and opportunities for improvement in services and patient care. The QAPI plan further indicated the following: “-The QAPI program will provide an ongoing system for monitoring and evaluating important aspects of patient care. The data compiled is analyzed according to the performance improvement plan on quality measurement and performance improvement activities, using methodologies such as Plan-Do-Check-Act (PDCA) and Plan-Do-Study-Act (PDSA). The hospital improves performance and takes action when improvement priorities are identified or when it does not achieve or sustain planned improvements according to established performance goals. -In determining the priority of a study, consideration must be given to the scope of patients affected, the effect on patient care, and the overall impact on the quality and safety of services provided. -Data is collected for each indicator and evaluated on an ongoing basis by departments, services, and programs. The findings from monitoring activities are analyzed to identify problems or opportunities to improve care. When an issue is identified, action is taken to resolve the problem. -Reports of monitoring and evaluation activities are submitted to the Director of Quality Improvement, and these reports include the specific actions and follow-up necessary to prevent or correct the problem and improve patient care. -The monitoring and evaluation process is designed to assist the facility in identifying potential areas for performance improvement in patient care. This process includes a proactive and preventive approach to continually improving the processes and systems required to meet the needs of patients. The program establishes thresholds for each indicator, monitors important aspects of care by collecting and organizing data, evaluates care when thresholds are reached, takes action to improve performance, and assesses the effectiveness of the interventions to determine whether the improvements have been sustained... -An informal approach is used when the cause of the problem is likely to be obvious once identified, and corrective action can be taken based on preliminary findings without collecting additional data. This method is most appropriate when statistical data alone is sufficient to support the corrective action. -A formal approach is used when the defined problem may have multiple variables, when those variables involve clinical judgment or skills, or when there is no agreement regarding the attribution or cause. A formal evaluation involves establishing predetermined criteria that are clinically valid and stated in measurable terms, measuring actual practice against the criteria, and analyzing the differences between the expected criteria and actual practice.” During a review of the facility’s policy and procedure (P&P) titled Reporting of “Unusual Occurrences” to Local Regulatory Agencies,” dated 11/2021, the P&P indicated that, “To ensure the safety and welfare of patients and employees and to report to licensing [State] Department of Public Health (DPH), Department of Health Care Services (DHCS) and the [City] County Department of Mental Health (CDMH) any occurrence which threatens the welfare, safety and health of patient(s), personnel and visitors. The following are considered critical incidents: Elopement resulting in serious physical injury to a patient or third party or significant property destruction; Major altercation or threat between patients or between staff and patient(s); Physical harm to others, occurring during treatment or within 30 days of discharge.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to identify opportunities for improvement and take actions to mitigate environmental safety hazards associated with the addition of nine (9) unlicensed “C beds (portable metal beds with removable metal springs and foldable metal frames)” placed across three inpatient units, for five (5) high-risk patients (Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5) sampled from 34 patients, who were housed in rooms containing the added “C beds.” The hazards included obstruction of emergency-response pathways (blocked physical space needed for care), ligature hazards (items that could be used for self-harm), and weaponization hazards (items that could be used to harm others). This deficient practice had the potential to result in delayed emergency treatment for Patient 1, increased risk of patient self-harm, and increased risk of physical harm to Patients 1, 2, 3, 4, and 5 and all other patients or staff at the facility due to unsecured and removable metal components. Findings: During a concurrent observation and interview on 2/3/2026 at 12:10 p.m. with the Director of Nursing (DON) in West Unit rooms 220 and 221, a “C bed (portable metal bed frame with foldable components),” was observed in each room (rooms 2202 and 221). The “C” beds were unbolted (not attached to the floor or wall), constructed with metal frames (solid metal structures), and contained removable metal springs (detachable metal supports). The “C” beds lacked tamper-proof hardware (fasteners resistant to removal) and were easily movable (able to be pushed or repositioned with little effort). The DON confirmed the beds used throughout the hospital were portable and not bolted. During a concurrent observation on 2/3/2026 at 12:20 p.m. with the DON, additional “C beds” were observed in rooms 232 and 238 in the North Unit. During a review of Patient 1’s “Psychiatric Evaluation,” dated 11/16/2025, the evaluation indicated suicidal ideation (thoughts of self-harm) and paranoia (an unfounded belief that others intend to harm or follow the person). Patient 1 was assigned to a room containing a “C bed.” During a review of Patient 2’s “Psychiatric Evaluation,” dated 2/2/2026, the evaluation indicated Patient 2 was admitted on a 5150 hold (a California law allowing temporary involuntary detention for danger to self, danger to others, or grave disability) and reported auditory hallucinations (hearing voices not present). During a review of “Acute Nursing Progress Note,” dated 2/3/2026, the note indicated a suicide?risk score of 3 (defined by Intake as high risk for suicide). Patient 2 was assigned to a room containing a “C bed.” During a review of Patient 3’s “Psychiatric Evaluation,” dated 2/2/2026, the evaluation indicated Patient 3 walked in traffic and experienced visual hallucinations (seeing objects not present) and auditory hallucinations (hearing voices not present) instructing self-harm. During a review of Patient 3’s “High-Risk Alert” form, dated 2/3/2026, the form indicated suicide ideation (thoughts of self-harm), potential danger to others, and risk of self-injury due to prior cutting behavior. Patient 3 was assigned to a room containing a “C bed.” During a review of Patient 4’s “Psychiatric Evaluation,” dated 2/2/2026, the evaluation indicated Patient 4 was admitted on a 5585 hold (a California law allowing temporary involuntary detention of a minor during a mental-health crisis), with depression (persistent low mood), suicidal ideation, a plan to overdose (take an excessive amount of a substance), and a recent suicide attempt (an act of trying to end one’s life). Patient 4 was assigned to a room containing a “C bed.” During a review of Patient 5’s “Psychiatric Evaluation,” dated 2/2/2026, with DIR 3, the report indicated Patient 5 was brought in on a 5150 hold for danger to self. The report indicated Patient 5 reported suicide ideation (thoughts of wanting to end one’s own life). Patient 5 reported, “He wish to be dead.” The Psychiatric Evaluation also indicated that Patient 5 stated, “I want to hurt the people who did this to me.” The report indicated Patient 5 also reported psychosis (a mental state involving loss of contact with reality) and A/H (auditory hallucinations-hearing voices or sounds that are not present) that were command in nature (“They tell me to kill myself”). During a concurrent observation, interview and surveillance video review on 2/4/2026 at 11:02 a.m. with the Chief Executive Officer (CEO), the surveillance video, dated 11/17/2025, showed that at 8:05 a.m., staff pushed a “C bed (portable metal bed with removable components)” from Patient 1’s room into the hallway to create space for CPR (cardiopulmonary resuscitation-an emergency procedure used when breathing or heartbeat stops). The CEO confirmed that staff had to move the C bed to the hallway to make room for staff to treat Patient 1 during an emergency response. During an interview on 2/4/2026 at 3:05 p.m. with the Director of Quality (DQ), the DQ stated the facility did not evaluate environmental risks associated with the “C beds” within the QAPI program (a hospital-wide program that uses data to identify problems, test solutions, and improve patient safety and quality). During an interview on 2/4/2026 at 3:08 p.m. with Plant Operations/Safety Officer (SO 1), SO 1 stated the “C bed” contained metal spring parts (detachable metal support pieces) and confirmed these components could be removed by hand. SO 1 confirmed Environmental Rounding (routine checks of the physical environment to identify hazards) did not address the presence or safety characteristics of the “C beds.” During a concurrent interview and record review on 2/4/2026 at 3:20 p.m. with Plant Operations/Safety Officer (SO 1), the facility’s Emergency, Fire, and Evacuation Plans (written procedures for responding to emergencies, fires, and relocation of patients to safety), were reviewed. SO 1 confirmed the plans did not include the “C beds.” During a review of the facility’s policy and procedure (P&P) titled “Unit Patio,” dated November 2025, the P&P required the hospital to maintain ligature-free environments (areas without items that could be used for self-harm) and conduct routine checks for hazards in patient-care areas. During a review of the facility’s “Fire Safety Management Plan,” (undated), the plan indicated objectives to comply with local, state, and federal guidelines, provide a fire-safe environment, and reduce hazards through pro-active inspections and processes in accordance with Life Safety Code NFPA 101 and other standards (NFPA 99, 72, 13).”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 46238 Based on interviews and record reviews, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) program (defined as the hospital-wide, data-driven program required to monitor, analyze, and improve the quality and safety of patient care) established and maintained an effective system for identifying, tracking, analyzing, and reporting adverse patient events (An event in which care resulted in an undesirable clinical outcome) that included incidents of patient elopements (when a patient leaves a healthcare facility without authorization, discharge, or notifying staff, often posing severe safety risks) with or without injury for three (3) of 34 sampled patients (Patients 11, 15, and 16) and incidents of patient assault (the act of causing physical harm or unwanted physical contact to another person) with or without injury for three (3) of 34 sampled patients (Patients 18, 29 and 30). The QAPI committee did not maintain a log of patient-to-patient assaults, did not track adverse events (involving patient elopements or patient assault) resulting in patient harm (including injuries and Emergency Department transfers), and did not track or report abuse-related incidents, in accordance with regulatory requirements. This prevented the facility from demonstrating the ongoing monitoring required for compliance with patient-safety and quality-improvement programs and from maintaining formal records of investigations in accordance with its QAPI plan (defined as the facility’s structured, data-driven method for reviewing adverse events, identifying causes, implementing corrective actions, and measuring improvement). In addition, the facility failed to report abuse-related events-including patient-to-patient assaults and injuries requiring Emergency Department evaluation-to the State regulatory authority as required, which can affect all patients at the facility. This deficient practice had the potential to place all patients at the facility, not just the six (6) sampled patients (Patients 11, 15, 16, 18, 29 and 30), at risk for unrecognized and unmitigated harm. The failure to report these events also had the potential to hinder external oversight, delay protective actions, and lead to repeated incidents of patient harm such as additional incidents of Patient elopement and/or patient abuse/assault. Findings: 1.a. During a concurrent interview and record review on 2/4/2026 at 1:40 p.m. with the Director of Quality Assessment and Performance (QA), the facility’s elopement (when a patient leaves a healthcare facility without authorization, discharge, or notifying staff, often posing severe safety risks) log, dated January 2025 through January 2026, was reviewed. Three sampled patients (Patient 11, Patient 15, and Patient 16) who had attempted or completed elopements from the facility, were reviewed from the log and indicated the following: -Patient 11 (3/10/2025): Patient 11 began complaining of chest pain. Staff called 911, and the patient (Patient 11) was transported to the ED (Emergency Department), from which the patient (Patient 11) eloped and did not return to the facility. -Patient 15 (8/7/2025): Patient 15 attempted to elope by jumping over the fence during patio break. Upon impact, the patient endorsed landing on both heels and was unable to bear weight. Patient 15 required transfer to the ED (Emergency Department), where Patient 15 was diagnosed with a right heel fracture (broken bone). -Patient 16 (3/7/2025): Patient 16 ran to the patio fence and jumped over. Police were notified. Patient 16 did not return to the facility and was discharged. During a review of Patient 11’s psychiatric evaluation (Psych Eval, a mental health assessment used to diagnose emotional, behavior, and cognitive conditions), dated 3/10/2025, the Psych Eval indicated that Patient 11 was suicidal, admitted to wanting to end own life, and requested to be voluntarily admitted (voluntary admission means the patient is seeking inpatient psychiatric treatment of their own choice and is willing to remain in the hospital for evaluation and care). During a review of Patient 15’s psychiatric evaluation (Psych Eval), dated 8/1/2025, the Psych Eval indicated that Patient 15 was admitted to the facility due to being paranoid (meaning the patient exhibited irrational distrust or suspicion of others), psychotic (experiencing a loss of contact with reality, such as delusions or hallucinations), hostile, and aggressive, and was placed on a legal hold (an involuntary, short-term detention-typically 72 hours-of an individual experiencing a mental health crisis) due to being a danger to self (meaning the patient’s behaviors or statements indicated a risk of self-harm) and gravely disabled (meaning the patient was unable to provide for basic needs such as food, clothing, or shelter due to a mental health disorder). During a review of Patient 16’s psychiatric evaluation (Psych Eval), dated 3/7/2025, the Psych Eval indicated that Patient 16 was admitted to the facility voluntarily, admitting that Patient 16 was suicidal (meaning the patient expressed thoughts, intentions, or desires to harm or kill themself). During an interview on 2/4/2026 at 1:40 p.m. with the Director of Quality Assessment and Performance (QA), QA stated that elopement was considered a patient safety event due to the nature of the patient’s psychiatric condition. QA explained that law enforcement was always notified when an elopement occurred but confirmed not being familiar with regulatory requirements for reporting elopement to regulatory body. During the same interview on 2/4/2026 at 1:40 p.m. with the Director of Quality Assessment and Performance (QA), QA further stated that the facility would report patient safety events that result in patient death but confirmed that Patient 15’s injury resulting in a broken heel was not reported to the state.QA also stated that the facility did not maintain a log or centralized system for tracking patient safety events or adverse event (An event in which care resulted in an undesirable clinical outcome) reporting such as incidents of elopement. QA confirmed that there was no method or system in place to verify reporting of patient safety events other than reviewing individual patient charts. Without a clear reporting system, tracking and analyzing patient safety events-and supporting ongoing performance improvement- would be difficult. The facility also did not have an established tracking system for elopement. During an interview on 2/4/2026 at 3:09 p.m. with the Director of Quality Assessment and Performance Improvement/Risk Management (QA), QA stated that QA was not familiar with the State’s regulatory requirements for adverse events reporting for incidents such as elopement. During a review of the facility’s Quality Assessment and Performance Improvement (QAPI) plan, dated 2026, the plan indicated that the purpose of the QAPI program was to provide an objective and systematic approach to performance improvement related to the quality of care and services provided, with the goal of ensuring continuous performance improvement through effective leadership involvement in quality assessment and improvement activities. The program emphasizes analysis of the appropriateness of care, as well as the evaluation of problems, concerns, and opportunities for improvement in services and patient care. During a review of the facility’s Quality Assessment and Performance Improvement (QAPI) plan, dated 2026, the plan also indicated that the QAPI program will provide an ongoing system for monitoring and evaluating important aspects of patient care. The data compiled is analyzed according to the performance improvement plan on quality measurement and performance improvement activities, using methodologies such as Plan-Do-Check-Act (PDCA) and Plan-Do-Study-Act (PDSA). The hospital improves performance and takes action when improvement priorities are identified or when it does not achieve or sustain planned improvements according to established performance goals. During a review of the facility’s policy and procedure (P&P) titled “Reporting of ‘Unusual Occurrences’ to Local Regulatory Agencies,” dated 11/2021, the P&P indicated that, “To ensure the safety and welfare of patients and employees and to report to licensing [State] Department of Public Health (DPH), Department of Health Care Services (DHCS) and the [City] County Department of Mental Health (CDMH) any occurrence which threatens the welfare, safety and health of patient(s), personnel and visitors. The following are considered critical incidents: Elopement resulting in serious physical injury to a patient or third party or significant property destruction; Major altercation or threat between patients or between staff and patient(s); Physical harm to others, occurring during treatment or within 30 days of discharge Any other serious adverse event...” 1.b. During a review of facility incidents of abuse on 2/4/2026 at 1:40 p.m., the surveyor reviewed the first sampled incident of patient abuse which involved Patient 28’s medical records that indicated Patient 28 (perpetrator) repeatedly engaged in aggressive and sexually inappropriate behaviors on 5/25/2025 and, due to lack of escalation to the physician or to higher nursing leadership with regards to Patient 28’s observation level, Patient 28 physically assaulted two other patients (Patient 29 and Patient 30, first and second victim of assault by Patient 28) on separate occasions (5/31/2025 and 6/1/2025, respectively), causing facial injuries and exposing other patients and staff to ongoing risk of harm. The reviewed medical records further indicated the following: -Patient 29 had swelling to the left cheek and forehead (swelling defined as enlargement of the tissue due to injury), a cut on the lip (a break in the skin caused by trauma), and redness in the right eye (irritation or bleeding under the surface of the eye). -Patient 30 had redness on the right side of the face and nose (skin irritation related to impact) and a bloody mouth (bleeding inside or around the mouth caused by trauma). During a review on 2/5/2026 at 9:30 a.m. regarding the second incident of abuse which involved Patient 33, who had been identified as high risk for assault (meaning the patient had a known history or behavior pattern that indicated a likelihood of harming others), the records indicated that Patient 33 assaulted Patient 18 without provocation (meaning Patient 18 did nothing to trigger the incident) while Patient 18 was asleep in Patient 18’s room. Patient 18 had bruising on the right forehead and left eyelid (bruising defined as discoloration caused by broken blood vessels under the skin), a small abrasion on the left eyelid (a superficial scrape on the skin), and slight drooping of the eyelid (drooping defined as the eyelid sitting lower than normal due to swelling or muscle injury) after being assaulted by Patient 33. During an interview on 2/5/2026 at 9:30 a.m. with House Supervisor (HS 1), HS 1 stated that the incident involving Patient 18 (assault victim of Patient 33) was not reported to local regulatory agencies. HS 1 verified that, per facility policy regarding reporting of abuse, “In our policy we do an incident report. We either report to police or public health. Per policy we only report to one [entity].” HS 1 then confirmed that no internal incident report was completed for the abuse/assault (which was essential for tracking and analyzing patient safety events for continuous performance improvement). During a concurrent interview and record review on 2/6/2026 at 12:37 p.m. with the Director of Quality Assessment and Performance Improvement/Risk Management (QA), the facility’s policy and procedure titled “Reporting of ‘Unusual Occurrences’ to Local Regulatory Agencies,” revised on 11/2025, was reviewed. The policy indicated that any events or allegations of abuse may be reported to appropriate regulatory agencies (law enforcement, DPH [State Department of Public Health, state regulatory authority responsible for oversight of healthcare facilities and mandated abuse reporting]), and APS (Adult Protective Services, agency that investigates reports of abuse, neglect, or exploitation of vulnerable adults). The policy further clarified that abuse, (including but not limited to physical abuse) included incidents such as “patient?to?patient incidents ...” QA confirmed that the abuse incidents involving Patient 18, Patient 29, and Patient 30, were not reported to DPH. During a concurrent interview and record review on 2/9/2026 at 1:38 p.m. with the Director of Quality (QA), the facility’s Assaults Report for Q1-Q4 2025, was reviewed and indicated the following: -Q1 2025: The report indicated 70 assaults; an 89% increase compared to Q4 2024. Of these, 25 were patient-to-patient assaults, with 8 patients sustaining injuries. Data elements collected included shift, day of week, days in treatment, and staffing adequacy. The report further indicated two patients were sent to the Emergency Department (ED)-one for a closed head injury and another for head, neck, and back pain. -Q3 2025: The report indicated 87 total assaults; 36 were patient-to-patient assaults. Ten patients sustained injuries, and two patients required ED transfer due to nasal fracture (a crack or break in the bone or cartilage of the nose, often resulting from traumatic impact) and closed fracture (a broken bone that does not pierce the skin, leaving the surrounding skin intact) of the nasal bone. -Q4 2025: The report indicated 85 assaults, a 2% decrease from Q3 2025. Nine patients sustained injuries. One patient requested ED transfer after being hit in the eye and was diagnosed with bacterial conjunctivitis (an infection of the eye’s transparent outer membrane [conjunctiva] caused by bacteria, resulting in red, irritated eyes with thick yellow or green discharge) related to the trauma. -QA stated the facility collects quarterly assault data (counts, injuries, ED transfers, shift/day) but does not maintain a log to track, monitor, or trend patient?to?patient assaults. QA was unable to provide information regarding which patients were sent to the ED after sustaining injuries and confirmed no data was available for review pertaining to those injured patients. QA reported the facility did not maintain a specific log documenting assault incident. During an interview on 2/9/2026 at 2:26 p.m. with Director of Quality Assessment and Performance Improvement/Risk Management (QA), QA stated that the facility had been reporting some patient adverse events to APS (Adult Protective Services, the agency responsible for investigating allegations of abuse, neglect, or exploitation of dependent adults). QA said they need to check which patient events and patients were reported to APS. QA further confirmed that the facility did not maintain a log to track which events were reported to APS. QA stated that the only way to determine if a report was made was to review individual patient charts for the presence of an APS report case number. During an interview on 2/10/2026 at 11:27 a.m. with the Director of Quality Assessment and Performance Improvement Risk Management (QA), the QA stated physical assault was considered an abuse and should be reported to the State Department of Public Health (DPH, state regulatory authorities) to protect the patients. During an interview on 2/10/2026 at 11:32 a.m. with the Director of Quality Assessment and Performance Improvement/Risk Management (QA), QA stated, “Because we’re psych [psychiatric facility], we report as an assault. The investigator said that it should be classified as abuse. So now, we consider patient-to-patient assault as physical abuse. Therefore, it should be reported to State DPH.” QA further stated, “Policy should be aligned with [State Code of Regulations] for patient safety; we want to ensure that we’re following best practice.” During a review of the facility’s policy and procedures (P&P) titled, “Introduction to policies and procedures/manuals,” revised 11/2025, the P&P indicated, “Policy -A statement that communicates the expectations and philosophy of the hospital, department, and management. It provides guidelines for decision-making ...The Quality Assurance Performance Improvement (QAPI) Committee shall review all policies and procedures submitted for approval...” During a review of the facility’s Quality Assessment and Performance Improvement (QAPI) plan, dated 2026, the plan indicated that the purpose of the QAPI program was to provide an objective and systematic approach to performance improvement related to the quality of care and services provided, with the goal of ensuring continuous performance improvement through effective leadership involvement in quality assessment and improvement activities. The program emphasizes analysis of the appropriateness of care, as well as the evaluation of problems, concerns, and opportunities for improvement in services and patient care. During a review of the facility’s Quality Assessment and Performance Improvement (QAPI) plan, dated 2026, the plan also indicated that the QAPI program will provide an ongoing system for monitoring and evaluating important aspects of patient care. The data compiled is analyzed according to the performance improvement plan on quality measurement and performance improvement activities, using methodologies such as Plan-Do-Check-Act (PDCA) and Plan-Do-Study-Act (PDSA). The hospital improves performance and takes action when improvement priorities are identified or when it does not achieve or sustain planned improvements according to established performance goals. During a review of the facility’s policy and procedure (P&P), titled IDENTIFYING AND REPORTING DEPENDENT ADULT/ELDER ABUSE, revised 12/2025, the P&P indicated that, “Once identified, said abuse will be reported per hospital reporting policies. A. All staff will receive education about abuse reporting laws and hospital policy. All reports, and/or incidents of suspected adult abuse involving patients must be reported to a supervisor. The staff member receiving information and/or observing any incident of abuse must report it immediately: The Nursing Supervisor will be responsible to inform the Chief Nursing Officer. The RN will take pictures of the patient if there is physical evidence of abuse. Documentation in the patient’s chart will be noted by the staff member who obtained the information. The staff member receiving the information will be responsible for reporting to appropriate agencies and law enforcement if appropriate. The staff member will consult with the Charge Nurse and/or Supervisor, if necessary. Then notify the appropriate county of Adult Protective Services immediately, complete the report and submit to the proper agency online, fax, or mail. The report must be completed and submitted within 36 hours, although we ask our staff to complete the same shift that the information is discovered to ensure timeliness. The State Abuse Reporting laws cover all adult patients at [Facility]. Any events or allegations of abuse that occur during their inpatient hospitalization will be reported to one of the appropriate regulatory agencies (e.g. CDPH, APS, law enforcement, etc.). Abuse includes patient-to-patient, patient-to-staff, staff-to-patient events/allegations. Abuse may include, but is not limited to the following: 1. Physical 2. Sexual 3. Financial 4. Neglect -CDPH reporting must be made within five days of detection. However, if the adverse event is an ongoing or urgent threat to the welfare, health, or safety of patients, personnel or visitors, a report must be made within 24 hours of detection.” During a review of the All Facilities Letter (AFL) 25?15, the AFL indicated that Acute Psychiatric Hospitals (APHs) “are required to report adverse events and unusual occurrences in accordance with Title 22 and Health & Safety Code requirements, and failure to meet the required reporting timeframes may result in civil penalties issued by the California Department of Public Health (CDPH).” During a review of the facility’s policy and procedure (P&P) titled “Reporting of ‘Unusual Occurrences’ to Local Regulatory Agencies,” dated 11/2021, the P&P indicated that, “To ensure the safety and welfare of patients and employees and to report to licensing [State] Department of Public Health (DPH), Department of Health Care Services (DHCS) and the [City] County Department of Mental Health (CDMH) any occurrence which threatens the welfare, safety and health of patient(s), personnel and visitors. The following are considered critical incidents: Elopement resulting in serious physical injury to a patient or third party or significant property destruction; Major altercation or threat between patients or between staff and patient(s); Physical harm to others, occurring during treatment or within 30 days of discharge Any other serious adverse event...””

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) 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: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 46238 Based on interviews and record reviews, the executive leadership (Governing Body, GB- defined as the entity legally responsible for the conduct of the hospital, including oversight of quality, safety, and compliance), responsible for defining, implementing, and maintaining hospital-wide programs that improve patient safety and reduce adverse events, failed to ensure that its QAPI (Quality Assessment and Performance Improvement, defined as the hospital-wide, data-driven program required to monitor, analyze, and improve the quality and safety of patient care) program addressed priorities for improved quality of care and patient safety as evidenced by a high number of ongoing patient-to-patient assault (the act of causing physical harm or unwanted physical contact to another person) events as evidenced by patient-to-patient assault cases involving three (3) of 34 sampled patients (Patients 18, 29, and 30). Specifically, the Governing Body failed to ensure that the facility’s action plan for reducing assaults was evaluated for effectiveness and failed to ensure that systems were in place to track assaults, assess risk, determine whether corrective actions were effective, and ensure compliance with abuse-reporting mandates. This deficient practice had the potential to place Patients 18, 29 and 30 including all other patients admitted to the facility, at continued risk for harm due to continued patient assaults and unmitigated safety hazards. Findings: During a complaint validation survey (defined as a State-agency investigation that verifies whether a facility followed regulations in response to a complaint), completed from 2/3/2026 through 2/10/2026, an IJ (Immediate Jeopardy, defined as a situation in which a facility’s noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was called on 2/9/2026 at 10:29 a.m. due to two separate physical abuse incidents (physical abuse defined as one patient causing physical harm or injury to another patient). The first incident occurred on [5/31/2025 through 6/1/2025], when Patient 28 repeatedly showed aggressive behavior (actions that threaten or attempt to harm others) and sexually inappropriate behavior (any sexual act or exposure toward another person without consent). Staff did not escalate the situation to the physician (the medical provider responsible for ordering safety interventions) or to higher nursing leadership, and the patient remained on the same observation level (the assigned degree of monitoring used to keep patients safe). Within less than 24 hours, Patient 28 assaulted two other patients (assault defined as physically attacking another person). Patient 29 had swelling to the left cheek and forehead (swelling defined as enlargement of the tissue due to injury), a cut on the lip (a break in the skin caused by trauma), and redness in the right eye (irritation or bleeding under the surface of the eye). Patient 30 had redness on the right side of the face and nose (skin irritation related to impact) and a bloody mouth (bleeding inside or around the mouth caused by trauma). The second incident involved Patient 33, who had been identified as high risk for assault (meaning the patient had a known history or behavior pattern that indicated a likelihood of harming others). Patient 33 assaulted Patient 18 without provocation (meaning Patient 18 did nothing to trigger the incident) while Patient 18 was asleep in Patient 18’s room. Patient 18 had bruising on the right forehead and left eyelid (bruising defined as discoloration caused by broken blood vessels under the skin), a small abrasion on the left eyelid (a superficial scrape on the skin), and slight drooping of the eyelid (drooping defined as the eyelid sitting lower than normal due to swelling or muscle injury). During an interview on 2/5/2026 at 9:30 a.m. with House Supervisor (HS 1), HS 1 stated that the incident involving Patient 18 was not reported to local regulatory agencies. HS 1 verified that, per facility policy regarding reporting of abuse, “In our policy we do an incident report. We either report to police or public health. Per policy we only report to one [entity].” HS 1 then confirmed that no internal incident report was completed for the abuse/assault. During a concurrent interview and record review on 2/6/2026 at 12:37 p.m. with Director of Quality Assessment and Performance Improvement/Risk Management (QA), the facility’s policy and procedure titled “Reporting of ‘Unusual Occurrences’ to Local Regulatory Agencies,” revised on 11/2025, was reviewed. The policy indicated that any events or allegations of abuse may be reported to appropriate regulatory agencies (law enforcement, DPH [State Department of Public Health, state regulatory authority responsible for oversight of healthcare facilities and mandated abuse reporting]), and APS (Adult Protective Services, agency that investigates reports of abuse, neglect, or exploitation of vulnerable adults). The policy further clarified that abuse, (including but not limited to physical abuse) included cases such as “patient-to-patient incidents ...” QA confirmed that abuse incidents involving Patient 18, Patient 29, and Patient 30 were not reported to DPH. During a concurrent interview and record review on 2/6/2026 at 12:37 p.m. with the Director of Quality Assessment and Performance Improvement/Risk Management (QA), the facility’s policy and procedure titled “Reporting of ‘Unusual Occurrences’ to Local Regulatory Agencies,” revised on 11/2025, was reviewed. The policy indicated that any events or allegations of abuse may be reported to appropriate regulatory agencies (law enforcement, DPH [State Department of Public Health, state regulatory authority responsible for oversight of healthcare facilities and mandated abuse reporting]), and APS (Adult Protective Services, agency that investigates reports of abuse, neglect, or exploitation of vulnerable adults). During an interview on 2/9/2026 at 2:26 p.m. with the Director of Quality Assessment and Performance Improvement/Risk Management (QA), QA stated that the facility had been reporting some patient adverse events (An event in which care resulted in an undesirable clinical outcome) to APS (Adult Protective Services, the agency responsible for investigating allegations of abuse, neglect, or exploitation of dependent adults). QA said they need to check which patient events and patients were reported to APS. QA further confirmed that the facility did not maintain a log to track which events were reported to APS. QA stated that the only way to determine if a report was made was to review individual patient charts for the presence of an APS report case number. During a review of the facility’s 2025 QAPI “Assaults” reports, the data showed the following quarterly totals: Q1: 70 assaults Q2: 76 assaults Q3: 87 assaults Q4: 85 assaults During an interview on 2/9/2026 at 2:26 p.m. with the Director of Quality Assessment and Performance Improvement/Risk Management (QA), the QA confirmed that Assaults increased throughout 2025, with only a small decrease in Q4. However, the QAPI program did not evaluate whether any interventions were effective, and there was no documented analysis, measurable goals, follow-up, or re-evaluation of the actions taken. During an interview on 2/10/2026 at 10:16 a.m. with the Chief Executive Officer (CEO), the CEO stated that the Governing Body (GB) was responsible for the overall stewardship of the facility, including oversight of the hospital’s operations and organizational performance. The CEO explained that the CEO was a voting member of the Governing Body, and that the QAPI committee reported to the GB, along with other facility committees. During the same interview on 2/10/2026 at 10:16 a.m. with the Chief Executive Officer (CEO), the CEO confirmed that assaults were considered a high, problem?prone area for the facility and stated awareness of the facility’s 2025 QAPI Assaults Report. During an interview on 2/10/2026 at 10:16 a.m. with the Chief Executive Officer (CEO), the CEO stated that one of the primary actions taken by leadership to reduce elopements and assaults was the implementation of monthly multidisciplinary team meetings. The CEO explained that these meetings included nursing leadership, clinical staff, and the medical director, and were used to conduct a retrospective review of each incident. The CEO stated that during these reviews, the team examined video footage, assessed verbal de-escalation attempts, and evaluated whether those interventions were effective. The CEO further stated that the team reviewed warning signs or symptoms prior to an aggressive outburst and discussed strategies to proactively prevent similar situations. The CEO also said that these meetings were intended to identify patterns, determine opportunities for improvement, and provide targeted education or feedback to staff involved. During further interview on 2/10/2026 at 10:16 a.m. with the Chief Executive Officer (CEO), the CEO was asked how leadership measured success in determining whether implemented interventions resulted in measurable or sustained improvement. The CEO stated that measuring improvement “is tough numerically” because the facility did not yet have a full year of complete data to trend. The CEO explained that leadership’s approach to evaluating success focused on performing a “thorough analysis of each case” and using those findings to provide “meaningful training” intended to mitigate similar events in the future. During the same interview on 2/10/2026 at 10:16 a.m. with the Chief Executive Officer (CEO), the CEO did not identify any specific metrics used to evaluate the effectiveness of interventions and did not describe any tracking system that would demonstrate whether improvements were sustained over time. The CEO stated that “quarterly, we definitely review the data,” and suggested that the facility experienced a reduction in events from Q3 to Q4 of 2025, but no documentation or measurable indicators were provided to substantiate this claim. During a review of the facility’s Quality Assessment and Performance Improvement (QAPI) plan, dated 2026, the plan indicated that the governing body of the facility has the ultimate responsibility and authority to establish, maintain, and support the ongoing Quality Assessment and Performance Improvement (QAPI) program. The board is required to review and evaluate activities designed to assess and continuously improve the overall quality and efficiency of patient care. The governing body ensures that quality improvement and patient safety priorities are addressed and that the hospital evaluates the effectiveness of actions taken to improve performance.”

“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: 46333 Based on observation, interview, and record review, the facility failed to ensure nursing staff escalated monitoring and interventions (actions taken to keep the patient safe) and failed to notify the physician (the medical doctor responsible for the patient’s care) for one (1) of 34 sampled patients (Patient 1) after Patient 1 scored 6 (the highest possible risk of suicide) on the suicide risk assessment (a test to measure how likely a person is to try to end their own life) at 5:12 p.m. on 11/16/2025, as required by the facility’s “Precautions and Observation Levels” policy for imminent suicide risk (danger that someone may try to end their own life very soon). This deficient practice resulted in Patient 1 remaining in a room with a C bed (portable metal bed with removable components) with a metal frame and removable metal springs and was not placed under a higher level of observation (such as 1:1 level of observation [defined as continuous, one-to-one observation in which a staff member remains within arm’s reach of a patient at all times to ensure immediate intervention and prevent harm), leaving Patient 1 without required protective interventions for approximately 14 hours (from 5:12 p.m. on 11/16/2025 until found unresponsive [not awake and not responding] at 8:02 a.m. on 11/17/2025), placing the patient (Patient 1) at immediate risk for serious harm, injury, or death. On 2/9/2026 at 3:45 p.m., the survey team called a 3rd Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the Chief Executive Officer (CEO), Executive Administrator (EA), and the Director of Quality Assessment and Performance Improvement/Risk Management (QA). The IJ was called due to the facility’s failure to ensure nursing staff escalated monitoring and interventions after a patient scored 6 (highest risk level) on the Suicide (injure oneself with the intent to die) Risk Assessment (a standardized tool used to evaluate a patient’s likelihood of attempting suicide) at 5:12 p.m. on 11/16/2025. Despite documented suicidal ideations (thoughts of ending one’s life), a formulated plan (a specific method identified by the patient to carry out self-harm), and lethal intent (the patient’s stated intention to use a method that could cause death), interventions remained unchanged from earlier lower-risk assessments. The patient (Patient 1) was housed in a room with a bed that was a ligature risk (objects or fixtures that could be used for hanging or strangulation) and was not placed under continuous 1:1 observation (one staff member assigned exclusively to monitor one patient) within arm’s length (close physical proximity to prevent self-harm), as required by the facility’s policy titled “Managing Suicidal Patients/Risk Reduction Guidelines,” (dated 11/2025). As a result, Patient 1 was left without required protective interventions from 5:12 p.m. on 11/16/2025 until being found unresponsive at 8:02 a.m. on 11/17/2025, placing the patient at immediate risk for serious harm, injury, or death. On 2/9/2026, during interviews with the House Supervisor (HS 1, a nurse overseeing hospital operations during a shift), Registered Nurse (RN 7, a licensed nurse responsible for patient care), and Lead Behavioral Health Specialist (Lead-BHS 4, responsible for staff training on therapeutic interventions), all confirmed that when a patient scored 6 (highest risk) on the Suicide Risk Assessment, facility policy required immediate escalation, including notifying the psychiatrist (a physician specializing in mental health) and initiating 1:1 observation within arm’s length. HS 1 acknowledged these steps were not taken. RN 7 stated the expectation was to notify the psychiatrist and begin 1:1 monitoring. BHS 4 confirmed a score of 6 required escalation to the house supervisor and psychiatrist for possible 1:1 monitoring. Record review of Patient 1’s medical record indicated Patient 1 scored 2 (moderate risk) at 7:00 a.m. on 11/16/2025, with interventions including suicide precautions (measures to reduce self-harm risk) and q15 checks (observations every 15 minutes). At 5:12 p.m., Patient 1 scored 6 (highest risk), answering “Yes” to all critical questions: hopelessness (a sense of despair), suicidal ideation (thoughts of suicide), suicidal thoughts with a plan (specific method identified), and lethal intent (intent to use a deadly method). Despite this escalation, interventions remained unchanged, and the psychiatrist was not notified. The Facility’s policy titled “Managing Suicidal Patients/Risk Reduction Guidelines” required immediate escalation to 1:1 observation within arm’s length for patients with a formulated plan and lethal intent. On 2/10/2026 at 5:35 p.m. the IJ was removed in the presence of the Chief Executive Officer (CEO), Executive Administrator (EA), Director of Quality Assessment and Performance Improvement/Risk Management (QA), Chief Nursing Officer (CNO), Director of Nursing services (DON), Director of Clinical Services (DIR 4), Director of Intake (DIR 3), Nurse Educator (RN 6), 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 included the following: Immediate Actions: - Provider Notification: Effective immediately, all inpatient Registered Nurses (RNs) must notify the provider when a patient answers “Yes” to more than 50% of the six Suicide Assessment Screener questions. - Observation Levels: If a patient endorses active suicidal ideation with an executable plan, the RN must initiate increased observation - every-5-minute checks (observing the patient every five minutes), line-of-sight monitoring (keeping the patient continuously in view), or 1:1 observation (one staff member assigned exclusively to monitor one patient) - while notifying the provider. - Staffing: Additional Behavioral Health Specialist (BHS) staff will be assigned for 1:1 monitoring; no staff will monitor more than one patient on 1:1. - Medical Staff Education: All psychiatric providers will be trained to expect RN notification and determine additional interventions. - Documentation: RNs will document provider notification, current interventions, and orders (or rationale for no change) in a separate progress note. -Education: Leadership began in-services on 2/9/2026 night shift, continuing through subsequent shifts; new hires trained during orientation. - Completion Goal: 100% of active nursing staff educated by 2/16/2026; psychiatric medical staff educated via email and Medical Executive Committee (MEC, defined as the body of physician leaders responsible for oversight of clinical care quality and safety) by 2/18/2026. - Monitoring: The Director of Nursing (DON) or designee will audit 30 random records monthly for compliance; noncompliance addressed immediately and reported in Quality Assurance and Performance Improvement (QAPI, defined as the hospital-wide, data-driven program designed to monitor, analyze, and improve the quality of patient care and safety), MEC, and Governing Body (leadership group legally responsible for hospital operations, quality, and safety). -Systemic Action: Facility leadership will review all policies related to suicidal patient care and revise processes as needed; staff will be retrained on any changes. Findings: During a review of Patient 1’s Psychiatric Evaluation (defined as a formal and comprehensive assessment conducted by a psychiatrist to determine the patient’s mental status, diagnosis, and treatment needs) report, dated 11/16/2025, the report indicated Patient 1 was admitted voluntarily after reporting suicidal ideation (having thoughts of wanting to end one’s life), stating he (Patient 1) wanted “to drive my car off the cliff.” The report also indicated that Patient 1 reported paranoia (an unfounded belief that others intend to harm or follow someone), stating that someone was following him (Patient 1) and that they had an air gun. During a review of Patient 1’s “Acute Nursing Progress Note,” dated 11/16/2025 at 5:12 p.m., the note indicated, “(Patient 1’s name) states ‘I’m still hearing the voices, they’re telling me to kill myself, they’re telling me to drive off a cliff’.’ (Patient 1’s name) reports having VH (Visual Hallucinations- sensory perceptions of seeing things-objects, people, or lights-that are not actually present, occurring without external stimuli) of random figures and faces. (Patient 1’s name) is slow to respond at times, having long pauses before answering writer’s questions. Thought process is poorly concentrated, mood remains sad/depressed, with current symptoms of AH (Auditory Hallucinations- sensory perceptions of hearing sounds-most commonly voices-without an external source)/VH. (Patient 1’s name) is not attending group therapy sessions but is medication compliant, reporting no side effects. Writer educated (Patient 1’s name) to remain compliant with medication regimen and to notify staff if thoughts of self-harm become unmanageable.” During a concurrent interview and record review on 2/3/26 at 2:14 p.m. with the Director of Intake (DIR 3), Patient 1’s Order flowsheet, dated 11/14/2025 through 11/17/2025, was reviewed. The flowsheet indicated that Patient 1 had an order for every 15-minute monitoring (direct observation of patients at a minimum of every 15 minutes) throughout the stay, and DIR 3 confirmed that the monitoring level was never increased-even after the SI (Suicidal Ideation) score increased to 6. During a concurrent observation, interview and surveillance video review on 2/4/2026 at 11:02 a.m. with the Chief Executive Officer (CEO), the surveillance video of the North Unit hallway, with a view of Patient 1’s room doorway, dated 11/17/2025, was reviewed. The video showed that at 8:05 a.m., during the emergency response for Patient 1, staff pushed a “C bed (a portable metal bed with foldable and removable components)” from Patient 1’s room into the hallway to create physical space for CPR (cardiopulmonary resuscitation, a life-saving procedure used when a person’s heart or breathing stops). The CEO confirmed that at 8:05 a.m. staff moved a portable “C bed” from Patient 1’s room into the hallway to create space for CPR. During an interview on 2/3/2026 with the charge nurse (CN 1), CN 1 stated that when a patient had a change in suicide?risk assessment to a higher risk level, the nurse would assess the patient, and the physician (the medical doctor responsible for the patient’s care) would be notified. CN 1 stated the physician may order increased monitoring, such as every five-minute observation (staff visually verifying the patient’s safety every five minutes) or one-to-one observation (1:1, one staff member staying with the patient at all times, within arm’s length, unless otherwise ordered). CN 1 stated that the nurse should document that the physician was called and should update the Kardex (a patient-care summary tool used by nursing staff) and the monitoring form (the record where required observation intervals are documented). CN 1 stated these actions must occur immediately when a patient reached imminent-risk criteria. During an interview on 2/9/2026 at 11:20 a.m. with Lead Behavioral Health Specialist (Lead-BHS), Lead-BHS stated that if a patient’s suicide risk assessment score was 6 (the highest possible risk), the charge nurse (the nurse in charge of the shift) and supervisor must be made aware to escalate (increase) to higher observation (closer watching) or higher acuity unit (a hospital area for patients with more severe needs), and it needed to be escalated to house supervisor (the nurse in charge of the unit) and psychiatrist (a medical doctor who specializes in mental health) for possible 1:1 (one staff member staying with the patient at all times, within arm’s length). During a concurrent interview and record review on 2/9/2026 at 11:30 a.m. with House Supervisor (HS 1), Patient 1’s Acute Nursing Progress Note, dated 11/16/2025 at 5:12 p.m., was reviewed. The section titled “Suicide Assessment (SI),” was reviewed. The questions and answers documented on the suicide assessment were as follows: -Feelings of hopelessness, helplessness, or despair? - Yes (Y) -Having suicidal ideations? - Yes (Y) -Suicidal thoughts with a plan? - Yes (Y) -Involves serious/lethal intent? - Yes (Y) -Delusional (holding fixed, false beliefs despite incontrovertible evidence to the contrary) or hallucinatory content? - Yes (Y) -Evidence or concern the patient may be concealing or denying suicidal thoughts or behaviors? - Yes (Y) -HS 1 confirmed that Patient 1’s SI (Suicide?Risk Assessment) score prior to 7:00 a.m. on 11/16/2025 was 2, and that on 11/17/2025 at 6:00 a.m., the assessment was documented as “unable to assess.” HS 1 stated that at 8:02 a.m. on 11/17/2025, Patient 1 was found unresponsive (not awake and not responding). During the same concurrent interview and record review on 2/9/2026 at 11:30 a.m. with House Supervisor (HS 1), HS 1 stated that a total score of 6 represented the highest risk for suicide, and that the interventions (actions taken to keep the patient safe) for Patient 1 remained the same as when Patient 1 had scored 2 (moderate risk) on the suicide-risk assessment. HS 1 stated that the interventions were not increased after Patient 1 scored 6 (the highest possible risk) at 5:12 p.m. on 11/16/2025. HS 1 stated that “the patient (Patient 1) remains on every 15-minutes observation since his admission.” During the same concurrent interview and record review on 2/9/2026 at 11:30 a.m. with House Supervisor (HS 1), HS 1 also confirmed that there was no documented evidence that the physician (the medical doctor responsible for the patient’s care) was notified of the change in Patient 1’s condition, stating that this notification would have been documented in the Acute Nursing Progress Note under the Narrative Note section. During an interview on 2/9/2026 at 11:55 a.m. with Registered Nurse (RN 7), RN 7 stated that if the patient scored 6 on the suicide risk assessment, the psychiatrist (a medical doctor who specializes in mental health) should be notified to assess (evaluate) the patient and communicate (talk) with the team, and an order for 1:1 monitoring should be requested, with the patient kept at arm’s length with a monitoring staff (a staff member watching the patient closely). During a review of the facility’s policy and procedure titled, “Precautions and Observation Levels,” dated 9/2024, the policy indicated: “A registered nurse (a nurse with advanced training and a nursing license) may institute precautions (special steps to keep a patient safe from self-harm) and increase level of observation (watching the patient more closely) based on clinical assessment (the nurse’s judgment about the patient’s condition), to be followed by a physician order (a doctor’s written instruction) as soon as possible. ... One to One Observation (1:1): When a patient’s status is clinically deemed to present an imminent risk (danger that could happen at any moment) of danger to self or others, the patient shall be placed on constant observation (watched at all times) by a single designated staff (one staff member assigned to the patient), who shall remain readily available and accessible to the patient at all times (within arm’s length unless otherwise ordered by the doctor).” During a review of the facility’s policy and procedure (P&P) titled, “Managing Suicidal Patients /Risks Reduction Guidelines,” dated November 2025, the P&P indicated, “A comprehensive intake assessment for suicide potential, suicidal ideation, rumination and/or planning is performed and documented on all patients judged to be suicidal or potentially suicidal at the time of admission...The attending physician will order a degree of staff supervision and restriction from potentially harmful objects or activities consistent with the risk identified. Level of precaution is a matter of clinical judgment. The basis for clinical judgment should be specified in the medical record... Patients with suicidal ideation who present reasonable significant symptoms of suicide potential. Patient must be within visual range of assigned staff at all times. Direct supervision is provided during use of the bathroom unless ordered otherwise by the physician, in which case staff must be in close proximity during use of the bathroom, that is, within the eyesight of the bathroom door and within hearing range. Access to sharps, belts, cords, and laces is denied.” During a review of the facility’s policy and procedure (P&P) titled, “Patient with a Deterioration Medical Condition,” dated December 2025, the P&P indicated, “A patient who appears to have a change in medical condition or a patient about whom the nurse has concerns will receive an assessment and immediate treatment if needed ... The Charge Nurse or designee will examine and question the patient if possible, to learn more about the symptoms and will also review the patient’s chart for potential cause of the problem if time permits. The Charge Nurse or designee will direct a staff member to call the patient’s attending physician immediately and symptoms will be reviewed with the physician and necessary orders will be obtained.” During a review of the facility’s policy and procedure (P&P) titled, “Notification of Administrators and /or Authorities,” dated November 2025, the P&P indicated, “To identify when, who, by whom and how authorities are to be notified. List may include, but is not limited to the following: In Case Of: Admission of Suicidal or Very Disturbed Patient, Notify: Patient’s Attending Psychiatrist, Nursing Supervisor.” During a review of the facility’s policy and procedure (P&P) titled, “Hospital Plan for the Provision of Nursing Services,” dated December 2025, the P&P indicated, “The nurse, as the practitioner with continuous patient/family contact, will serve to identify, communicate, and influence the outcome of problems in the actual or potential realms ...Registered nurses shall use assessment skills initially and on an on-going basis to determine the level of care and necessary interventions to ensure that the identified needs are addressed. The appropriateness of interventions will be evaluated for effectiveness with targeted positive patient outcomes as the criteria. Modifications shall be made in treatment strategies based on the nurse’s evaluation of the patient’s response to interventions; thus ensuring that the delivery of care is representative of the patient’s individualized needs.” During a review of the facility’s policy and procedure (P&P) titled, “Rounds for Patient Observation,” dated December 2025, the P&P indicated, “To monitor for the safety of each individual patient by visualizing and intervening when any potential hazard is present. To ensure that each individual patient is being monitored in a timely manner for their status and safety ... “Q15” (Every 15 minutes observation): This is minimum level of observation for all patients at ACOH and involves direct observation of patients at a minimum of every 15 minutes on the rounds sheet for ordered precautions, patient location and activity. “1:1” (l-to-1, Constant Observation at all times): This is the highest level of observation of the patient and involves continuous monitoring and physical proximity to the patient at all times. A physician’s order must be obtained to implement this higher level of observation ...Patients on this level are considered highest risk and documentation must reflect the need for continued l-to-1. Improvement in behaviors and reduced risk allows the patient to be safely monitored at a 5-minute level of observation.””

“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: 46333 Based on interview and record review, the facility failed to ensure nursing staff prepared and administered medications, in accordance with the practitioner’s orders and accepted standards of practice regarding medication preparation and administration, for one (1) of 34 sampled patients (Patient 5). Specifically, nursing staff did not obtain baseline vital signs (heart rate, blood pressure, temperature, and breathing rate) before administering STAT (immediate-use) medications (Ativan- a sedative medication, Benadryl 50 mg oral liquid- an antihistamine medication, and Haldol 5 mg oral concentration- an antipsychotic medication) for agitation (sudden episode of extreme restlessness, irritability, or aggressive behavior that poses a risk to the patient or others), and staff did not complete a post-administration reassessment as required by the practitioner’s orders and the facility’s policy titled “Administration and Documentation of Medications.” The only nursing documentation entered into the Medication Administration Record (MAR) was the single word “effective,” which did not include vital signs, physical assessment findings, mental?status assessment, or any observable description of the patient’s (Patient 5) response to the medications. This deficient practice resulted in the facility not identifying the patient’s (Patient 5) physical condition before receiving medications that may lower blood pressure or cause sedation (the medical use of sedative medications to induce a state of relaxation, calmness, or sleepiness, reducing anxiety and discomfort), and not identifying the patient’s (Patient 5) physical or mental response after medication administration. Findings: During a review of Patient 5’s “Psychiatric Evaluation (defined as a formal and comprehensive assessment conducted by a psychiatrist to determine the patient’s mental status, diagnosis, and treatment needs),” report, dated 2/3/2026, the report indicated: Patient 5 was brought into the facility on a 5150 hold (an involuntary mental?health hold for danger to self [DTS]). The psychiatric evaluation indicated that the patient (Patient 5) reported suicidal thoughts and reported hearing voices giving self-harm instructions. The Columbia Suicide Severity Rating Scale (C-SSRS, a screening tool for suicide risk) indicated a score of 3, which indicated high suicide risk (danger that someone may try to end their own life very soon). During a review of Patient 5’s “Order,” dated 2/2/2026 at 9:09 p.m., the order indicated that the practitioner directed staff to obtain vital signs (heart rate, blood pressure, temperature, and breathing rate). The order also showed STAT (immediate-use) medication orders for Ativan 2 mg (milligrams, a unit of measure) oral tablet (a sedative medication), Benadryl 50 mg oral liquid (an antihistamine medication), and Haldol 5 mg oral concentration (an antipsychotic medication) for agitation (sudden episode of extreme restlessness, irritability, or aggressive behavior that poses a risk to the patient or others), aggression, danger to self (DTS), and danger to others (DTO). During a review of Patient 5’s “Acute Nursing Progress Note,” dated 2/2/2026 at 9:39 p.m., the documentation showed a mental and physical assessment. The documentation did not include vital signs before medication administration. During a review of Patient 5’s Medication Administration Record (MAR), dated 2/2/2026, the MAR showed nursing staff administered Haldol (antipsychotic), Ativan (sedative), and Benadryl (antihistamine) at 9:40 p.m. During a review of Patient 5’s MAR, dated 2/2/2026, the only post-administration entry was the word “effective.” The documentation did not include vital signs, mental status assessment, physical assessment findings, or any description of the patient’s (Patient 5) response to the STAT medications. During an interview on 2/3/2026 at 10:58 p.m. with the Licensed Psychiatric Technician (LPT 1), LPT 1 stated they (the facility staff) were assigned to medication-administration duties on 2/3/2026. LPT 1 stated that when Haldol, Ativan, and Benadryl were given together, staff were required to obtain vital signs before administration because Ativan could lower blood pressure. LPT 1 also stated staff must complete a physical and mental assessment before the medication (Ativan) was given. During an attempted interview on 2/4/2026 at 4:10 p.m., the licensed nursing staff member who administered (RN 11) the STAT (immediate?use) medications to Patient 5 on 2/2/2026 was requested for interview but was not available. During a concurrent interview and record review on 2/4/2026 at 4:00 p.m. with the Director of Intakes (DIR 3), DIR 3 reviewed Patient 5’s vital signs flow sheet and confirmed that no vital signs were documented on 2/2/2026 before or after the medications were administered. DIR 3 also confirmed the STAT medication orders (Haldol, Ativan, and Benadryl) administered on 2/2/2026. During a review of the facility’s policy titled, “Administration and Documentation of Medications,” dated December 2025, the policy indicated nursing staff must assess the patient’s physical and mental status, including vital signs (heart rate, blood pressure, temperature, and breathing rate), when appropriate, before administering STAT (immediate-use) medication. The policy also indicated nursing staff must reassess the patient one hour after medication administration and document the patient’s response. During a review of the facility’s policy and procedure (P&P) titled, “Standards of Psychiatric and Mental Health Nursing practice,” dated December 2025, the P&P indicated, “The Standards are stated according to a Systematic approach to nursing practice: the assessment of the patient’s status, the plan of nursing actions, the implementation of the plan, and the evaluation. These specific divisions are not intended to imply that practice consists of a series of discrete steps, taken in strict sequence, beginning with assessment, and ending with evaluation. The process described is used concurrently and recurrently. Assessment, for example, frequently continues during implementation; similarly, evaluation dictates reassessment and replanning. These Standards of Psychiatric Nursing Practice apply to nursing practice in any setting. Nursing practice in all settings must possess the characteristics identified by these standards if patients are to receive a high quality of nursing care ...Nurses document pertinent observations, interpretations, interventions, and evaluations of the patient’s response to the plan of care given.””

“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 healthcare staff documented all active therapeutic efforts provided during a Code Blue (an in-hospital medical emergency requiring immediate resuscitation), in the medical record, for one (1) of 34 sampled patients (Patient 1). This failure was evidenced by the Code Blue sheet (the form used to document resuscitation actions and times) not indicating the application of the automated external defibrillator (AED, a device that analyzes the heart’s electrical rhythm and advises “shock” or “no shock”) and not indicating pulse checks (assessment for a detectable heartbeat), including the time a pulse check occurred and whether a pulse re-check occurred. This deficient practice resulted in incomplete documentation of the emergency resuscitation (life-saving treatment) and failed to communicate the patient’s (Patient 1) clinical status and the interventions performed during the Code Blue (including AED rhythm analysis and pulse checks). As a result, subsequent care providers, including emergency medical services (EMS-paramedic responders) and receiving clinicians, did not have complete and accurate information regarding the patient’s condition and the treatments already performed, which had the potential to delay or interfere with timely, appropriate, and coordinated patient care and clinical decision-making during and after the medical emergency. In addition, inadequate documentation can lead to inaccurate treatment decisions and may put other patients, at the facility, at risk of harm. Findings: During a review of Patient 1’s “Acute Nursing Progress Notes,” dated 11/17/2025 at 8:03 a.m., the note indicated the following: Patient 1 was found unresponsive (not reacting), with no pulse (no detectable heartbeat) and no breathing (apnea). A Code Blue (an in-hospital medical emergency requiring immediate resuscitation [the immediate, lifesaving effort to restart a patient’s heart and breathing when they have stopped]) was called. CPR (cardiopulmonary resuscitation-cycles of chest compressions and rescue breaths) began immediately using a bag-valve-mask (BVM, a hand-held device used to provide breaths), a backboard was placed under the patient (Patient 1), and 911 was called. The note further indicated the AED (automated external defibrillator, a device that analyzes the heart’s electrical rhythm and advises “shock” or “no shock”) was placed at 0804 (8:04 a.m.), with “no shock advised,” and that CPR providers were switched every two minutes until EMS (emergency medical services) arrived at 8:16 a.m. and continued chest compressions. During a review of Patient 1’s Code Blue report (the form used to document resuscitation actions and times), the report indicated that Registered Nurse (RN) 12 and RN 13 were the first two nurses to initiate CPR during the Code Blue. During attempted interviews on 2/3/2026, RN 12 and RN 13 were requested for interview but were not available. During a concurrent observation and interview on 2/3/2026 at 12:15 p.m. with Registered Nurse (RN 6), the AED was observed in the exam room with pads available, oxygen available, and the device able to be powered on. RN 6 stated that when a patient was found unresponsive, staff must call a Code Blue, have someone bring the AED, and begin the required emergency response. RN 6 stated staff must document all interventions applied during the Code Blue in the Code Blue sheet to ensure continuity of care when the patient was transferred. During a concurrent interview and record review on 2/3/2026 at 2:14 p.m. with the Director of Intake (DIR 3), Patient 1’s Code Blue sheet, was reviewed. DIR 3 confirmed that RN 6 (interview on 2/3/2026 at 12:15 p.m.) was the staff member who completed the Code Blue report. During a concurrent interview and record review on 2/3/2026 at 2:15 p.m. with the Director of Intake (DIR 3), DIR 3 reviewed Patient 1’s Code Blue sheet and confirmed: - There was no documentation that an AED was applied. - There was no documentation whether the AED advised “shock” or “no shock.” -There was no documentation of any pulse check, including the time a pulse was checked or whether a pulse re-check occurred. -DIR 3 confirmed a discrepancy between the Acute Nursing Progress Note, which indicated an AED application at 0804 (8:04 a.m.) with “no shock advised,” and the Code Blue sheet, which did not indicate any AED use. During an interview on 2/9/2026 at 11:55 a.m. with Registered Nurse (RN 1), RN 1 stated the Code Blue sheet must indicate the time of the event, vital signs (including pulse and respirations [the medical term for breathing]), interventions performed, supplies used (including the AED), the AED rhythm analysis (“shock advised” or “no shock advised”), and ambulance arrival and departure times. RN 1 stated that if a patient had no pulse, staff must document “no pulse,” and if a patient had no respirations, staff must document that respirations were not present. During a concurrent interview and record review on 2/10/2026 at 3:06 p.m. with the Chief Nursing Officer (CNO), the CNO stated that during a Code Blue, vital signs and all interventions must be documented to ensure continuity of care. During a review of the facility’s policy titled “Emergency Medical Treatment for Patients/Code Blue,” dated November 2025, the policy indicated: “The Medical Record must reflect a description of the occurrence, interventions and responses, which ensued prior to, during and immediately after the emergency incident, with times noted.” During a review of the American Heart Association (AHA) Adult Basic Life Support guidelines, the AHA guidelines indicated: -Responders must apply an automated external defibrillator (AED) to analyze the heart’s electrical rhythm. -The AED will prompt “shock advised” or “no shock advised.” -Providers must check for a pulse and re-assess at appropriate intervals. -Documentation should reflect the AED application, the rhythm analysis outcome, and resuscitative actions to ensure continuity of care.”