Bhc Fremont Hospital Inc.

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 52233 Based on observation, interview and record review, the facility failed to ensure the parent or surrogate of two of eight sampled minor (age 17 or younger) patients, Patient 25 and Patient 30, were provided with and gave verbal consent acknowledging the advance directive (healthcare directive for a minor child to authorize a parent/surrogate to make healthcare decisions) at the time of admission. This failure resulted in Patient 25 and Patient 30’s advance directive forms not having a designated individual to authorize health care decisions. Under California Family Code § 6500, a minor is defined as any individual under 18 years of age. Minors are generally subjected to parental control until they reach the age of majority or become emancipated. During a review of Patient 30’s “Advance Directive/Healthcare Surrogate Acknowledgement” form dated October 21, 2025, the form indicated Patient 30 was a minor and this form was not completed on admission and did not name a surrogate decision maker. During a review of Patient 25’s “Advance Directive/Healthcare Surrogate Acknowledgement” form dated October 23, 2025, the form indicated Patient 25 was a minor and this form was not completed on admission and named the patient, a minor, as the surrogate decision maker. During an interview on 2/24/26 at 11:00 a.m. with the Director of Nursing, DON stated if the “Advance Directive/Healthcare Surrogate Acknowledgement” form was discussed with the healthcare surrogate. the staff would have indicated the patient’s parent/legal guardian name, phone number, and had them sign the form or give verbal consent. During a concurrent interview and record review on 2/26/26 at 1:05 p.m. with the Director of the Business Officer (DBO) and Chief Financial Officer (CFO), the “Advance Directive/Healthcare Surrogate Acknowledgement” form dated October 21, 2025, was reviewed. The indicated Patient 30 was a minor; the patient had signed the form; designated decision maker fields and the advance directive questions were left blank. The DBO stated, if the parent/surrogate does not arrive on admission with the minor patient and sign the form, a business office team member would call the parent/surrogate decision maker and get verbal authorization. The staff getting verbal authorization would sign the document and write verbal consent from parent/surrogate decision maker, consent giver’s name and phone number. During a review of the facility’s policy and procedure (P&P) titled, “Advance Directive,” dated 2/26, the P&P indicated, “Advance Directive: A written instruction establishing a substitute decision making process for the provision of withholding of medical treatment in the event that the individual ...unable to make such decisions. Surrogate Decision Maker: an individual acting on behalf of a patient to determine what the patients’ healthcare decisions should be. As part of the admitting process, the patient, parent, guardian, conservator, or surrogate decision maker will be asked if the patient has completed an advanced directive. If the patient has an advanced directive, the admitting staff member will inquire if the patient has brought a copy to the hospital. I. If yes, a copy will be made and placed in the patient’s medical record. II. If no, the patient or surrogate will be asked to arrange for a copy to be brought to the hospital. The corresponding boxes will be checked on the Advance Directive/Surrogate Acknowledgement Form, and the form will be signed by the patient/surrogate and witnessed by a Fremont Hospital staff member and will be filed in legal/consent section of medical record.””

“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: 50146 The Condition of Participation - Governing Body was not met as evidenced by the Hospital’s failure to: Based on staff interview and record review, the hospital failed to maintain an effective governing body when the hospital’s governing body failed to ensure the hospital’s Quality Assessment and Performance Improvement (QAPI) Program reflected the complexity of the hospital’s organization and services. The hospital’s QAPI program did not accurately measure, analyze, and track allegations of abuse for 14 residents. The hospital’s failure to maintain an effective governing body placed all patients at risk for further abuse and possible death. Therefore, the cumulative failure to effectively address and ensure this occurred, resulted in the hospital’s failure to meet the Condition of Participation for Governing Body. (See A-0263 and A-0273) Findings: During a review of the facility document titled “Quality Assessment and Performance Improvement (QAPI) 2025”, undated, the “Quality Assessment and Performance Improvement (QAPI) 2025” indicated “The Governing Body ... has the ultimate responsibility and authority to establish, maintain, and support an effective QAPI program.”.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50146 The Condition of Participation- Patient’s Rights was not met as evidenced by the Hospital’s failure to: Based on interview and record review, the facility failed to protect patient’s rights in accordance with recognized standards of abuse prevention and reporting when 14 of 14 sampled patients were not free from all forms of abuse. This failure occurred when: 1. Patients 6, 8, 12, 14, 17, 24, 31, 37, and 43 each reported allegations of sexual abuse during their hospitalization, and Patients 1, 22, 26, 39, 40 each reported allegations of physical abuse during their hospitalization. (Refer to A-0145) 2. The facility did not thoroughly investigate allegations of abuse for Patients 6, 17, 24, 26, 39, and 43. (Refer to A-0145) 3. The facility did not appropriately report allegations of abuse for Patients 6, 8, 12, 14, 17 22, 24, 26, 31, 39, 40, 42, and 43 to the required agencies. (Refer to A-0145) This failure resulted in an Immediate Jeopardy (IJ, a situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient if not immediately corrected) situation. The hospital’s Chief Executive Officer (CEO) was verbally notified of the IJ situation on 4/11/25 at 4:00 p.m. The hospital submitted an acceptable Plan of Action on 4/14/25 at 3:57 p.m., and the IJ was removed. These cumulative failures resulted in the hospital’s inability to protect and promote patient’s rights and deliver safe patient care in accordance with the Patient’s Rights Condition of Participation. (Refer to A-0145)”

“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: 50146 The Condition of Participation - Quality Assessment and Performance Improvement Program was not met as evidenced by the Hospital’s failure to: Based on staff interview and record review, the hospital failed to implement and maintain an ongoing data-driven Quality Assessment and Performance Improvement (QAPI) program. The hospital’s QAPI program did not accurately measure, analyze, and track allegations of abuse for 14 patients. The hospital’s failure to address, develop, and implement an effective data-driven QAPI Program for abuse placed all patients at risk for experiencing abuse and possible death. Therefore, the cumulative failure to effectively address and ensure this occurred, resulted in the hospital’s failure to meet the Condition of Participation for QAPI. (See A-0273)”

“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: 50146 The Condition of Participation - Nursing Services was not met as evidenced by the Hospital’s failure to: Based on staff interview and record review, the hospital failed to create a collaborative, individualized, comprehensive treatment plan for 10 patients. The hospital’s failure to maintain a current care plan for its patients placed all patients at risk for abuse, maltreatment, and possible death. Therefore, the cumulative failure to effectively address and ensure this occurred, resulted in the hospital’s failure to meet the Condition of Participation for Nursing Services. (See A-0396)”

“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: 50146 Based on interview and record review, the facility failed to ensure 14 of 14 sampled patients were free from all forms of abuse. This failure occurred when: 1. Patients 6, 8, 12, 14, 17, 24, 31, 37, and 43 each reported allegations of sexual abuse during their hospitalization, and Patients 1, 22, 26, 39, 40 each reported allegations of physical abuse during their hospitalization. 2. The facility did not thoroughly investigate allegations of abuse for Patients 6, 17, 24, 26, 39, and 43. 3. The facility did not appropriately report allegations of abuse for Patients 6, 8, 12, 14, 17 22, 24, 26, 31, 39, 40, and 43 to the required agencies. This failure resulted in 14 of 14 patients experiencing physical, mental, and emotional anguish, and placed all patients in the facility at risk of experiencing abuse. An Immediate Jeopardy situation (IJ, a situation in which a facility’s actions places one or more residents/patients in jeopardy of being significantly harmed up to the point of possible death if not immediately corrected) was identified and called due to the failure of the facility to prevent and report abuse. The Chief Executive Officer (CEO) was verbally notified of the IJ situation on 4/11/25 at 4:00 p.m. During a visit to the facility on 4/14/25, the facility provided an acceptable plan of action and the IJ was removed at 3:57 p.m. Findings: During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 1, the “Patient Demographic Profile” indicated Patient 1 was admitted to the facility in June 2023 with unspecified mood disorder (a type of mental health condition where there is a disconnect between actual life circumstances and the person’s state of mind or feeling). During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 42, the “Patient Demographic Profile” indicated Patient 42 was admitted to the facility in June 2023. During a review of the facility’s document titled “Interdisciplinary Progress Notes”, dated 6/12/23, for Patient 1 were reviewed. The “Interdisciplinary Progress Notes” indicated, Patient 1 reported to Registered Nurse (RN) 2 on 6/12/23, “on the first night of [Patient 1]’s hospitalization their former roommate (Patient 42), grabbed [Patient 1] by the neck and forced a kiss [on 6/6/23] at 10:00 p .m.,” then the next morning, Patient (1) stated “her former roommate [Patient 42] tried to pull down her pants.” During an interview on 4/16/25 at 11:40 a.m. with the Director of Nursing (DON) and Director of Quality and Risk Management (RISK), RISK stated the facility did not report the incident regarding abuse to the California Department of Public Health (CDPH) or the police. DON and RISK were unable to state why the incident was not reported to CDPH or the police. During a review of the facility’s undated document titled “Patient Demographic Profile” for Patient 5, the “Patient Demographic Profile” indicated Patient 5 was admitted in February 2023 with a diagnosis of major depressive disorder (MDD, a mental health condition characterized by persistently low mood, loss of interest in activities, and other symptoms like sleep and appetite disturbances and difficulty concentrating). During a review of the facility’s undated document titled “Patient Demographic Profile” for Patient 6, the “Patient Demographic Profile” indicated Patient 6 was admitted in February 2023 with a diagnosis of bipolar disorder (a mood disorder characterized by periods of depression alternating with mania). During a review of the facility’s document titled, “Interdisciplinary Progress Notes,” dated 2/25/23, for Patient 5 were reviewed. The “Interdisciplinary Progress Notes” indicated on 2/25/23, “Patient 5 was accused , by her previous roommate [Patient 6] that [Patient 5] touched her breast yesterday [2/24/23] in the shower.” During an interview on 4/16/25 at 11:40 a.m. with DON and RISK, both DON and RISK stated they did not report the allegation of abuse by Patient 6 to CDPH or the police. DON and RISK were unable to state why the incident was not reported to CDPH or the police. During a review of the facility’s undated document titled, “Patient Demographic Profile”, for Patient 8, the “Patient Demographic Profile” indicated Patient 8 was admitted to the facility in April 2022, with a diagnosis of bipolar disorder. During a concurrent interview and record review on 4/14/25 at 1:40 pm with Nurse Manager 1 (NM1), the facility’s document titled, “Interdisciplinary Progress Notes”, dated 4/29/22 , for Patient 8 were reviewed. NM1 stated the “Interdiscipliary Progress Notes” indicated Patient 8 reported to staff on 4/29/22 around 1 p.m. that another patient touched her breast and tried to get her to go to his room. NM1 stated the progress notes indicated Patient 8’s mother called the police the evening of 4/29/22 to report her daughter was touched inappropriately on her breast. During an interview on 4/9/25 at 3:08 p.m. with RISK, RISK stated the facility did not call the police or CDPH to report the incident. DON and RISK were unable to state why the incident was not reported to CDPH or the police. During a concurrent interview and record review on 4/16/25 at 11:30 a.m., with Psychiatrist1 (PSY1), the facility’s documents titled, “Interdisciplinary Progress Notes” dated 4/29/22, and the “Psychiatry Progress Note”, dated 4/30/22, for Patient 8 were reviewed. PSY1 stated the “Interdisciplinary Progress Notes” and the “Psychiatry Progress Note”, indicates on 4/29/22 Patient 8 reported she was inappropriately touched and there was no indication that the doctor (MD) was notified. PSY1 stated he saw Patient 8 on 4/30/22 and noted she was significantly agitated on 4/29/22. PSY1 stated the psychiatrist should always be notified after an incident where a patient reports that they were touched inappropriately because it could trigger trauma, and they could experience anxiety or agitation afterwards. During a record review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 12, the “Patient Demographic Profile” indicated Patient 12 was admitted to the facility in May 2022 with a diagnosis of bipolar disorder. During an interview and concurrent record review on 4/9/25 at 11:46 am with DON, the facility’s document titled, “Interdisciplinary Progress Notes” dated 5/14/22, for Patient 12 were reviewed. DON stated the “Interdisciplinary Progress Notes” indicated on 5/14/22, Patient 12 reported to a nurse that Mental Health Technician 1 [MHT 1] touched her breast and buttock on 5/13/22. During an interview and concurrent record review on 4/9/25 at 11:50 am with RISK, the “Nursing Admission Assessment,” dated 5/13/22, “Daily Nursing Assessment,” dated 5/13/22, 5/14/22, 5/15/22, 5/16/22, and 5/17/22 and “Patient Observation Rounds,” dated 5/13/22, 5/14/22, 5/15/22, 5/16/22, and 5/17/22 for Patient 12 were reviewed. RISK stated the documents indicated Patient 12 had a history of sexual victimization (any unwanted or forced sexual activity, ranging from unwanted physical contact to rape) prior to admission. RISK stated the documents indicated Patient 12 was put on sexual victimization precautions (measures taken to provide support to sexual assault and abuse victims) on 5/13/22 and was not put on sexual victimization precautions on 5/14/22, 5/15/22, 5/16/22, and 5/17/22. RISK stated Patient 12 should have been on sexual victimization precautions during her entire admission due to her history of sexual victimization and due to the allegation that a staff member touched her inappropriately on 5/13/22. During an interview on 4/9/25 at 11:50 a.m. with RISK, RISK stated the facility did not report Patient 12’s allegation that a staff member touched her breast and buttock on 5/13/22 to the police or to CDPH. RISK stated Patient 12 called the police to report the incident after she was discharged on 5/17/22. RISK stated the facility’s policy about notifying police after incidents involving a staff member was not followed. DON and RISK were unable to state why the incident was not reported to CDPH or the police. During a review of Patient 14’s “Patient Demographic Profile,” dated 12/11/23, Patient 14 was admitted to the facility in October 2023 with a diagnosis of unspecified psychosis (a mental condition where people have a disconnection from reality). During an interview on 4/12/25 at 12:30 p.m. with RISK, RISK stated Patient 14 alleged on 12/13/23 that [MHT 1] exposed himself to her and requested oral sex during her admission in October 2023. RISK stated the incident was not reported to CDPH or to the police. DON and RISK were unable to state why the incident was not reported to CDPH or the police. During a review of Patient 17’s “Patient Demographic Profile,” dated 12/13/23, the “Patient Demographic Profile” indicated Patient 17 was admitted to the facility in November 2023 with a diagnosis of unspecified psychosis. During an interview and concurrent record review on 4/14/25 at 2:24 pm with NM1, the facility’s document titled, “Interdisciplinary Progress Notes,” dated 11/30/23, for Patient 17 was reviewed. NM1 stated the “Interdisciplinary Progress Notes” indicated Patient 17 reported to staff that she might have been sexually assaulted and she requested a sexual assault exam (also known as rape kit, an exam done to collect evidence after a sexual assault). During an interview with DON on 4/12/25 at 11:21 am, the DON stated if a patient requests a sexual assault exam, the police should be called to facilitate getting the exam and investigate the allegation. During an interview on 4/14/25 at 2:24 pm with NM1, NM1 stated if a patient requests a sexual assault exam, the police will need to be called, and the facility should assist the patient. During an interview on 4/12/25 at 12:22 p.m. with RISK, RISK stated the incident was not reported to CDPH or the police, and Patient 17 was not assisted with receiving a sexual assault exam. During an interview on 4/16/25 at 2:00 p.m. with DON and RISK, RISK stated the facility did not report the incident to the police or to CDPH. DON and RISK were unable to state why the incident was not reported to CDPH or the police. During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 22, the “Patient Demographic Profile” indicated Patient 22 was admitted to the facility in June 2022 with a diagnosis of MDD. During a review of the facility’s document titled, “Interdisciplinary Progress Notes,” dated 6/16/22, for Patient 22, the “Interdisciplinary Progress Notes” indicated on 6/16/22, “at 1640, pt (Patient) [22] had an episode where he was hit in the head by 2 pt’s ... After phone call with mom at 2030, pt expressed to mom that he had dizziness, blurred vision, and headache ... Medical team and Psychiatrist notified and received order to transfer pt. Due to lack of transport and legal guardian’s request pt transferred to ED via 911 ... Pt transferred around 2100.” During a review of the facility’s document titled, “Interdisciplinary Progress Notes,” dated 6/20/22, for Patient 22, the “Interdisciplinary Progress Notes” indicated on 6/20/22 at 10:35 a.m., “Pt arrived on the unit ... and reported a pain score of 8 at the left shoulder ... x-ray done on both left and right shoulders ... x-ray found a space between left shoulder not found in right shoulder ...” During an interview on 4/16/25 at 1:30 p.m. with the DON and RISK, RISK stated the facility did not report the allegation of abuse made by Patient 22 on 6/16/22 to CDPH or the police. DON and RISK were unable to state why the incident was not reported to CDPH or the police. During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 24, the “Patient Demographic Profile” indicated Patient 24 was admitted to the facility in August 2022 with unspecified schizophrenia (a mental condition which makes it difficult to think clearly, have normal emotional responses, act normally in social situations, and tell the difference between what is real and what is not real). During a review of the facility document titled, “Daily Nursing Assessment,” dated 8/3/22, for Patient 24, the “Daily Nursing Assessment” indicated on 8/3/22, “At around 0130 , this patient [24] reported to the staff that he was sexually assaulted. Patient states ‘last night at 11 pm a man is not part of the hospital, raped me, It’s a security guard, some guy at the emergency room. The guy named Jonathan rubbed my back with his dick.’ Patient is pointing at the Mental Health Technician [MHT 1] .... House Supervisor aware and [MHT 1] was moved to another unit ...” During an interview on 4/16/25 at 12:50 p.m. with DON and RISK, RISK confirmed MHT 1, accused by Patient 24, was not sent home by the facility. MHT 1 continued to work in the facility before an investigation was completed. RISK stated MHT 1 should have been sent home after being accused of sexual abuse by staff. The DON stated failing to send the staff home placed Patient 24 and all other patients at risk of further sexual abuse by staff. DON and RISK stated the allegation of abuse was not reported to CDPH or the police. DON and RISK were unable to state why the incident was not reported to CDPH or the police. During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 26, the “Patient Demographic Profile” indicated Patient 26 was admitted to the facility in March 2023 with a diagnosis of Post Traumatic Stress Disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 46, the “Patient Demographic Profile” indicated Patient 46 was admitted to the facility in March 2023 with a diagnosis of bipolar disorder. During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 47, the “Patient Demographic Profile” indicated Patient 47 was admitted to the facility in March 2023 with a diagnosis of bipolar disorder. During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 48, the “Patient Demographic Profile” indicated Patient 48 was admitted to the facility in March 2023 with a diagnosis of attention-deficit hyperactivity disorder (ADHD, a neurodevelopmental condition characterized by persistent patterns of inattention, hyperactivity, and impulsivity). During a review of the facility’s document titled, “Interdisciplinary Progress Notes,” dated 3/18/23, for Patient 26, the “Interdisciplinary Progress Notes” indicated on 3/18/23, “During 1830 rounds, staff went into [Patient 26]’s room. [Patient 26] was crying and said that he just got punched by [Patient 46] a couple of times in the head ... [Patient 26] reported headache pain 3/10 ...[Patient 26] stated he is unsure of why he got punched ...” During a review of the facility’s document titled, “Interdisciplinary Progress Notes”, dated 3/19/23, for Patient 26, the “Interdisciplinary Progress Notes” indicated on 3/19/23, “[Patient 26] is pushed by [Patient 47] to the wall at 1524. [Patient 26] hit head to the wall. [Patient 26] use hand to stop hitting the wall ... Ice pack is given for head and hand injury ...” During a review of the facility’s document titled, “Interdisciplinary Progress Notes,” dated 3/22/23, for Patient 26, the “Interdisciplinary Progress Notes” indicated on 3/22/23, “At approximately 1858, staff reported that [Patient 48] was found in [Patient 26]’s room and observed [Patient 48] hitting [Patient 26] on the face and head. Staff redirected [Patient 48 back to his room. While staff is on his way to get help and inform RNs about the incident, [Patient 48] went back to [Patient 26]’s room and hit [Patient 26] on the face and head again ... Legal guardian (father) notified regarding the incident ... upset and insisting [Patient 26] to be sent out to the ER ... As per the medical team no need for [Patient 26] to be sent out to the ER ...” During an interview on 4/16/25 at 1:30 p.m. with DON and RISK, RISK stated none of the incidents from 3/18/23, 3/19/23, or 3/22/23 were investigated by the facility, and none of the incidents were reported to CDPH or the police. RISK stated Patient 26’s father reported the incident to the police, who came to the facility to investigate the incident. RISK stated, “this case was not reported due to lack of injury,” despite documentation in “Interdisciplinary Progress Notes” Patient 26 experienced head and hand injuries due to three assaults. RISK stated the failure to investigate the incident could potentially place Patient 26 and other patients at risk of experiencing abuse, assault, and injury. During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 30, the “Patient Demographic Profile” indicated Patient 30 was admitted to the facility in March 2022 with a diagnosis of psychosis (a term used to describe a set of symptoms, including hallucinations and delusions, that can indicate a significant disconnection from reality). During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 22, the “Patient Demographic Profile” indicated Patient 22 was admitted to the facility in March 2022 with a diagnosis of bipolar disorder. During a review of the facility’s document titled, “Interdisciplinary Progress Notes,” dated 3/17/22, for Patient 30, the “Interdisciplinary Progress Notes” indicated on 3/17/22, “@ 2:30 staff was coming out of room to check on other pts for rounds when we heard screaming coming out of room [room number]. Pt’s roommate [Patient 43] was screaming ’[Patient 30] kissed me in my sleep!’ and also roommate stated ‘get [Patient 30] away from me before I kill him ...’” During an interview on 4/16/25 at 1:30 p.m. with DON and RISK, RISK stated the facility did not report the allegation of abuse to the CDPH or the police. DON and RISK were unable to state why the incident was not reported to CDPH or the police. During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 31, the “Patient Demographic Profile” indicated Patient 31 was admitted to the facility in September 2024 with a diagnosis of MDD. During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 41, the “Patient Demographic Profile” indicated Patient 41 was admitted to the facility in October 2024 with a diagnosis of MDD. During a review of the facility’s document titled, “Interdisciplinary Progress Notes,” dated 10/23/24, for Patient 31, the “Interdisciplinary Progress Notes” indicated on 10/23/24, “Around 2135 patient reported to a MHT that another patient [Patient 41] -which is now discharged had gone into [Patient 31]’s room multiple times and also fingered [sexual stimulation of the vulva, including the clitoris or vagina, by using the fingers] [Patient 31] in the day room multiple times. Writer made aware of information ... [Patient 31] stated they were going to be smiling but were just nervous ... [Patient 31] stated they now feel guilty of the incidents and therefore that is why they told the MHT...” During an interview on 4/12/25 at 11:45 a.m. with DON and RISK, RISK stated the allegation of sexual abuse made by Patient 31 on 10/23/24 was confirmed as being true via a review of cameras in the day room. RISK confirmed the allegation of sexual abuse was not reported to CDPH or the police. RISK stated the incident “was not considered intercourse”, and the allegation was made after Patient 41 had discharged, and because of these factors, the incident was not reported. During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 32, the “Patient Demographic Profile” indicated Patient 32 was admitted to the facility in October 2022 with a diagnosis of unspecified mood disorder. During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 36, the “Patient Demographic Profile” indicated Patient 36 was admitted to the facility in October 2022 with a diagnosis of MDD. During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 39, the “Patient Demographic Profile” indicated Patient 39 was admitted to the facility in October 2022 with a diagnosis of MDD. During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 44, the “Patient Demographic Profile” indicated Patient 44 was admitted to the facility in October 2022 with a diagnosis of MDD. During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 45, the “Patient Demographic Profile” indicated Patient 45 was admitted to the facility in October 2022 with a diagnosis of MDD. During a review of the facility’s document titled, “Interdisciplinary Progress Notes,” dated 10/29/22, for Patient 39, the “Interdisciplinary Progress Notes” indicated on 10/29/22, “Around 1912,[Patient 39] was in the room sitting, another peer [Patient 32] approached [Patient 39]’s doorway and started saying ‘okay gonna talk shit about everyone, come I have my team here with me.’ [Patients 32, 36, 44, and 45] ganged up against [Patient 39] and ran to [Patient 39’s] room to jump on her ... peers punched [Patient 39] on back and visible superficial scratches to [Patient 39’s] right forearm ...” During an interview on 4/16/25 at 1:30 p.m. with DON and RISK, RISK stated the facility did not report the witnessed episode of physical abuse of Patient 39 the CDPH or the police. DON and RISK were unable to state why the incident was not reported to CDPH or the police. During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 37, the “Patient Demographic Profile” indicated Patient 37 was admitted to the facility in March 2022 with a diagnosis of MDD. During a review of the facility’s undated document titled, “Patient Demographic Profile,” for Patient 38, the “Patient Demographic Profile” indicated Patient 38 was admitted to the facility in March 2022 with a diagnosis of MDD. During a review of the facility’s document titled, “Interdisciplinary Progress Notes,” dated 3/30/22, for Patient 37, the “Interdisciplinary Progress Notes” indicated on 3/30/22, “At approximately 1835, [Patient 37] appears tearful, anxious, quiet with other patients ... went to talked with staff in the Consult Room ... [Patient 37] at first refused to talk to writer. [Patient 37] stated, ‘It happened on the weekend. I felt so dirty and gross because I let it happen.’ [Patient 37] remained tearful. [Patient 37] stated ‘It happened for the past 3 days. We made out, too. It was both, anal and oral too. I agreed to it but I told [Patient 38] to stop. But [Patient 38] said two more minutes so I let [Patient 38] finish’...” During an interview on 4/16/25 at 2:00 p.m. with DON and RISK, RISK stated the allegation of sexual abuse made by Patient 37 was not reported to CDPH or the police. DON and RISK were unable to state why the incident was not reported to CDPH or the police. During a review of the facility document titled, “Psychiatric Evaluation,” dated 2/6/25, for Patient 40, the “Psychiatric Evaluation” indicated Patient 40 was admitted to the facility in February 2025 with diagnoses of MDD and PTSD. During review of the facility’s document titled, “Interdisciplinary Progress Notes”, dated 2/12/25, for Patient 40, the “Interdisciplinary Progress Notes” indicated on 2/12/25, “[Patient 40] inside bathroom, began to actively self-harm by tying blue shirt around her neck to choke herself. Blue shirt confiscated to stop [Patient 40] from hurting herself. [Patient 40] then began to choke herself by putting hands around her neck. Physical hold on [Patient 40] initiated from 1705 to 1715 ... [Patient 40] educated on criteria for the physical hold to be released. [Patient 40] verbalized understanding and physical hold released at 1715 ...” During review of the facility’s document titled, “Interdisciplinary Progress Notes”, dated 2/13/25, for Patient 40, the “Interdisciplinary Progress Notes” indicated on 2/13/25, “at 1300 [Patient 40] made a complaint to a Charge Nurse regarding staff from last evening. Administrator and nurse manager notified. Patient had reported ’[RN 1] slapped me on the p.m. shift last night.’ [Patient 40] states ‘the nurse hit [Patient 40] on their right arm in their room. Patient stated male MHT was in the room too.” During review of the facility’s document titled, “Interdisciplinary Progress Notes”, dated 2/14/25, for Patient 40, the “Interdisciplinary Progress Notes” indicated “police were at the facility interviewing [Patient 40] for [a] police investigation.” The “Interdisciplinary Progress Notes” for Patient 40 did not state if or when Patient 40 reported the allegation of abuse to police. During the review of the facility’s document titled, “Interdisciplinary Progress Notes”, dated 2/14/25, for Patient 40, the “Interdisciplinary Progress Notes” indicated on 2/14/25, “MHT approached [RN 1] about concerns around a female staff and their response during a time they were trying to deescalate [on 2/12/25] [Patient 40], who was attempting to self-harm. Per MHT while [staff] were trying to remove [Patient 40]’s hand who was intermittently choking herself, [Patient 40] brushed [RN 1]’s hand. [RN 1] responded by quickly tapping [Patient 40]’s right hand, stating, ‘if you hit me, I will hit you ’.” During an interview on 4/16/25 at 1:40 p.m. with DON and RISK, DON and RISK stated they did not report the incident regarding abuse to CDPH. DON and RISK were unable to state why the incident was not reported to CDPH or the police. A review of the hospital’s policy and procedure (P&P) titled “Abuse and Neglect Reporting,” dated 09/2024, indicated “It is the policy of Fremont Hospital to protect our patients from all types of abuse or neglect and to act as their advocate in any instances where there is a suspected or substantiated instance of physical, emotional, sexual, of fiduciary abuse and/or neglect ... Fremont Hospital employees are mandated reporters as defined in the California Penal Code...” The policy further states “If a staff member becomes aware that a patient was sexually assaulted or raped either before admission or during their hospitalization, they are to take the following steps ... 2. Report immediately to the charge nurse, who is responsible for notifying ... Police department (if minor, requested by patient, or allegation of rape ...”, and “A potential act of abuse or neglect against a patient by hospital employees or contracted service must be reported to local law enforcement ... the alleged staff will be placed on administrative leave until investigation is done ...” The P&P did not contain any information on requirements for reporting to CDPH for allegations of abuse.”

“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: 50146 Based on staff interview and record review, the hospital failed to accurately measure, analyze, and track quality indicators and other aspects of performance that assess processes of care, hospital service and operations. The hospital’s Quality Assessment and Performance Improvement (QAPI) program did not accurately measure, analyze, and track allegations of abuse for 14 patients. The hospital’s failure to accurately measure, analyze, and track quality indicators and other aspects of performance that assess processes of care, hospital service and operations for abuse placed all patients in the facility at risk for experiencing abuse and possible death. Findings: During an interview on 4/16/25 at 11:00 a.m. with the Director of Nursing (DON) and Director of Risk Management (RISK), DON and RISK stated 14 investigated allegations of abuse from 2022 until present day were not measured, tracked, or analyzed as abuse cases. DON and RISK were unable to state why the facility did not consider these cases as abuse. During a review of the facility’s document titled “Quality Assessment and Performance Improvement Meeting Minutes”, dated January 2024, the “Quality Assessment and Performance Improvement Meeting Minutes” indicated the facility did not make any changes to its abuse prevention and reporting policy and procedure. During a review of the facility’s document titled “Quality Assessment and Performance Improvement Meeting Minutes”, dated February 2024, the “Quality Assessment and Performance Improvement Meeting Minutes” indicated the facility did not make any changes to its abuse prevention and reporting policy and procedure. During a review of the facility’s document titled “Quality Assessment and Performance Improvement Meeting Minutes”, dated March 2024, the “Quality Assessment and Performance Improvement Meeting Minutes” indicated the facility did not make any changes to its abuse prevention and reporting policy and procedure. During a review of the facility document titled “Quality Assessment and Performance Improvement Meeting Minutes”, dated April 2024, the “Quality Assessment and Performance Improvement Meeting Minutes” indicated the facility did not make any changes to its abuse prevention and reporting policy and procedure. During a review of the facility document titled “Quality Assessment and Performance Improvement Meeting Minutes”, dated May 2024, the “Quality Assessment and Performance Improvement Meeting Minutes” indicated the facility did not make any changes to its abuse prevention and reporting policy and procedure. During a review of the facility document titled “Quality Assessment and Performance Improvement Meeting Minutes”, dated June 2024, the “Quality Assessment and Performance Improvement Meeting Minutes” indicated the facility did not make any changes to its abuse prevention and reporting policy and procedure. During a review of the facility document titled “Quality Assessment and Performance Improvement Meeting Minutes”, dated July 2024, the “Quality Assessment and Performance Improvement Meeting Minutes” indicated the facility did not make any changes to its abuse prevention and reporting policy and procedure. During a review of the facility document titled “Quality Assessment and Performance Improvement Meeting Minutes”, dated August 2024, the “Quality Assessment and Performance Improvement Meeting Minutes” indicated the facility did not make any changes to its abuse prevention and reporting policy and procedure. During a review of the facility document titled “Quality Assessment and Performance Improvement Meeting Minutes”, dated September 2024, the “Quality Assessment and Performance Improvement Meeting Minutes” indicated the facility reviewed its abuse prevention and reporting policy and procedure but did not make any changes to the policy. During a review of the facility document titled “Quality Assessment and Performance Improvement Meeting Minutes”, dated October 2024, the “Quality Assessment and Performance Improvement Meeting Minutes” indicated the facility did not make any changes to its abuse prevention and reporting policy and procedure. During a review of the facility document titled “Quality Assessment and Performance Improvement Meeting Minutes”, dated November 2024, the “Quality Assessment and Performance Improvement Meeting Minutes” indicated the facility noted an increase in allegations of abuse, including staff-to-patient abuse, but no changes were made to the facility’s abuse prevention and reporting policy and procedure. During a review of the facility document titled “Quality Assessment and Performance Improvement Meeting Minutes”, dated December 2024, the “Quality Assessment and Performance Improvement Meeting Minutes” indicated the facility noted another increase in allegations of abuse, including staff-to-patient abuse, but no changes were made to the facility’s abuse prevention and reporting policy and procedure. During a review of the facility document titled “Quality Assessment and Performance Improvement (QAPI) 2025”, undated, the “Quality Assessment and Performance Improvement (QAPI) 2025” record did not contain any references to measuring, tracking, and analyzing any and all allegations of abuse.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 49983 Based on staff interview and record review, the facility failed to revise treatment plans for eight of 15 sampled patients (Patients 1, 8, 12, 16, 17, 18, 24 and 27) after the facility became aware that the patients were at risk for sexual victimization (any unwanted or forced sexual activity, ranging from unwanted physical contact to rape) or sexual aggression. Furthermore, the facility failed to update the treatment plan at a minimum of every seven days for one of 15 sampled patients (Patient 18). This failure had the potential to result in patients not receiving appropriate care and treatment. (Cross-reference: A-0145) Findings: During a review of the facility’s document titled, “Patient Demographic Profile”, dated 6/14/23, for Patient 1, the “Patient Demographic Profile” indicated, Patient 1 was admitted to the facility in June 2023 with a diagnosis of unspecified mood disorder (a mental health condition that affects the emotional state). During an interview and concurrent record review on 4/14/25 at 1:35 p.m. with Nurse Manager 1 (NM1), the facility’s documents titled “Progress Notes”, dated 6/12/23, and “Master Treatment Plan” (a document used to guide patient care), dated 6/8/23, for Patient 1 were reviewed. NM1 stated the “Progress Notes” indicated Patient 1 reported to staff on 6/12/23 that her roommate forced her to kiss them and tried to pull down her pants. NM1 stated the “Master Treatment Plan” was not updated to reflect the incident and it should have been. During a review of the facility’s document titled, “Patient Demographic Profile”, dated 5/7/22, for Patient 8, the “Patient Demographic Profile” indicated Patient 8 was admitted to the facility in April 2022 with a diagnosis of bipolar disorder (a mood disorder characterized by periods of depression alternating with mania). During a concurrent interview and record review on 4/14/25 at 1:40 pm with NM1, the facility’s documents titled, “Progress Notes”, dated 4/29/22, and “Master Treatment Plan”, dated 4/23/22, for Patient 8 were reviewed. NM1 stated the “Progress Notes” indicated Patient 8 reported to staff on 4/29/22 that another patient touched her breast and tried to get her to go to his room. NM1 stated the “Progress Notes” indicated Patient 8’s mother called the police to report the incident, and that Patient 8 threw a chair at the other patient and punched him several times in the face. NM1 stated there was no recommendation made to update the “Master Treatment Plan”, and it should have been updated to reflect the report of inappropriate touching and the assault on the other patient. During a concurrent interview and record review on 4/14/25 at 1:40 pm with NM1, the facility’s documents titled, “Patient Observation Rounds”, dated 4/30/22, and “Daily Nursing Assessment”, dated 4/30/22, for Patient 8 were reviewed. NM1 stated the “Patient Observation Rounds” and the “Daily Nursing Assessment” documents indicated that Patient 8 was not placed on sexual victimization precautions or assault precautions after the incident and [Patient 8] should have been. During a review of the facility’s document titled, “Patient Demographic Profile”, dated 5/18/22, for Patient 12, the “Patient Demographic Profile” indicated Patient 12 was admitted to the facility in May 2022 with a diagnosis of bipolar disorder. During an interview and concurrent record review on 4/9/25 at 11:46 am, with the Director of Nursing (DON), the facility’s documents titled, “Progress Notes”, dated 5/14/22, and “Master Treatment Plan”, dated 5/15/22, for Patient 12 were reviewed. DON stated the “Progress Notes” indicated on 5/14/22, Patient 12 reported to staff that a staff member touched her breast and buttock on 5/13/22. DON stated the “Master Treatment Plan” was not updated after Patient 12 reported that she had been touched inappropriately on 5/13/25 and it should have been updated to reflect the incident. During a review of the facility’s document titled, “Patient Demographic Profile”, dated 5/27/22, for Patient 16, the “Patient Demographic Profile” indicated Patient 16 was admitted to the facility in May 2022 with a diagnosis of Major Depressive Disorder (MDD, a mental health condition characterized by persistently low mood, loss of interest in activities, and other symptoms like sleep and appetite disturbances and difficulty concentrating). During an interview and concurrent record review on 4/14/25 at 2:21 p.m., with NM1, the facility’s documents titled, “Progress Notes”, dated 5/22/22 and 5/26/22, and “Master Treatment Plan”, dated 5/19/22, for Patient 16 were reviewed. NM1 stated the “Progress Notes” on 5/22/22 indicated another patient reported that Patient 16 touched them inappropriately. NM1 stated the “Progress Notes” dated 5/26/22 indicated Patient 16 reported to staff that she had a prior history of being a victim of abuse. NM1 stated there was no recommendation to update the “Master Treatment Plan” after the allegation that Patient 16 touched another patient inappropriately or after Patient 16 reported she had a history of being sexually victimized. NM1 stated the “Master Treatment Plan” should have been updated after both incidents. NM1 stated the reason to update the treatment plan after reports of a history of sexual victimization or allegations of sexually aggressive behavior is so that staff can watch and monitor for these behaviors. During an interview and concurrent record review on 4/14/25 at 2:21 p.m., with NM1, the facility’s documents titled “Nursing Daily Assessment”, dated 5/24/22, and “Patient Observation Rounds”, dated 5/24/22 for Patient 16 were reviewed. NM1 stated the “Nursing Daily Assessment” and “Patient Observation Rounds” documents indicated that Patient 16 was not placed on sexual aggressor precautions after the allegation that she inappropriately touched another patient. NM1 stated she should have been on sexual aggressor precautions. During a review of the facility’s document titled, “Patient Demographic Profile”, dated 12/13/23, for Patient 17, the “Patient Demographic Profile” indicated Patient 17 was admitted to the facility in November 2023 with a diagnosis of unspecified psychosis (a collection of symptoms that involve a disconnection from reality). During an interview and concurrent record review on 4/14/25 at 2:24 pm with NM1, the facility’s documents titled, “Progress Notes”, dated 11/30/23, “Master Treatment Plan”, dated 11/27/23, and “Nursing Daily Assessment”, dated 12/1/23, for Patient 17 were reviewed. NM1 stated the “Progress Notes” indicated Patient 17 reported to staff on 11/30/23 that she might have been sexually assaulted. NM1 stated there was no recommendation to update the “Master Treatment Plan” to reflect that Patient 17 alleged that she was sexually assaulted, and there should have been. NM1 stated the “Nursing Daily Assessment”, indicated Patient 17 was not put on sexual victimization precautions after her allegation and she should have been. During a review of the facility’s document titled, “Patient Demographic Profile”, dated 12/17/22, for Patient 18, the “Patient Demographic Profile” indicated Patient 18 was admitted to the facility in November 2022 with a diagnosis of schizoaffective disorder (a thought disorder that includes psychotic features and mood symptoms). During an interview and concurrent record review on 4/14/25 at 2:30 p.m. with NM1, the facility’s documents titled “Progress Notes”, dated 12/3/22, “Master Treatment Plan”, dated 11/30/22, and “Master Treatment Plan” dated 12/15/22, for Patient 18 were reviewed. NM1 stated the “Progress Notes” indicated Patient 18 reported that a male patient exposed himself to her and touched her inappropriately on 12/3/22. NM1 stated there was no recommendation to update the “Master Treatment Plan” after the incident and there was no mention of the allegation on the “Master Treatment Plan”. NM1 stated the “gap” between updating the “Master Treatment Plan” between 11/30/22 and 12/15/22 was too long. NM1 stated the “Master Treatment Plan” should be updated every 7 days. NM1 stated “Master Treatment Plans” are updated so that staff are giving appropriate treatments to patients. During an interview and concurrent record review on 4/16/25 at 10:20 am with DON, the facility’s documents titled, “Master Treatment Plan”, dated 11/30/22, and “Master Treatment Plan Update”, dated 12/15/22, for Patient 18 were reviewed. DON stated there should have been a “seven-day update” in between 11/30/22 and 12/15/22. DON also stated there was no “seven-day update” in Patient 18’s chart. During a review of the facility’s undated document titled “Patient Demographic Profile” for Patient 24, the “Patient Demographic Profile” indicated Patient 24 was admitted to the facility in August 2022 with a diagnosis of schizophrenia (a mental disorder that affects how people think, feel, and behave). During a concurrent interview and record review on 4/14/25 at 3:07 pm with NM1, the facility’s documents titled “Progress Notes”, dated 8/2/23, and “Master Treatment Plan”, dated 8/3/22, for Patient 24 were reviewed. NM1 stated the “Progress Notes” indicated Patient 24 informed staff that he engaged in behavior that would be defined as sexually aggressive prior to admission. NM1 stated there was no recommendation to update the “Master Treatment Plan” to reflect the sexually aggressive behavior. NM1 stated the “Master Treatment Plan” should have been updated. NM1 stated updating the “Master Treatment Plan” for a patient with a history of sexually aggressive behavior would have triggered Patient 24 being placed on sexual aggression precautions. During a concurrent interview and record review on 4/14/25 at 3:10 p.m. with NM1, the facility’s documents titled, “15 Minute Observation Log”, dated 8/3/22, and the “Nursing Daily Assessment”, dated 8/3/22, for Patient 24 were reviewed. NM1 stated Patient 24 should have been placed on “sexual aggression assessment or precautions” on 8/3/22, but they were not. During a review of the facility’s document titled, “Patient Demographic Profile”, dated 2/4/23, for Patient 27, the “Patient Demographic Profile” indicated Patient 27 was admitted to the facility in January 2023 with a diagnosis of unspecified mood disorder. During a concurrent interview and record review on 4/14/25 at 3:19 p.m. with NM1, the facility’s documents titled, “Progress Notes”, dated 1/29/23 and 2/2/23, “Master Treatment Plan”, dated 1/31/23, “Daily Nursing Assessment”, dated 1/30/23, and “Patient Observation Rounds”, dated 1/30/23, for Patient 27 were reviewed. NM1 stated the “Progress Notes” indicated Patient 27’s roommate stated Patient 27’s had been sexually inappropriate with her on 1/29/23. NM1 stated the “Master Treatment Plan” was not updated to reflect this allegation. NM1 stated the “Daily Nursing Assessment” and “Patient Observation Rounds” indicated that Patient 27 was not placed on sexual aggression assessment or precautions after the incident. NM1 stated that after an allegation is made of sexually aggressive behavior, the “Master Treatment Plan” should be updated and the patient should be put on sexual aggression assessments and precautions. During an interview on 4/16/26 at 11:30 a.m. with Psychiatrist 1 (PSY1), PSY1 stated the “Master Treatment Plan” should be updated if a patient reports being sexually assaulted so that the patient can receive specific interventions and treatment. During a review of the facility’s policy and procedure (P&P) titled “Interdisciplinary Patient-Centered Care Planning”, dated 6/2024, the P&P indicated “ ...treatment team will complete a review of the treatment plan as clinically indicated, or at a minimum every seven days ...”. The P&P also indicated “ ...The following would be cause for conducting a review of the plan and developing a revision:...A new impairment/problem or significant information about an existing impairment is identified”. During a review of the facility’s P&P titled “Sexual Acting Out”, dated 4/2018, the P&P indicated “ ...each patient is to be assessed for risk of sexual victimization and sexual aggression ... Patients with a risk for sexual victimization will be placed on Sexual Victim precautions ...Patients with a risk for sexual aggression will be placed on Sexual Aggressor precautions...””

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 49983 Based on interview and record review, the facility failed to create a collaborative, individualized, comprehensive treatment plan for 10 of 30 reviewed patients (Patients 1, 12, 16, 17, 18, 22, 23, 25, 27, and 30). This failure had the potential to increase the risk of assault and abuse. (Cross-reference: A-0145 and A-0396) Findings: During a review of the facility’s document titled, “Patient Demographic Profile”, dated 6/14/23, for Patient 1, the “Patient Demographic Profile” indicated Patient 1 was admitted to the facility in June 2023 with a diagnosis of unspecified mood disorder (a mental health condition that affects the emotional state). During an interview and concurrent record review on 4/14/25 at 1:35 p.m. with Nurse Manager 1 (NM1), the facility’s documents titled “Nursing Admission Assessment” (assessment done by the nurse when they are first admitted to the facility), dated 6/6/23, “Initial Treatment Plan” (a document initiated by the admitting RN), dated 6/6/23, and “Master Treatment Plan” (a tool to guide care), dated 6/8/23, for Patient 1 were reviewed. NM1 stated the “Nursing Admission Assessment” indicated Patient 1 had a history of sexual victimization (any unwanted or forced sexual activity, ranging from unwanted physical contact to rape) in the past six months. NM1 stated the “Initial Treatment Plan” included the history of sexual victimization, but it was not on the “Master Treatment Plan” and should have been included. NM1 stated the “Master Treatment Plan” was not signed by Patient 1 and there was no indication that Patient 1 refused to sign or was unable to sign. NM1 stated the reason to include history of recent sexual victimization in the treatment plan is to provide the patient with appropriate interventions and precautions and to guide their care. NM1 stated there is a risk to not providing patients with a history of sexual victimization with appropriate precautions. During a review of the facility’s document titled, “Patient Demographic Profile”, dated 5/18/22, for Patient 12, the “Patient Demographic Profile” indicated Patient 12 was admitted to the facility in May 2022 with a diagnosis of bipolar disorder (a mood disorder characterized by periods of depression alternating with mania). During an interview and concurrent record review on 4/9/25 at 11:46 am with the Director of Nursing (DON), the facility’s documents titled “Nursing Admission Assessment”, dated 5/13/22, “Initial Treatment Plan”, dated 5/13/22, and “Master Treatment Plan”, dated 5/15/22 for Patient 12 were reviewed. DON stated the “Nursing Admission Assessment” indicated Patient 12 had a history of sexual victimization. DON stated the “Initial Treatment Plan” did not include risk of sexual victimization and it should have been included due to patient’s history of sexual victimization. DON stated the “Initial Treatment Plan” included Depressed Mood/Suicidal and Mood lability: anxiety/mania. DON stated the “Master Treatment Plan” did not include anxiety/mania or risk for sexual victimization and both should have been included. DON stated sexual victimization risk precautions were not “checked” on the “Master Treatment Plan” and should have been. DON stated the reason for including risk of sexual victimization on the “Master Treatment Plan” and for adding sexual victimization risk precautions is to protect patients with a history of sexual victimization and to provide appropriate interventions for them. DON stated Patient 12 did not sign the “Master Treatment Plan” and it was not indicated that they refused or was unable to sign. DON also stated the “Master Treatment Plan” is a collaborative document, and it should be signed by the patient or indicate if they refused or were unable to sign. During an interview and concurrent record review on 4/14/25 at 1:52 pm with NM1, the facility’s documents titled, “Nursing Daily Assessment” dated 5/13/22, 5/14/22, and 5/15/22 and the “Patient Observation Rounds” dated 5/13/22, 5/14/22, and 5/15/22 for Patient 12 were reviewed. NM1 stated the documents indicated that Patient 12 was on sexual victimization precautions on 5/13/25, but they were incorrectly discontinued due to an error. NM1 stated Patient 12 was not on sexual victimization precautions on 5/14/22 and 5/15/22 and she should have been. During a review of the facility’s document titled “Patient Demographic Profile”, dated 5/27/22, for Patient 16, the “Patient Demographic Profile” indicated Patient 16 was admitted in May 2022 with a diagnosis of Major Depressive Disorder (MDD, a mental health condition characterized by persistently low mood, loss of interest in activities, and other symptoms like sleep and appetite disturbances and difficulty concentrating). During a concurrent interview and record review on 4/14/25 at 2:21 p.m. with NM1, the facility’s document titled “Master Treatment Plan”, dated 5/19/22, for Patient 16 was reviewed. NM1 stated the “Master Treatment Plan” was not signed by Patient 16 and there was no indication that Patient 16 refused or was unable to sign. During a review of the facility’s document titled “Patient Demographic Profile”, dated 12/13/23, for Patient 17, the “Patient Demographic Profile” indicated Patient 17 was admitted to the facility in November 2023 with a diagnosis of unspecified psychosis (a collection of symptoms that involve a disconnection from reality). During an interview and concurrent record review on 4/14/25 at 2:24 pm with NM1, the facility’s document titled “Master Treatment Plan”, dated 11/27/23, for Patient 17 was reviewed. NM1 stated the “Master Treatment Plan” did not include a psychiatric diagnosis and the psychiatric problem list is blank. NM1 stated the “Master Treatment Plan” is not complete and this could impact patient care. NM1 stated the “Master Treatment Plan” should be signed by a nurse and it was not. During a review of the facility’s document titled, “Patient Demographic Profile”, dated 12/17/22, for Patient 18, the “Patient Demographic Profile” indicated Patient 18 was admitted to the facility in November 2022 with a diagnosis of schizoaffective disorder (a thought disorder that includes psychotic features and mood symptoms). During an interview and concurrent record review on 4/14/25 at 2:30 p.m. with NM1, the facility’s document titled “Master Treatment Plan”, dated 11/30/22, for Patient 18 was reviewed. NM1 stated the “Master Treatment Plan” was not signed by Patient 18 and there is no indication that Patient 18 refused or was unable to sign. During a review of the facility’s document titled, “Patient Demographic Profile”, dated 6/26/22, for Patient 22, the “Patient Demographic Profile” indicated Patient 22 was admitted to the facility in June 2022 with a diagnosis of MDD. During an interview and concurrent record review on 4/14/25 at 2:39 p.m. with NM1, the facility’s documents titled “Initial Treatment Plan”, dated 6/11/22, and “Master Treatment Plan”, dated 6/13/22, for Patient 22 were reviewed. NM1 stated the “Initial Treatment Plan” indicated Patient 22 was admitted with aggressive behavior. NM1 stated the “Master Treatment Plan” did not include assaultive/aggressive behavior and interventions and should have. NM1 stated assault precautions were not implemented on the “Master Treatment Plan” and should have been implemented. NM1 stated the “Master Treatment Plan” was not signed by Patient 22 or Patient 22’s family member and there was no indication that they refused or were unable to sign. During a review of the facility’s document titled, “Patient Demographic Profile”, dated 2/1/23, for Patient 23, the “Patient Demographic Profile” indicated Patient 23 was admitted in January 2023 with a diagnosis of MDD. During an interview and concurrent record review on 4/14/25 at 2:54 p.m. with NM1, facility’s documents titled “Initial Treatment Plan”, dated 1/17/23, and “Master Treatment Plan”, dated 1/19/23, for Patient 23 were reviewed. NM1 stated the “Initial Treatment Plan” indicated Patient 23 was admitted with aggressive behavior. NM1 stated the “Master Treatment Plan” did not include assaultive/aggressive behavior and interventions and should have. NM1 stated assaultive and aggressive behavior is added to treatment plans so the facility can implement interventions for that behavior. NM1 stated if assaultive/aggressive interventions are not in place, it could contribute to incidents. NM1 stated the “Master Treatment Plan” was not signed by Patient 23 or Patient 23’s family member and there was no indication that they refused or were unable to sign. During a review of facility’s document titled “Patient Demographic Profile”, dated 12/17/22, for Patient 25, the “Patient Demographic Profile” indicated Patient 25 was admitted to the facility in December 2022 with a diagnosis of unspecified mood disorder. During a concurrent interview and record review on 4/14/25 at 3:11 p.m. with NM1, facility’s documents titled “Master Treatment Plan”, dated 12/13/22, for Patient 25 was reviewed. NM1 stated the “Master Treatment Plan” contained no entries under the psychiatric problem list and there was nothing written under psychiatric diagnosis. NM1 stated it is an incomplete “Master Treatment Plan” and could negatively impact patient care. NM1 stated the “Master Treatment Plan” was not signed by Patient 25 and there was no indication that they refused or were unable to sign. During an interview on 4/16/26 at 11:30 a.m. with Psychiatrist 1 (PSY1), PSY1 stated the “Master Treatment Plan” should include a psychiatry problem list. PSY1 stated that if a patient has a history of sexual or physical assault, it should be reflected on their “Master Treatment Plan” so that the patient can receive specific interventions and treatment. During a review of facility’s document titled “Patient Demographic Profile”, dated 2/4/23, for Patient 27, the “Patient Demographic Profile” indicated Patient 27 was admitted to the facility in January 2023 with a diagnosis of unspecified mood disorder. During a concurrent interview and record review on 4/14/25 at 3:19 p.m. with NM1, facility’s documents titled “Initial Treatment Plan”, dated 1/29/23, “Master Treatment Plan”, dated 1/31/2, for Patient 27 were reviewed. NM1 stated the “Initial Treatment Plan” was not signed by a nurse and should have been. NM1 stated the “Master Treatment Plan” was not signed by a physician or a nurse and should have been. NM1 stated the “Master Treatment Plan” was not signed by the patient or family and there was no indication that they refused or were unable to sign. NM1 stated aggressive behavior towards others was included on the “Initial Treatment Plan” and it was not included on the “Master Treatment Plan” and should have been. During a review of facility’s document titled “Patient Demographic Profile”, dated 3/20/22, for Patient 30, the “Patient Demographic Profile” indicated Patient 30 was admitted to the facility in March 2022 with a diagnosis of unspecified psychosis. During a concurrent interview and record review on 4/14/25 at 3:26 pm with NM1, the facility’s documents titled “Initial Treatment Plan”, dated 3/14/22, “Master Treatment Plan”, dated 3/30/22, and “7-day Update”, dated 3/23/22, for Patient 30 were reviewed. NM1 stated the “Master Treatment Plan” was only signed by the physician and should also be signed by Nursing and Case Management/Social Services. NM1 stated the “Master Treatment Plan” was not signed by Patient 30 and there was no indication they refused or were unable to participate. During a review of the facility’s policy and procedure (P&P) titled “Sexual Acting Out”, dated 4/2018, the P&P indicated, “...Upon admission each patient is to be assessed for risk of sexual victimization or sexual aggression ...” The P&P also indicated, “ ... Throughout hospitalization the Registered Nurse is to reassess patient for risk of sexual victimization or sexual aggression, as appropriate ... Once a patient has been identified as a potential risk for sexual victimization or sexual aggression, Psychiatrist or RN should initiate sexual victimization or sexual aggression precautions ...”. During a review of the facility’s P&P titled “Interdisciplinary Patient-Centered Care Planning”, dated 6/2024, the P&P indicated, “the treatment team will complete the Master Treatment Plan including: completion of diagnosis, problem list, and patient assets on the Treatment Plan Cover Sheet, completion of an individual Problem Sheet for each active psychiatric or medical problem. The Problem Sheets will include the problem ...” The P&P also indicated “ ...The patient/family and/or representative is to sign the treatment plan to indicate their agreement with and participation in development of the plan ... If the patient refuses to sign or is unwilling to sign, that will be documented.” The P&P also indicated “ ...The following would be cause for conducting a review of the plan and developing a revision:...A new impairment/problem or significant information about an existing impairment is identified”.”