Pacific Grove Hospital

“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: 38479 Based on interview and record review, for one of eight (8) sample patients, the facility failed to promote patient safety when Patient 4’s response to an emergency drug therapy (Haldol, Ativan, and Benadryl are given together-frequently referred to as a “B52” injection or medical cocktail-to rapidly calm and sedate patients who are experiencing severe acute agitation, distress, or aggressive behavior) administered on 7/18/26 at 1:20 a.m., to treat acute agitation was not monitored or assessed for effectiveness and potential adverse effect. The facility’s failure resulted in the delay of identification of adverse reaction/complication as a result of administering three combined drug therapy medications that may have potentially contributed to Patient 4’s fall on 7/18/26 at 4:10 a.m. Findings: During review of Patient 4’s record on 8/4/26, at 8:53 a.m., with the Director of Quality (DQ), the “PRACTITIONER ORDER SHEET,” dated 7/18/26, at 1:19 a.m. indicated, “Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, intramuscular (IM) x 1 now,” was ordered for management of psychosis, anxiety, and extrapyramidal syndrome (EPS- drug-induced movement disorders that involve muscle stiffness, tremors, involuntary spasms, or severe inner restlessness commonly occur as side effects of antipsychotic medications). The record verified the combination medications were administered by the Licensed Vocational Nurse (LVN 1) but there was no documented evidence that Patient 4 was monitored for effectiveness and potential adverse effects of the medication. During a concurrent interview and record review of Patient 4’s record with the Interim Chief Nursing Officer (ICNO) on 8/5/26, at 2:31 p.m., the ICNO stated Haldol is a medication for psychosis (a mental state where a person loses touch with reality), Ativan is a medication used for anxiety (the body’s natural response to stress, marked by feelings of tension, worried thoughts, and physical changes like a fast heartbeat), and Benadryl to prevent side effects. The ICNO stated staff should make sure Patient 4 had normal breathing and no throat swelling because Ativan is a benzodiazepine (prescription central nervous system depressants that slow brain activity) that can slow down breathing, respiration, and blood pressure can drop from these medications. The ICNO stated these medications can cause sedation and drowsiness and patients should be monitored for safety to make sure they don’t lose balance and fall. The ICNO further clarified that Patient 4 was a fall risk because he had a history of seizure (a sudden, uncontrolled burst of electrical activity in the brain that temporarily changes how a person acts, moves, feels, or experiences awareness) while withdrawing from alcohol. The ICNO stated a lot of things had been going on for Patient 4 and taking the combination medication had further increased his risk for fall. The ICNO verified the record and confirmed LVN 1 should have assessed and documented the effectiveness and potential adverse reaction/complication of the three administered combined medications. A review of facility policy and procedure (P&P) “USE OF PRN (as needed) MEDICATIONS” dated 08/2025, indicated, “STATEMENT OF POLICY: The Pharmacy in conjunction with the facility’s Medical Staff and Administration will advocate the use of “PRN” medications provided certain guidelines are followed...PROCEDURE...The nurse who administers the “PRN” medication will document, in the appropriate section of the patient record, the purpose for which the medication was given and whether the patient’s outcome was effective or ineffective in response to the medication...””

“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: 38479 Based on interview and record review, for one of eight (8) sample patients, the facility failed to document a complete and accurate recording of Patient 4’s response to the effectiveness of drug therapy administered (Haldol, Ativan, and Benadryl are given together-frequently referred to as a “B52” injection or medical cocktail-to rapidly calm and sedate patients who are experiencing severe acute agitation, distress, or aggressive behavior) to treat acute agitation on 7/18/26 at 1:20 a.m. The facility ’ s failure resulted in an incomplete record of Patient 4 ’ s response to the drug therapy, preventing an accurate reflection of the treatment the patient received. Findings: During review of Patient 4’s record on 8/4/26, at 8:53 a.m., with the Director of Quality (DQ), the “PRACTITIONER ORDER SHEET,” dated 7/18/26, at 1:19 a.m. indicated, “Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, intramuscular (IM) x 1 now,” was ordered for management of psychosis, anxiety, and extrapyramidal syndrome (EPS- drug-induced movement disorders that involve muscle stiffness, tremors, involuntary spasms, or severe inner restlessness commonly occur as side effects of antipsychotic medications). The record verified the combination medications were administered by the Licensed Vocational Nurse (LVN 1) but there was no documented evidence that Patient 4 was monitored for effectiveness and potential adverse effects of the medication. During a concurrent interview and record review of Patient 4’s record with the Interim Chief Nursing Officer (ICNO) on 8/5/26, at 2:31 p.m., the ICNO stated Haldol is a medication for psychosis (a mental state where a person loses touch with reality), Ativan is a medication used for anxiety (the body’s natural response to stress, marked by feelings of tension, worried thoughts, and physical changes like a fast heartbeat), and Benadryl to prevent side effects. The ICNO stated staff should make sure Patient 4 had normal breathing and no throat swelling because Ativan is a benzodiazepine (prescription central nervous system depressants that slow brain activity) that can slow down breathing, respiration, and blood pressure can drop from these medications. The ICNO stated these medications can cause sedation and drowsiness and patients should be monitored for safety to make sure they don’t lose balance and fall. The ICNO further clarified that Patient 4 was a fall risk because he had a history of seizure (a sudden, uncontrolled burst of electrical activity in the brain that temporarily changes how a person acts, moves, feels, or experiences awareness) while withdrawing from alcohol. The ICNO stated a lot of things had been going on for Patient 4 and taking the combination medication had further increased his risk for fall. The ICNO verified the record and confirmed LVN 1 should have assessed and documented the effectiveness and potential adverse reaction/complication of the three administered combined medications. A review of facility policy and procedure (P&P) “Documentation Protocol, IM-009” dated 05/2026, indicated, “POLICY: Facility records, charts and documents are to be accurate, truthful, timely, and complete. Staff are to document accurately our services provided...PURPOSE: To provide a means of communication between healthcare providers; to provide legal record to protect the patient, the facility and healthcare team; and, to provide information in the medical record for performance improvement...””

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 38479 Based on interview and record review, for one (1) of eight (8) sample patients (Patient 1), the facility failed to ensure a homeless patient was safely discharged on 5/12/26, when the shelter (community-based housing, supportive housing for recovery of individuals experiencing chronic homelessness, mental health conditions, and addictions) was not contacted to confirm Patient 1 was accepted and a bed was secured for admission. This failure resulted in Patient 1 being denied a shelter bed and departing the shelter to an unknown destination and placed Patient 1 at risk for adverse health consequences due to the absence of appropriate post-discharge accommodation. Findings: During a concurrent interview and record review on 6/23/26, at 10:38 a.m., with the Director of Quality (DQ), Patient 1’s records were reviewed. The document titled “DISCHARGE SUMMARY”, dated 5/12/26, indicated Patient 1,” ...was placed on 5150 (involuntary legal hold) for grave disability ...out of touch with reality and unable to provide for her basic needs ...admitted to [name of hospital] for further psychiatric stabilization ...” The DQ stated Patient 1 was discharged from the facility on 5/12/26 at 1:36 p.m. During a concurrent interview and record review on 6/23/26 at 11:30 a.m. with the DQ, DQ stated that the Social Worker (SW) note dated 5/12/26 at 4:00 p.m. indicated, “SW received a call from [name of shelter] in regard to (Patient 1), a patient discharged a few hours earlier. The Case Worker reported that there were no more beds available for walk-in clients and noted that Patient 1 needed to be transferred elsewhere for care. The SW reported that we [facility] can assist and ask to speak to the patient however she had already left the [shelter].” The DQ stated the SW was not available but her supervisor, the Director of Clinical Services (DCS) was there to answer questions. During an interview and record review on 6/23/26 at 12:03 p.m. with the DCS, the DCS stated Patient 1 had limited options for discharge placement. DCS stated Patient 1 had no health insurance and she was indigent. DCS stated they could not refer her to a crisis residential facility, and she has no income so they could not place her in a boarding care or room and board. The DCS stated the shelter does not require insurance, was a first come first serve basis, and bed availability usually closed by 4:00 p.m. On 6/23/26 at 12:28 p.m., the DQ joined the DCS for the interview. The DQ stated that shelters do not hold a bed; it is a first come first serve basis. There was no documented evidence in Patient 1’s record which indicated the facility had made efforts to secure a bed at the shelter and confirm accommodation for the night when Patient 1 was sent to the shelter 2 to 3 hours away, a few hours before beds were no longer available. During an interview with the DQ on 6/23/26 at 12:40 p.m., the DQ stated, “Discharge planning is important to be able to arrange aftercare appointments and follow up, and to see if patient will be discharging home or to another level of outside treatment for safe discharge.” A review of facility policy and procedure titled, “Homeless Discharge Planning, PC 91,” dated May 2019, indicated, “1. PURPOSE ...2. Help prepare the homeless patient to return to the community by connecting him/her with available resources, treatment, shelter, and other support services. The discharge planning shall be guided by the best interest of the homeless patient, his or her mental condition, and the homeless patient’s preferences for placement. The homeless patient shall be informed of available placement options ...POLICY ...1. Current housing status ...c. Unless the homeless patient is being transferred to another licensed health facility, the policy shall require the hospital to identify a post-discharge destination for the homeless patient as follows, with priority given to identifying a sheltered destination with supportive services ...i. A social services agency, nonprofit social services provider, or governmental service provider that has agreed to accept the homeless patient, if he or she has agreed to the placement ...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure care in a safe setting was provided, for three of eight sampled patients (Patients A, 2, and 7) when: 1. For Patient A, the facility document titled, “Clinical Opiate [a class of powerful prescription medications used to manage pain] Withdrawal Scale [COWS, a rating scale composed of ten criteria associated with opiate withdrawal (the physical and mental reaction that occurs when someone stops or reduces heavy, long-term use of opioid drugs)],” was not completed for Patient A in accordance with the physician’s order (Refer to A-0144); 2. For Patient A, the physician was not notified when Patient A had an abnormal oxygen saturation level (the oxygen level in the blood, normal is 95 to 100 percent) (Refer to A-0144); 3. For Patient A, the patient had a code blue (a facility code for an emergency event when a patient’s breathing and/or pulse stops) and the code blue record was not completed (Refer to A-0144); and 4. For Patient A, trazodone (a medication to treat depression [mood disorder characterized by persistent feelings of sadness], and causes drowsiness) was administered routinely (to be administered on a regular, recurring basis) when it was ordered to be administered as needed (PRN) (Refer to A-0144). 5. For Patient 2, the “Restraint/Seclusion Packet” was not completed (Refer A-0144); and 6. For Patient 7, the “Belongings List” was not completed when the patient was admitted to, during Patient 7’s admission in the facility, and upon Patient 7’s discharge from the facility (Refer A-0144). The cumulative effects of these systemic failures could have compromised Patients A’s health, may result in delay of care, and may have contributed to Patient A’s death, in Patient 2’s assessment to not be conducted and the respiratory rate (the number of breaths taken by a patient in a minute) to not be monitored during the period while Patient 2 was in physical restraints (when a person or persons is/are physically holding a patient to restrict the patient’s movement), and in the inability of the facility to account for Patient 7’s personal properties, safeguard the items brought to the facility by Patient 7’s family after she was admitted to the facility, and reconcile the list of Patient 7’s belongings upon Patient 7’s discharge from the facility.”

“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: 42512 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for three of eight sampled patients (Patients A, 2, and 7), when: 1a. For Patient A, the facility document titled, “Clinical Opiate [opioid, a class of powerful prescription medications used to manage pain] Withdrawal Scale [COWS, a rating scale which quantifies the severity of opioid withdrawal (the physical and mental reaction that occurs when someone stops or reduces heavy, long-term use of opioid drugs), with a score of five to 12 meaning mild, 13 to 24 meaning moderate, 25 to 36 meaning moderately severe, and more than 36 meaning severe withdrawal],” was not completed for Patient A in accordance with the physician’s order and the facility’s policy and procedure (P&P) (Refer to A-0398); b. For Patient A, the physician was not notified when Patient A had an abnormal oxygen saturation level (the oxygen level in the blood, normal is 95 to 100 percent) (Refer to A-398); c. For Patient A, the patient had a code blue (a facility code for an emergency event when a patient’s breathing and/or pulse stops) and the code blue record was not completed (Refer to A-398); and d. For Patient A, trazodone (a medication to treat depression [mood disorder characterized by persistent feelings of sadness], and causes drowsiness) was administered routinely (to be administered on a regular, recurring basis) when it was ordered to be administered as needed (PRN); 2. For Patient 2, the “Restraint/Seclusion Packet” was not completed (Refer A-0398); and 3. For Patient 7, the “Belongings List” was not completed when the patient was admitted to, during Patient 7’s admission in the facility, and upon Patient 7’s discharge from the facility (Refer A-0398). The cumulative effects of these systemic failures could have compromised Patients A’s health, may result in delay of care, and may have contributed to Patient A’s death, in Patient 2’s assessment to not be conducted and the respiratory rate (the number of breaths taken by a patient in a minute) to not be monitored during the period while Patient 2 was in physical restraints (when a person or persons is/are physically holding a patient to restrict the patient’s movement), and in the inability of the facility to account for Patient 7’s personal properties, safeguard the items brought to the facility by Patient 7’s family after she was admitted to the facility, and reconcile the list of Patient 7’s belongings upon Patient 7’s discharge from the facility.”

“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: 42512 Based on interview and record review, the facility failed to ensure care in a safe setting was provided, for three of eight sampled patients (Patients A, 2, and 7) when: 1. For Patient A, the facility document titled, “Clinical Opiate [opioid, a class of powerful prescription medications used to manage pain] Withdrawal Scale [COWS, a rating scale which quantifies the severity of opioid withdrawal (the physical and mental reaction that occurs when someone stops or reduces heavy, long-term use of opioid drugs), with a score of zero to five meaning no active or very mild withdrawal symptoms, a score of five to 12 meaning mild, 13 to 24 meaning moderate, 25 to 36 meaning moderately severe, and more than 36 meaning severe withdrawal symptoms],” was not completed for Patient A in accordance with the physician’s order and the facility’s policies and procedures (P&Ps); 2. For Patient A, the physician was not notified when Patient A had an abnormal oxygen saturation level (the oxygen level in the blood, normal is 95 to 100 percent); 3. For Patient A, the patient had a code blue (a facility code for an emergency event when a patient’s breathing and/or pulse stops) and the code blue record was not completed; 4. For Patient A, trazodone (a medication to treat depression [mood disorder characterized by persistent feelings of sadness], and causes drowsiness) was administered routinely (on a regular schedule) when it was ordered to be administered as needed (PRN); 5. For Patient 2, the facility document titled, “Restraint/Seclusion Packet,” was not completed; and 6. For Patient 7, the facility document titled, “Belongings List,” was not completed when the patient was admitted to, during admission and discharged from the facility. These failures could have compromised Patients A’s health, may result in delay of care, and may have contributed to Patient A’s death, in Patient 2’s assessment to not be conducted and the respiratory rate (the number of breaths taken by a patient in a minute) to not be monitored during the period while Patient 2 was in physical restraints (when a person or persons is/are physically holding a patient to restrict the patient’s movement), and in the inability of the facility to account for Patient 7’s personal properties, safeguard the items brought to the facility by Patient 7’s family after she was admitted to the facility, and reconcile the list of Patient 7’s belongings upon Patient 7’s discharge from the facility. Findings: 1. On November 7, 2025, at 10:10 a.m., a concurrent interview and review of Patient A’s record were conducted with the Director of Performance Improvement and Risk Management (DOP). A facility document titled, “History & [and] Physical,” dated October 30, 2025, was reviewed. The document indicated Patient A was admitted for Oxycontin (a brand name of oxycodone, an opioid) detoxification (the process of clearing of toxins from the body of the patient who is acutely intoxicated and/or dependent on substances of abuse). The document indicated Patient A had a past medical history of opioid use disorder (a complex illness characterized by compulsive use of opioid drugs even when the person wants to stop), alcohol use disorder (the compulsion to use alcohol and the inability to control and stop the use of alcohol), smoking, obesity, and right pterygium (a noncancerous, raised, growth on the surface of the eye). A facility document titled, “INITIAL PSYCHIATRIC EVALUATION,” dated October 31, 2025, was reviewed. The document indicated Patient A had no significant past medical history and wanted to be admitted for detoxification from oxycodone addiction. The document indicated, “...INITIAL PLAN OF CARE...COWS protocol...Q [every] 4 [four] Hr [hours]...” A facility document titled, “HIGH RISK NOTIFICATION FORM,” dated October 30, 2025, was reviewed. The document indicated an order for COWS protocol. A facility document titled, “Medication Orders & Prior Medication Reconciliation,” dated October 30, 2025, was reviewed. The document indicated, “...Date started 10/30/25 [October 30, 2025]...Medication...Subutex [a medication which acts like a substitute opioid by tricking the brain into feeling satisfied enough to prevent the symptoms and discomfort of opioid withdrawal]...dose...4 mg [milligrams, unit of measurement]...route...SL [administered under the tongue]...freq [frequency]...Q 4 Hr PRN...COWS Protocol for 48 hours....” A facility document titled, “Progress Notes,” dated November 1, 2025, at 4:44 a.m., was reviewed. The document indicated, “...BHA [Behavioral Health Associate, a specialized healthcare professional who supports individuals with mental health, emotional, or behavioral issues by providing direct care, monitoring progress, and assisting with treatment plans] loudly called ‘code blue [room number]!’ RN [Registered Nurse] charge, RN med [medication, RN who is assigned to administer medications to the patients] nurse, and floor RN [RN who monitors patients in the unit] immediately rushed to room. Supervisor who was on floor at time also rushed to code [room where the code blue was called for]. Staff immediately did a sternum rub [vigorous rubbing of the knuckles of a closed fist vertically up and down the center of the patient’s breastbone to check on the patient’s responsiveness) and checked pulse. House supervisor [an RN who acts as the administrative leader for the entire facility] immediately directed med nurse to page a Code Blue...staff started chest compressions [a critical, life-saving emergency procedure involving firm, rapid, and rhythmic pressure on the center of the chest to revive a patient]...paramedics arrived on scene and assumed control and directed all staff except RN charge nurse and supervisor to clear the room...Time of death called by first responders, paramedics and firefighters on scene...” A facility document titled, “Clinical Opiate Withdrawal Scale (COWS) - Score Sheet,” was reviewed. The document indicated: - On October 30, 2025, at 8 p.m., “...Blood Pressure [the force of blood pushing against the walls of the arteries [blood vessels carrying oxygenated blood) as the heart pumps it throughout the body, normal is 120/80]...Asleep...Resting Pulse Rate [the number of times the heart beats while a person is at rest]...Asleep...Total COWS Score...3...;” - On October 30, 2025, at 10 p.m., “...Blood Pressure...Asleep...Resting Pulse Rate...Asleep...Total COWS Score...3...;” -On October 31, 2025, at 12 a.m., “...Blood Pressure...Asleep...Resting Pulse Rate...Asleep...Total COWS Score...2...;” and - On November 1, 2025, at 12 a.m., “...Blood Pressure...Asleep...Resting Pulse Rate...Asleep... Total COWS Score...3...” There was no documented evidence Patient A had a COWS score assessed and completed on November 1, 2025, at 4 a.m. On November 7, 2025, at 10:50 a.m., a concurrent interview and review of Patient A’s record were conducted with RN House Supervisor (RN) 1. RN 1 stated Patient A was on COWS Protocol because he was withdrawing from opioids. RN 1 stated the COWS gives a numerical score and based on that number, a patient will be administered medication such as Subutex. RN 1 stated a COWS assessment is completed every four hours and includes a patient’s blood pressure and pulse, and should have been completed on November 1, 2025, at 4 a.m., prior to Patient A coding (when a patient is experiencing a critical, life-threatening situation) at 4:44 a.m. On November 7, 2025, at 11:45 a.m., a concurrent interview and review of Patient A’s record were conducted with RN House Supervisor (RN) 2. RN 2 stated Patient A was on COWS protocol every four hours which includes blood pressure and pulse. RN 2 further stated, COWS assessment was not completed on for Patient A on November 1, 2025, at 4 a.m., and the facility’s P&P was not followed. On November 7, 2025, at 2:20 p.m., a concurrent interview and review of Patient A’s record were conducted with the DOP. The DOP stated the COWS scoring should have been completed every four hours for Patient A and the score should have been documented on November 1, 2025, at 4 a.m., and this was not done. On November 13, 2025, at 3:40 p.m., an interview was conducted with RN 3. RN 3 stated Patient A was “detoxing [abstaining from or rid the body of opioid substances] and was on COWS protocol. RN 3 stated if a patient refuses to be awoken so that the COWS assessment could be conducted, the patient’s physician must be notified. RN 3 stated detoxing patients need frequent observation for respiratory depression (a dangerous condition where breathing becomes too slow or shallow) and seizures (convulsion, uncontrolled shaking of the body that occurs when a person abruptly stops or significantly cuts back their use of an addictive substance). On November 14, 2025, at 7:40 p.m., an interview was conducted with Charge Nurse (RN) 4. RN 4 stated COWS provides a baseline for the patient’s withdrawal experience and is crucial to manage symptoms and prevent deterioration. RN 4 stated blood pressure and pulse are necessary assessments to complete COWS. RN 4 stated Patient 4 should have had a COWS assessment every four hours. On November 17, 2025, at 11:55 a.m., an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated Patient A was on COWS, which requires blood pressure and pulse checks every four hours, or as ordered by the physician. The CNO stated, if the patient is asleep and does not want to be awaken to have COWS assessment completed, the physician must be notified and new physician orders should be obtained, and this was not done. The CNO confirmed the COWS was not completed for Patient A on November 1, 2025, at 4 a.m., and it should have been completed. On November 17, 2025, at 3:10 p.m., an interview was conducted with Physician (MD) 1. MD 1 stated Patient A was admitted for oxycodone detoxification. MD 1 stated the patient’s blood pressure and pulse must be monitored during COWS assessment. MD 1 stated the physician needs to be informed if a patient refuses to wake up for a COWS assessment. MD 1 stated he was not notified about Patient A’s refusal for a COWS assessment. A review of the facility’s P&P titled, “Clinical Opiate Withdrawal Scale (COWS) Procedure,” dated December, 2021, was reviewed. The P&P indicated, “...The Clinical Opiate Withdrawal Scale (COWS) is designed to be an objective rating scale composed of ten criteria associated with opiate withdrawal. It is a well validated tool which provides detailed and evidence-based measures for opiate withdrawal status...All patients are assessed upon admission for substance abuse history. Patients admitted for detoxification off of opiates will be assessed for withdrawal symptoms utilizing the COWS. If it is determined that patient is to be placed on opioid detox protocol, will be assessed q4 [every four] hours for 48 hours and/or until discontinued per MD. Should the patient experience increased symptoms between assessments, the nurse may complete an additional COWs and contact the MD if score indicates increase in withdrawal symptoms and need for additional orders...For patients admitted for opioid detox, the COWS will be re-administered q 4 hours (4a [4 a.m.], 8a [8 a.m.], 12n [12 noon], 4p [4 p.m.], 8p [8 p.m.] and 12p [12 p.m.]) for 48 hours and/or until discontinued by a physician...” 2. On November 7, 2025, at 10:10 a.m., a concurrent interview and review of Patient A’s record were conducted with the Director of Performance Improvement and Risk Management (DOP). A facility document titled, “GRAPHIC SHEET,” dated October 31, 2025, was reviewed. The document indicated, “...Time...0600 [6 a.m.]...O2 Sat [oxygen saturation]...90 % [percent]...” There was no documented evidence that the physician was notified of Patient A’s O2 Sat level of 90% on October 31, 2025, at 6 a.m. On November 10, 2025, at 1:45 p.m., an interview was conducted with BHA 1. BHA 1 stated, on November 1, 2025, he completed every 15 minute rounding (a patient observation protocol where staff members visually check on a patient every 15minutes) on Patient A. BHA 1 stated, at approximately 4:45 a.m., he noted Patient A was not breathing. BHA 1 stated Patient A was typically a loud snorer and heavy breather and he did not hear any breathing nor observe a rise and fall of Patient A’s chest. BHA 1 stated he attempted to wake Patient A but was not successful, then he ran to the nurses’ station to initiate a code blue. BHA 1 stated he recalled Patient A’s O2 Sat level on October 31, 2025, at 6 a.m., was 90% which he considered low and this was reported to the RN. On November 13, 2025, at 3:40 p.m., an interview was conducted with RN 3. RN 3 stated on October 31, 2025, at 6 a.m., Patient A’s O2 Sat was 90%, which is considered a low value. RN 3 stated, because Patient A was not in distress, he alerted the day shift (7 a.m. to 7 p.m.) RN and made a copy of the document indicating Patient A’s O2 Sat of 90% for the physician. RN 3 stated Patient A told him his (Patient A’s) O2 Sat was low due to being a long-time smoker with chronic obstructive pulmonary disease (COPD, a progressive lung disease). RN 3 stated he did not notify the physician of Patient A’s O2 Sat of 90% on October 31, 2025, at 6 a.m. On November 14, 2025, at 7:40 p.m., an interview was conducted with Charge nurse (RN) 4. RN 4 stated on October 31, 2025, at 6 a.m., when Patient A’s O2 Sat was 90%, the physician should have been notified. RN 4 stated the physician was not notified of Patient A’s change in condition on October 31, 2025, at 6 a.m. On November 17, 2025, at 11:55 a.m., an interview was conducted with the CNO. The CNO stated an O2 Sat of 90% is abnormal and should have been reported to the physician. On November 17, 2025, at 3:10 p.m., an interview was conducted with MD 1. MD 1 stated an O2 Sat of 90% should be reported to the physician. MD 1 stated he was not notified when Patient A’s O2 Sat was 90% on October 31, 2025, at 6 a.m., or that the patient had a history of COPD. On November 17, 2025, at 4 p.m., an interview was conducted with MD 2. MD 2 stated an O2 Sat of 90% should be reported to the physician. MD 1 further stated he was not notified when Patient A’s O2 Sat was 90% on October 31, 2025, at 6 a.m., or that the patient had a history of COPD. A review of the facility P&P, titled, “CHANGE IN CONDITION,” dated April, 2023, was conducted. The P&P indicated, “...Registered Nurse will provide assessment date to the physician/covering practitioner who will then give orders for treatment or additional assessment...Any concerns regarding the patient’s medical condition where nursing staff believes a delay may cause a negative outcome...” 3. On November 7, 2025, at 10:10 a.m., a concurrent interview and review of Patient A’s record were conducted with the Director of Performance Improvement and Risk Management (DOP). A facility document titled, “CODE BLUE RECORD,” authored by RN 1, dated November 7, 2025, at 2 p.m., was reviewed. The document indicated, “...Date of Event: 11/1/25 [November 1, 2025]...Time of Event...0444 [4:44 a.m.]...Description of Event...pt [Patient A] found unresponsive...Code Blue Called...Compressions [chest compression] Started...Patient assessment...no pulse...” On November 17, 2025, at 11:55 a.m., an interview was conducted with the CNO. The CNO stated the Code Blue Record should have been completed on November 1, 2025 in real time, and this was not done. The CNO stated the Code Blue Record should have been used as a guide to run the code blue. A review of the facility’s P&P titled, “Code Blue,” dated May, 2025, was conducted. The P&P indicated, “...Staff identifying the non-responsive patient will determine absence of pulse or respirations and call loudly for help by shouting ‘Code Blue.’ When a medical emergency exists that involves any patient, staff, or visitor, a code blue should be announced...The code blue event will be documented on the Code Blue Record and placed in the medical record when completed...” 4. On November 7, 2025, at 10:10 a.m., a concurrent interview and review of Patient A’s record were conducted with the Director of Performance Improvement and Risk Management (DOP). A facility document titled, “PRACTITIONER ORDER SHEET [Name of Facility] DETOX [detoxification, the process of removing toxic substances from the blood] ORDERS,” was reviewed. The document indicated, “...COWS DETOX PRN ORDERS...Date Order Written: Oct 30 2025 [October 30, 2025]...Trazodone 100 mg PO [by mouth] QHS [at bedtime]...Indication/Rationale...Insomnia [inability to fall asleep]...” The facility document titled, “MEDICATION ADMINISTRATION RECORD,” dated October 31, 2025, was reviewed. The document indicated, “...TRAZODONE TAB [tablet]...100 mg...PO...QHS [at bedtime]...GIVE 1 [one] TAB PO Q HS...” A facility document titled, “Medication Administration Record,” was reviewed. The document, “...DRUG - DOSE - ROUTE - FREQUENCY...10/30/2025 [October 30, 2025]...DESYREL [a brand name for trazadone] Tab [Tablet] 100 mg [milligram, unit of measurement]...PO QHS...TRAZADONE...2100 [9 p.m.]...[initials of staff who administered medication]...” The document further indicated, “...DRUG - DOSE - ROUTE - FREQUENCY...10/31/2025 [October 31, 2025]...DESYREL Tab 100 mg...PO QHS...TRAZADONE...2100...[initials of staff who administered medication]...” The document indicated trazadone was administered to Patient A every bedtime on October 30, 2025, and October 31, 2025. There was no documented evidence trazadone was ordered to be administered every bedtime to Patient A. On November 17, 2025, at 3:10 p.m., an interview was conducted with MD 1. MD 1 stated the trazodone was ordered by him and should have been administered if needed for sleep for Patient A and should not have been administered every bedtime to the patient. On November 19, 2025, at 10:35 a.m., an interview was conducted with Pharmacist (PHARM) 1. PHARM 1 stated trazodone was entered on the MAR record as routine to be administered to Patient A at bedtime every night at 9 p.m. PHARM 1 further stated trazodone was a routine medication ordered for Patient A and was not placed on the MAR as PRN as ordered by the physician. A review of the facility’s P&P titled, “NEW ORDER HANDLING,” dated May, 2019, was conducted. The P&P indicated, “...The medication order is checked (approved) by the RPH [Registered Pharmacist] for appropriateness of drug, dose, frequency, and route of administration...” 5. On January 27, 2026, at 1:41 p.m., a review of Patient 2’s record and concurrent interview were conducted with the Director of Quality (DQ). A facility document titled, “Initial Psychiatric Evaluation,” dated December 17, 2025, at 8:55 p.m., was reviewed. The document indicated Patient 2 was admitted to the facility on December 16, 2025, for being naked, lying in the street, and trying to get hit by a car. A facility document titled, “SECLUSION/RESTRAINT PACKET,” dated December 17, 2025, was reviewed. The document indicated, “...PRACTITIONER ORDER...Seclusion...Threat to immediate physical safety of others...Maximum Duration...Seclusion 4 hours adults 18 and over...Criteria for Release...No longer an immediate physical threat to others...12/17/2025 [December 17, 2025]...0024...[12:24 a.m.]...” Another facility document titled, “SECLUSION/RESTRAINT PACKET,” dated December 17, 2025, was reviewed. The document indicated, “...SECLUSION RESTRAINT RN ASSESSMENT...Physical Restraint...Time 0015 [12:15 a.m.]...RELEASE FROM SECLUSION/RESTRAINT...12/17/25 [December 17, 2025]...Physical Restraint...Time in [time restraint was initiated]...0015...[12:15 a.m.]Time Out [time restraint was released] 0022 [12:22 a.m.]...Behavior...D...Cursing...G...Kicking...O...Disrobing...Intervention...2 [two]...Release criteria discussed...3 [three]...Fluids offered...6 [six]...Discontinue restraint...Document MINIMUM...[every] 15 minutes...0015...D, G...2, 3...0022...O, G...2, 6...Staff Name [no information was documented]...Initials...[no information was documented]...” There was no documented evidence Patient 2’s respiratory rate (the number of a person’s breath per minute) was monitored. There was no documented evidence Patient 2 was monitored continuously for the full 15 minutes during the period when Patient 2 was in physical restraints. Additionally, there was no documented evidence staff member who completed the facility document titled, “Seclusion/Restraint Packet,” for Patient 2 on December 17, 2025, was identified. On January 28, 2026, an interview and concurrent review of Patient 2’s record were conducted with Registered Nurse (RN) 5. RN 5 stated the seclusion/restraint packet that needs to be filled out by staff is comprised of seven pages and needs to be filled out completely. RN 5 stated the RN must monitor the physically restrained patients for a full 15 minutes and must document the assessment on page six of the packet. RN 5 stated Patient 2’s restraint packet on December 17, 2025, was incomplete as the RN only documented for seven minutes and not the full 15 minutes. RN 5 stated the RN should have printed their name and initialed the facility document titled, “Seclusion/Restraint Packet,” and the RN did not perform this. RN 5 stated Patient 2 could have refused vital signs to be taken but the RN could have at least assessed the patient’s respiratory rate. A review of the facility’s P&P titled, “DOCUMENTATION PROTOCOL,” dated December 2023, was conducted. The P&P indicated, “...Facility records, reports, charts and documents are to be accurate, truthful, timely, and complete...All patient medical record entries are to be...legible, complete, dated, timed and authenticated in written or electronic form...” A review of the facility’s P&P titled, “Seclusion and Restraint of Patient,” dated October 2022, was conducted. The document indicated, “...Vital signs are to be completed immediately after restraints are applied or when placed in seclusion...Seclusion episode will be documented on the Restraint/Seclusion Packet, which includes the following forms...Restraint/Seclusion Practitioner Order, Face-to-Face Assessment, RN Restraint/Seclusion Assessment, Restraint/Seclusion Progress Note, Restraint/Seclusion Flow sheet, and Patient Debriefing...All patients in restraint or seclusion are assessed and their needs addressed by a Registered Nurse at the initiation of restraint or seclusion and every 15 minutes thereafter...” 6. On January 29, 2026, at 10:33 a.m., Patient 7’s record was reviewed with the Director of Quality (DQ). A facility document titled, “History and Physical,” dated December 14, 2025, at 9:50 p.m., was reviewed. The document indicated, “...Chief Complaint: Depression [a mood disorder with feelings of sadness]...Assessment and Plan: MDD [major depressive disorder, a clinical condition where a person experiences ongoing and persistent feeling of sadness or loss of interest]...” A facility document titled, “APPLICATION FOR ASSESSMENT, EVALUATION, AND CRISIS INTERVENTION FOR PLACEMENT FOR EVALUATION AND TREATMENT,” dated December 13, 2025, at 4:21 a.m., was reviewed. The document indicated, “...Consumer [Patient 7] hasn’t been taking Cymbalta [a medication to treat MDD] for two 2 [two] weeks. She [Patient 7] said she has plan to write goodbye letters to family. Consumer [Patient 7] stated, “It’s better that I’m not here and I wish I wasn’t living anymore.” Consumer [Patient 7] is unable to keep self safe. She does not trust herself...” A facility document titled, “...BELONGINGS LIST,” dated December 13, 2025, at 1:20 [the document did not indicate if it was a.m. or p.m.], was reviewed. The document indicated there were no entries made on the following, “...REMAINING WITH PATIENT...Quality...Color...Description...Location...Patient Contraband Safe...Received Date...Initial...Return Date...Initial...Disposition/Release of Property...Signature of Patient/Family/Legal Representative...Date...Time...” There was no documented evidence an inventory of Patient 7’s belongings was conducted on and during Patient 7’s admission to the facility, and upon Patient 7’s discharge from the facility. There was no documented evidence Patient 7’s [label of commercially manufactured athletic pair of pants] brought in by a family on December 13, 2025, was inventoried, secured, logged, or returned to Patient 7 when Patient 7 was discharged from the facility. There was no documented evidence the BHA inventoried, secured, logged, or reconciled Patient 7’s belongings from December 13, 2025, through December 17, 2025. On January 29, 2026, at 1:37 p.m., an interview and review of Patient 7’s record were conducted with the DQ. The DQ stated the Belonging Drop-Off Log for the month of December had been discarded. The DQ further stated, “I do not have the log to show what belongings were dropped off for this patient after admission.” On January 29, 2026, at 1:46 p.m., an interview and record review was conducted with BHA 2. BHA 2 stated the patient belongings list was not completed for Patient 7. BHA 2 stated the BHA is expected to document on the belongings list all items the patient brings into the facility at the time of a patient’s admission to the facility, as well as the items brought in by patient’s family and friends after the patient’s admission to the facility. BHA 2 stated upon the patient’s discharge, the BHA is expected to itemize all returned belongings and sign and date the belongings list once the items are returned to the patient. A review of the facility’s P&P titled, “Patient Belongings and Contraband,” dated October 2022, was conducted. The document indicated, “...It is the responsibility of all [Name of facility] employees to ensure patient belongings are secured safely...All patient’s property will be examined to determine if the property is appropriate and safe for the patient to have during the day. All items are logged onto the Patient Property/Clothing List and/or Patient Valuable envelope...All belongings brought to the unit should be inventoried with the patient present...All items are listed on the patient’s belonging list...Staff members checks disposition of each item. (Patient, Contraband, Safe)...The patient and staff members both sign that the list is accurate...Valuable items are inventoried on the valuable’s envelope. The patient and staff witness sign the envelope. The items are placed in the envelope and staff member takes reinventory to be sure all items listed are in the envelope. At that time the envelope is sealed and placed in the safe...Any items brought in after admission, by visitor are noted on the belonging log at reception. When the Staff comes to pick up the items, they sign the log showing the date and time they retrieved the items. The staff member then adds any new items to the belonging list. Noting the date that they are added...Just prior to patient to [sic] leaving the assigned staff will obtain the patients belongings from contraband room and hygiene box. The staff member will review and be sure the patient receives all items. The patient will sign the belonging list verifying they received those items...” A review of the facility’s P&P titled, “DOCUMENTATION PROTOCOL,” dated December 2023, was conducted. The P&P indicated, “...Facility records, reports, charts and documents are to be accurate, truthful, timely, and complete...All patient medical record entries are to be...legible, complete, dated, timed and authenticated in written or electronic form...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 42512 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for three of eight sampled patients (Patients A, 2 and 7), when: 1a. For Patient A, the facility document titled, “Clinical Opiate [opioid, a class of powerful prescription medications used to manage pain] Withdrawal Scale [COWS, a rating scale which quantifies the severity of opioid withdrawal (the physical and mental reaction that occurs when someone stops or reduces heavy, long-term use of opioid drugs), with a score of zero to five meaning no active or very mild withdrawal symptoms, a score of five to 12 meaning mild, 13 to 24 meaning moderate, 25 to 36 meaning moderately severe, and more than 36 meaning severe withdrawal symptoms],” was not completed for Patient A in accordance with the physician’s order and the facility’s policies and procedures (P&Ps); 1b. For Patient A, the physician was not notified when Patient A had an abnormal oxygen saturation level (the oxygen level in the blood, normal is 95 to 100 percent) (Refer to A-398); 1c. For Patient A, the patient had a code blue (a facility code for an emergency event when a patient’s breathing and/or pulse stops) and the code blue record was not completed; 1d. For Patient A, trazodone (a medication to treat depression [mood disorder characterized by persistent feelings of sadness], and causes drowsiness) was administered routinely (to be administered on a regular, recurring basis) when it was ordered to be administered as needed (PRN). These failures had the potential to impact the care and treatment of Patient A and may have contributed to Patient A’s death; 2. For Patient 2, the facility document titled, “Restraint/Seclusion Packet,” was not completed; and 3. For Patient 7, the facility document titled, “Belongings List,” was not completed when the patient was admitted to, during admission and discharged from the facility. These failures could have compromised Patients A’s health, may result in delay of care, and may have contributed to Patient A’s death, in Patient 2’s assessment to not be conducted and the respiratory rate (the number of breaths taken by a patient in a minute) to not be monitored during the period while Patient 2 was in physical restraints (when a person or persons is/are physically holding a patient to restrict the patient’s movement), and in the inability of the facility to account for Patient 7’s personal properties, safeguard the items brought to the facility by Patient 7’s family after she was admitted to the facility, and reconcile the list of Patient 7’s belongings upon Patient 7’s discharge from the facility. Findings: 1. On November 7, 2025, at 10:10 a.m., a concurrent interview and review of Patient A’s record were conducted with the Director of Performance Improvement and Risk Management (DOP). A facility document titled, “History & [and] Physical,” dated October 30, 2025, was reviewed. The document indicated Patient A was admitted for Oxycontin (a brand name of oxycodone, an opioid) detoxification (the process of clearing of toxins from the body of the patient who is acutely intoxicated and/or dependent on substances of abuse). The document indicated Patient A had a past medical history of opioid use disorder (a complex illness characterized by compulsive use of opioid drugs even when the person wants to stop), alcohol use disorder (the compulsion to use alcohol and the inability to control and stop the use of alcohol), smoking, obesity, and right pterygium (a noncancerous, raised, growth on the surface of the eye). A facility document titled, “INITIAL PSYCHIATRIC EVALUATION,” dated October 31, 2025, was reviewed. The document indicated Patient A had no significant past medical history and wanted to be admitted for detoxification from oxycodone addiction. The document indicated, “...INITIAL PLAN OF CARE...COWS protocol...Q [every] 4 [four] Hr [hours]...” A facility document titled, “HIGH RISK NOTIFICATION FORM,” dated October 30, 2025, was reviewed. The document indicated an order for COWS protocol. A facility document titled, “Medication Orders & Prior Medication Reconciliation,” dated October 30, 2025, was reviewed. The document indicated, “...Date started 10/30/25 [October 30, 2025]...Medication...Subutex [a medication which acts like a substitute opioid by tricking the brain into feeling satisfied enough to prevent the symptoms and discomfort of opioid withdrawal]...dose...4 mg [milligrams, unit of measurement]...route...SL [administered under the tongue]...freq [frequency]...Q 4 Hr PRN...COWS Protocol for 48 hours....” A facility document titled, “Progress Notes,” dated November 1, 2025, at 4:44 a.m., was reviewed. The document indicated, “...BHA [Behavioral Health Associate, a specialized healthcare professional who supports individuals with mental health, emotional, or behavioral issues by providing direct care, monitoring progress, and assisting with treatment plans] loudly called ‘code blue [room number]!’ RN [Registered Nurse] charge, RN med [medication, RN who is assigned to administer medications to the patients] nurse, and floor RN [RN who monitors patients in the unit] immediately rushed to room. Supervisor who was on floor at time also rushed to code [room where the code blue was called for]. Staff immediately did a sternum rub [vigorous rubbing of the knuckles of a closed fist vertically up and down the center of the patient’s breastbone to check on the patient’s responsiveness) and checked pulse. House supervisor [an RN who acts as the administrative leader for the entire facility] immediately directed med nurse to page a Code Blue...staff started chest compressions [a critical, life-saving emergency procedure involving firm, rapid, and rhythmic pressure on the center of the chest to revive a patient]...paramedics arrived on scene and assumed control and directed all staff except RN charge nurse and supervisor to clear the room...Time of death called by first responders, paramedics and firefighters on scene...” a. A facility document titled, “Clinical Opiate Withdrawal Scale (COWS) - Score Sheet,” was reviewed. The document indicated: - On October 30, 2025, at 8 p.m., “...Blood Pressure [the force of blood pushing against the walls of the arteries [blood vessels carrying oxygenated blood) as the heart pumps it throughout the body, normal is 120/80]...Asleep...Resting Pulse Rate [the number of times the heart beats while a person is at rest]...Asleep...Total COWS Score...3...;” - On October 30, 2025, at 10 p.m., “...Blood Pressure...Asleep...Resting Pulse Rate...Asleep...Total COWS Score...3...;” -On October 31, 2025, at 12 a.m., “...Blood Pressure...Asleep...Resting Pulse Rate...Asleep...Total COWS Score...2...;” and - On November 1, 2025, at 12 a.m., “...Blood Pressure...Asleep...Resting Pulse Rate...Asleep... Total COWS Score...3...” There was no documented evidence Patient A had a COWS score assessed and completed on November 1, 2025, at 4 a.m. On November 7, 2025, at 10:50 a.m., a concurrent interview and review of Patient A’s record were conducted with RN House Supervisor (RN) 1. RN 1 stated Patient A was on COWS Protocol because he was withdrawing from opioids. RN 1 stated the COWS gives a numerical score and based on that number, a patient will be administered medication such as Subutex. RN 1 stated a COWS assessment is completed every four hours and includes a patient’s blood pressure and pulse, and should have been completed on November 1, 2025, at 4 a.m., prior to Patient A coding (when a patient is experiencing a critical, life-threatening situation) at 4:44 a.m. On November 7, 2025, at 11:45 a.m., a concurrent interview and review of Patient A’s record were conducted with RN House Supervisor (RN) 2. RN 2 stated Patient A was on COWS protocol every four hours which includes blood pressure and pulse. RN 2 further stated, COWS assessment was not completed on for Patient A on November 1, 2025, at 4 a.m., and the facility’s P&P was not followed. On November 7, 2025, at 2:20 p.m., a concurrent interview and review of Patient A’s record were conducted with the DOP. The DOP stated the COWS scoring should have been completed every four hours for Patient A and the score should have been documented on November 1, 2025, at 4 a.m., and this was not done. On November 13, 2025, at 3:40 p.m., an interview was conducted with RN 3. RN 3 stated Patient A was “detoxing [abstaining from or rid the body of opioid subsances] and was on COWS protocol. RN 3 stated if a patient refuses to be awoken so that the COWS assessment could be conducted, the patient’s physician must be notified. RN 3 stated detoxing patients needs frequent observation for respiratory depression (a dangerous condition where breathing becomes too slow or shallow) and seizures (convulsion, uncontrolled shaking of the body that occurs when a person abruptly stops or significantly cuts back their use of an addictive substance). On November 14, 2025, at 7:40 p.m., an interview was conducted with Charge Nurse (RN) 4. RN 4 stated COWS provides a baseline for the patient’s withdrawal experience and is crucial to manage symptoms and prevent deterioration. RN 4 stated blood pressure and pulse are necessary assessments to complete COWS. RN 4 stated Patient 4 should have had a COWS assessment every four hours. On November 17, 2025, at 11:55 a.m., an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated Patient A was on COWS, which requires blood pressure and pulse checks every four hours, or as ordered by the physician. The CNO stated, if the patient is asleep and does not want to be awaken to have COWS assessment completed, the physician must be notified and new physician orders should be obtained, and this was not done. The CNO confirmed the COWS was not completed for Patient A on November 1, 2025, at 4 a.m., and it should have been completed. On November 17, 2025, at 3:10 p.m., an interview was conducted with Physician (MD) 1. MD 1 stated Patient A was admitted for oxycodone detoxification. MD 1 stated the patient’s blood pressure and pulse must be monitored during COWS assessment. MD 1 stated the physician needs to be informed if a patient refuses to wake up for a COWS assessment. MD 1 stated he was not notified about Patient A’s refusal for a COWS assessment. A review of the facility’s P&P titled, “Clinical Opiate Withdrawal Scale (COWS) Procedure,” dated December, 2021, was reviewed. The P&P indicated, “...The Clinical Opiate Withdrawal Scale (COWS) is designed to be an objective rating scale composed of ten criteria associated with opiate withdrawal. It is a well validated tool which provides detailed and evidence-based measures for opiate withdrawal status...All patients are assessed upon admission for substance abuse history. Patients admitted for detoxification off of opiates will be assessed for withdrawal symptoms utilizing the COWS. If it is determined that patient is to be placed on opioid detox protocol, will be assessed q4 [every four] hours for 48 hours and/or until discontinued per MD. Should the patient experience increased symptoms between assessments, the nurse may complete an additional COWs and contact the MD if score indicates increase in withdrawal symptoms and need for additional orders...For patients admitted for opioid detox, the COWS will be re-administered q 4 hours (4a [4 a.m.], 8a [8 a.m.], 12n [12 noon], 4p [4 p.m.], 8p [8 p.m.] and 12p [12 p.m.]) for 48 hours and/or until discontinued by a physician...” b. On November 7, 2025, at 10:10 a.m., a concurrent interview and review of Patient A’s record were conducted with the Director of Performance Improvement and Risk Management (DOP). A facility document titled, “GRAPHIC SHEET,” dated October 31, 2025, was reviewed. The document indicated, “...Time...0600 [6 a.m.]...O2 Sat [oxygen saturation]...90 % [percent]...” There was no documented evidence that the physician was notified of Patient A’s O2 Sat level of 90% on October 31, 2025, at 6 a.m. On November 10, 2025, at 1:45 p.m., an interview was conducted with BHA 1. BHA 1 stated, on November 1, 2025, he completed every 15 minute rounding (a patient observation protocol where staff members visually check on a patient every 15minutes) on Patient A. BHA 1 stated, at approximately 4:45 a.m., he noted Patient A was not breathing. BHA 1 stated Patient A was typically a loud snorer and heavy breather and he did not hear any breathing nor observe a rise and fall of Patient A’s chest. BHA 1 stated he attempted to wake Patient A but was not successful, then he ran to the nurses’ station to initiate a code blue. BHA 1 stated he recalled Patient A’s O2 Sat level on October 31, 2025, at 6 a.m., was 90% which he considered low and this was reported to the RN. On November 13, 2025, at 3:40 p.m., an interview was conducted with RN 3. RN 3 stated on October 31, 2025, at 6 a.m., Patient A’s O2 Sat was 90%, which is considered a low value. RN 3 stated, because Patient A was not in distress, he alerted the day shift (7 a.m. to 7 p.m.) RN and made a copy of the document indicating Patient A’s O2 Sat of 90% for the physician. RN 3 stated Patient A told him his (Patient A’s) O2 Sat was low due to being a long-time smoker with chronic obstructive pulmonary disease (COPD, a progressive lung disease). RN 3 stated he did not notify the physician of Patient A’s O2 Sat of 90% on October 31, 2025, at 6 a.m. On November 14, 2025, at 7:40 p.m., an interview was conducted with Charge nurse (RN) 4. RN 4 stated on October 31, 2025, at 6 a.m., when Patient A’s O2 Sat was 90%, the physician should have been notified. RN 4 stated the physician was not notified of Patient A’s change in condition on October 31, 2025, at 6 a.m. On November 17, 2025, at 11:55 a.m., an interview was conducted with the CNO. The CNO stated an O2 Sat of 90% is abnormal and should have been reported to the physician. On November 17, 2025, at 3:10 p.m., an interview was conducted with MD 1. MD 1 stated an O2 Sat of 90% should be reported to the physician. MD 1 stated he was not notified when Patient A’s O2 Sat was 90% on October 31, 2025, at 6 a.m., or that the patient had a history of COPD. On November 17, 2025, at 4 p.m., an interview was conducted with MD 2. MD 2 stated an O2 Sat of 90% should be reported to the physician. MD 1 further stated he was not notified when Patient A’s O2 Sat was 90% on October 31, 2025, at 6 a.m., or that the patient had a history of COPD. A review of the facility P&P, titled, “CHANGE IN CONDITION,” dated April, 2023, was conducted. The P&P indicated, “...Registered Nurse will provide assessment date to the physician/covering practitioner who will then give orders for treatment or additional assessment...Any concerns regarding the patient’s medical condition where nursing staff believes a delay may cause a negative outcome...” c. On November 7, 2025, at 10:10 a.m., a concurrent interview and review of Patient A’s record were conducted with the Director of Performance Improvement and Risk Management (DOP). A facility document titled, “CODE BLUE RECORD,” authored by RN 1, dated November 7, 2025, at 2 p.m., was reviewed. The document indicated, “...Date of Event: 11/1/25 [November 1, 2025]...Time of Event...0444 [4:44 a.m.]...Description of Event...pt [Patient A] found unresponsive...Code Blue Called...Compressions [chest compression] Started...Patient assessment...no pulse...” On November 17, 2025, at 11:55 a.m., an interview was conducted with the CNO. The CNO stated the Code Blue Record should have been completed on November 1, 2025 in real time, and this was not done. The CNO stated the Code Blue Record should have been used as a guide to run the code blue. A review of the facility’s P&P titled, “Code Blue,” dated May, 2025, was conducted. The P&P indicated, “...Staff identifying the non-responsive patient will determine absence of pulse or respirations and call loudly for help by shouting ‘Code Blue.’ When a medical emergency exists that involves any patient, staff, or visitor, a code blue should be announced...The code blue event will be documented on the Code Blue Record and placed in the medical record when completed...” d. On November 7, 2025, at 10:10 a.m., a concurrent interview and review of Patient A’s record were conducted with the Director of Performance Improvement and Risk Management (DOP). A facility document titled, “PRACTITIONER ORDER SHEET [Name of Facility] DETOX [detoxification, the process of removing toxic substances from the blood] ORDERS,” was reviewed. The document indicated, “...COWS DETOX PRN ORDERS...Date Order Written: Oct 30 2025 [October 30, 2025]...Trazodone 100 mg PO [by mouth] QHS [at bedtime]...Indication/Rationale...Insomnia [inability to fall asleep]...” The facility document titled, “MEDICATION ADMINISTRATION RECORD,” dated October 31, 2025, was reviewed. The document indicated, “...TRAZODONE TAB [tablet]...100 mg...PO...QHS [at bedtime]...GIVE 1 [one] TAB PO Q HS...” A facility document titled, “Medication Administration Record,” was reviewed. The document, “...DRUG - DOSE - ROUTE - FREQUENCY...10/30/2025 [October 30, 2025]...DESYREL [a brand name for trazadone] Tab [Tablet] 100 mg [milligram, unit of measurement]...PO QHS...TRAZADONE...2100 [9 p.m.]...[initials of staff who administered medication]...” The document further indicated, “...DRUG - DOSE - ROUTE - FREQUENCY...10/31/2025 [October 31, 2025]...DESYREL Tab 100 mg...PO QHS...TRAZADONE...2100...[initials of staff who administered medication]...” The document indicated trazadone was administered to Patient A every bedtime on October 30, 2025, and October 31, 2025. There was no documented evidence trazadone was ordered to be administered every bedtime to Patient A. On November 17, 2025, at 3:10 p.m., an interview was conducted with MD 1. MD 1 stated the trazodone was ordered by him and should have been administered if needed for sleep for Patient A and should not have been administered every bedtime to the patient. On November 19, 2025, at 10:35 a.m., an interview was conducted with Pharmacist (PHARM) 1. PHARM 1 stated trazodone was entered on the MAR record as routine to be administered to Patient A at bedtime every night at 9 p.m. PHARM 1 further stated trazodone was a routine medication ordered for Patient A and was not placed on the MAR as PRN as ordered by the physician. A review of the facility’s P&P titled, “NEW ORDER HANDLING,” dated May, 2019, was conducted. The P&P indicated, “...The medication order is checked (approved) by the RPH [Registered Pharmacist] for appropriateness of drug, dose, frequency, and route of administration...” 2. On January 27, 2026, at 1:41 p.m., a review of Patient 2’s record and concurrent interview were conducted with the Director of Quality (DQ). A facility document titled, “Initial Psychiatric Evaluation,” dated December 17, 2025, at 8:55 p.m., was reviewed. The document indicated Patient 2 was admitted to the facility on December 16, 2025, for being naked, lying in the street, and trying to get hit by a car. A facility document titled, “SECLUSION/RESTRAINT PACKET,” dated December 17, 2025, was reviewed. The document indicated, “...PRACTITIONER ORDER...Seclusion...Threat to immediate physical safety of others...Maximum Duration...Seclusion 4 hours adults 18 and over...Criteria for Release...No longer an immediate physical threat to others...12/17/2025 [December 17, 2025]...0024...[12:24 a.m.]...” Another facility document titled, “SECLUSION/RESTRAINT PACKET,” dated December 17, 2025, was reviewed. The document indicated, “...SECLUSION RESTRAINT RN ASSESSMENT...Physical Restraint...Time 0015 [12:15 a.m.]...RELEASE FROM SECLUSION/RESTRAINT...12/17/25 [December 17, 2025]...Physical Restraint...Time in [time restraint was initiated]...0015...[12:15 a.m.]Time Out [time restraint was released] 0022 [12:22 a.m.]...Behavior...D...Cursing...G...Kicking...O...Disrobing...Intervention...2 [two]...Release criteria discussed...3 [three]...Fluids offered...6 [six]...Discontinue restraint...Document MINIMUM...[every] 15 minutes...0015...D, G...2, 3...0022...O, G...2, 6...Staff Name [no information was documented]...Initials...[no information was documented]...” There was no documented evidence Patient 2’s respiratory rate (the number of a person’s breath per minute) was monitored. There was no documented evidence Patient 2 was monitored continuously for the full 15 minutes during the period when Patient 2 was in physical restraints. Additionally, there was no documented evidence staff member who completed the facility document titled, “Seclusion/Restraint Packet,” for Patient 2 on December 17, 2025, was identified. On January 28, 2026, an interview and concurrent review of Patient 2’s record were conducted with Registered Nurse (RN) 5. RN 5 stated the seclusion/restraint packet that needs to be filled out by staff is comprised of seven pages and needs to be filled out completely. RN 5 stated the RN must monitor the physically restrained patients for a full 15 minutes and must document the assessment on page six of the packet. RN 5 stated Patient 2’s restraint packet on December 17, 2025, was incomplete as the RN only documented for seven minutes and not the full 15 minutes. RN 5 stated the RN should have printed their name and initialed the facility document titled, “Seclusion/Restraint Packet,” and the RN did not perform this. RN 5 stated Patient 2 could have refused vital signs to be taken but the RN could have at least assessed the patient’s respiratory rate. A review of the facility’s P&P titled, “DOCUMENTATION PROTOCOL,” dated December 2023, was conducted. The P&P indicated, “...Facility records, reports, charts and documents are to be accurate, truthful, timely, and complete...All patient medical record entries are to be...legible, complete, dated, timed and authenticated in written or electronic form...” A review of the facility’s P&P titled, “Seclusion and Restraint of Patient,” dated October 2022, was conducted. The document indicated, “...Vital signs are to be completed immediately after restraints are applied or when placed in seclusion...Seclusion episode will be documented on the Restraint/Seclusion Packet, which includes the following forms...Restraint/Seclusion Practitioner Order, Face-to-Face Assessment, RN Restraint/Seclusion Assessment, Restraint/Seclusion Progress Note, Restraint/Seclusion Flow sheet, and Patient Debriefing...All patients in restraint or seclusion are assessed and their needs addressed by a Registered Nurse at the initiation of restraint or seclusion and every 15 minutes thereafter...” 3. On January 29, 2026, at 10:33 a.m., Patient 7’s record was reviewed with the Director of Quality (DQ). A facility document titled, “History and Physical,” dated December 14, 2025, at 9:50 p.m., was reviewed. The document indicated, “...Chief Complaint: Depression [a mood disorder with feelings of sadness]...Assessment and Plan: MDD [major depressive disorder, a clinical condition where a person experiences ongoing and persistent feeling of sadness or loss of interest]...” A facility document titled, “APPLICATION FOR ASSESSMENT, EVALUATION, AND CRISIS INTERVENTION FOR PLACEMENT FOR EVALUATION AND TREATMENT,” dated December 13, 2025, at 4:21 a.m., was reviewed. The document indicated, “...Consumer [Patient 7] hasn’t been taking Cymbalta [a medication to treat MDD] for two 2 [two] weeks. She [Patient 7] said she has plan to write goodbye letters to family. Consumer [Patient 7] stated, “It’s better that I’m not here and I wish I wasn’t living anymore.” Consumer [Patient 7] is unable to keep self safe. She does not trust herself...” A facility document titled, “...BELONGINGS LIST,” dated December 13, 2025, at 1:20 [the document did not indicate if it was a.m. or p.m.], was reviewed. The document indicated there were no entries made on the following, “...REMAINING WITH PATIENT...Quality...Color...Description...Location...Patient Contraband Safe...Received Date...Initial...Return Date...Initial...Disposition/Release of Property...Signature of Patient/Family/Legal Representative...Date...Time...” There was no documented evidence an inventory of Patient 7’s belongings was conducted on and during Patient 7’s admission to the facility, and upon Patient 7’s discharge from the facility. There was no documented evidence Patient 7’s [label of commercially manufactured athletic pair of pants] brought in by a family on December 13, 2025, was inventoried, secured, logged, or returned to Patient 7 when Patient 7 was discharged from the facility. There was no documented evidence the BHA inventoried, secured, logged, or reconciled Patient 7’s belongings from December 13, 2025, through December 17, 2025. On January 29, 2026, at 1:37 p.m., an interview and review of Patient 7’s record were conducted with the DQ. The DQ stated the Belonging Drop-Off Log for the month of December had been discarded. The DQ further stated, “I do not have the log to show what belongings were dropped off for this patient after admission.” On January 29, 2026, at 1:46 p.m., an interview and record review was conducted with BHA 2. BHA 2 stated the patient belongings list was not completed for Patient 7. BHA 2 stated the BHA is expected to document on the belongings list all items the patient brings into the facility at the time of a patient’s admission to the facility, as well as the items brought in by patient’s family and friends after the patient’s admission to the facility. BHA 2 stated upon the patient’s discharge, the BHA is expected to itemize all returned belongings and sign and date the belongings list once the items are returned to the patient. A review of the facility’s P&P titled, “Patient Belongings and Contraband,” dated October 2022, was conducted. The document indicated, “...It is the responsibility of all [Name of facility] employees to ensure patient belongings are secured safely...All patient’s property will be examined to determine if the property is appropriate and safe for the patient to have during the day. All items are logged onto the Patient Property/Clothing List and/or Patient Valuable envelope...All belongings brought to the unit should be inventoried with the patient present...All items are listed on the patient’s belonging list...Staff members checks disposition of each item. (Patient, Contraband, Safe)...The patient and staff members both sign that the list is accurate...Valuable items are inventoried on the valuable’s envelope. The patient and staff witness sign the envelope. The items are placed in the envelope and staff member takes reinventory to be sure all items listed are in the envelope. At that time the envelope is sealed and placed in the safe...Any items brought in after admission, by visitor are noted on the belonging log at reception. When the Staff comes to pick up the items, they sign the log showing the date and time they retrieved the items. The staff member then adds any new items to the belonging list. Noting the date that they are added...Just prior to patient to [sic] leaving the assigned staff will obtain the patients belongings from contraband room and hygiene box. The staff member will review and be sure the patient receives all items. The patient will sign the belonging list verifying they received those items...” A review of the facility’s P&P titled, “DOCUMENTATION PROTOCOL,” dated December 2023, was conducted. The P&P indicated, “...Facility records, reports, charts and documents are to be accurate, truthful, timely, and complete...All patient medical record entries are to be...legible, complete, dated, timed and authenticated in written or electronic form...””

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 42512 Based on interiew and record review, the facility failed to ensure, for one of eight sampled patients ( Patient A), a medication was entered on the Medication Administration Record (MAR, a facility document which indicates and tracks all medications ordered and administered to a patient) as it was ordered by the physician when Physican (MD 1) ordered trazadone (a medication to treat anxiety and/or depression [mood disorders]) to be administered to Patient A as needed (PRN) and Pharmacist (PHARM) 1 entered the medication to be administered to Patient A as routine (to be administered on a regular, recurring basis). This failure had the potiential to cause serious harm to Patient A. Findings: On November 7, 2025, at 10:10 a.m., a concurrent interview and review of Patient A’s record were conducted with the Director of Performance Improvement and Risk Management (DOP). A facility document titled, “PRACTITIONER ORDER SHEET [Name of Facility] DETOX [detoxification, the process of removing toxic substances from the blood] ORDERS,” was reviewed. The document indicated, “...COWS DETOX PRN ORDERS...Date Order Written: Oct 30 2025 [October 30, 2025]...Trazodone 100 mg PO [by mouth] QHS [at bedtime]...Indication/Rationale...Insomnia [inability to fall asleep]...” The facility document titled, “MEDICATION ADMINISTRATION RECORD,” dated October 31, 2025, was reviewed. The document indicated, “...TRAZODONE TAB [tablet]...100 mg...PO...QHS [at bedtime]...GIVE 1 [one] TAB PO Q HS...” A facility document titled, “Medication Administration Record,” was reviewed. The document, “...DRUG - DOSE - ROUTE - FREQUENCY...10/30/2025 [October 30, 2025]...DESYREL [a brand name for trazadone] Tab [Tablet] 100 mg [milligram, unit of measurement]...PO QHS...TRAZADONE...2100 [9 p.m.]...[initials of staff who administered medication]...” The document further indicated, “...DRUG - DOSE - ROUTE - FREQUENCY...10/31/2025 [October 31, 2025]...DESYREL Tab 100 mg...PO QHS...TRAZADONE...2100...[initials of staff who administered medication]...” The document indicated trazadone was administered to Patient A every bedtime on October 30, 2025, and October 31, 2025. There was no documented evidence trazadone was ordered to be administered every bedtime to Patient A. On November 17, 2025, at 3:10 p.m., an interview was conducted with MD 1. MD 1 stated the trazodone was ordered by him and should have been administered prn if needed for sleep for Patient A and should not have been administered every bedtime to the patient. On November 19, 2025, at 10:35 a.m., an interview was conducted with Pharmacist (PHARM) 1. PHARM 1 stated trazodone was entered on the MAR record as routine to be administered to Patient A at bedtime every night at 9 p.m. PHARM 1 further stated trazodone was a routine medication ordered for Patient A and was not placed on the MAR as PRN as ordered by the physician. A review of the facility’s P&P titled, “NEW ORDER HANDLING,” dated May, 2019, was conducted. The P&P indicated, “...The medication order is checked (approved) by the RPH [Registered Pharmacist] for appropriateness of drug, dose, frequency, and route of administration...””

“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: 50454 Based on observation, interview, and record review, the facility failed to ensure the medication consent (the process where a competent patient receives comprehensive information about a proposed medication, including its purpose, benefits, risks, potential side effects, and alternatives, to make a voluntary and informed decision to accept or refuses it) for psychotropic drugs (medications which affect the mind and behavior of a patient by altering the chemical balance in the brain) was signed in accordance with the facility’s policies and procedures (P&P), for four of 18 sample patients (Patient 3, 6, 8, and 9), when: 1. For Patient 3, the psychotropic medication consent was not obtained from Patient 3 for the prescribed Lexapro (a medication used to treat mental mood disorders) medication; 2. For Patient 6, the psychotropic medication consent was not obtained from Patient 6 for the prescribed Latuda (a medication used to treat mental health disorders) medication; 3. For Patient 8, the psychotropic medication consent was not obtained from Patient 8 for the prescribed Vistaril (a medication used to treat anxiety [a mood disorder], Trazadone (a medication used to treat anxiety and depression [mood disorders]), and Ativan (medication used to treat anxiety); and 4. For Patient 9, the psychotropic medication consent was not obtained from Patient 9 for the prescribed Vistaril medication. These failures had the potential for patients to not be aware of the risks and benefits of the prescribed pschotropic medication before they are administered to them, the patients’ safety, and violate the patients’ rights. Findings: 1. On September 3, 2025, at 9:21 a.m., a review of Patient 3’s record was conducted with the Chief Nursing Officer (CNO). A facility document titled, “INITIAL PSYCHIATRIC EVALUATION,” dated July 18, 2025, was reviewed and indicated Patient 3 was admitted to the facility on July 18, 2025, on an involuntary (a legal process which allows a person with a serious mental illness to be admitted to a psychiatric facility for treatment against their will, usually for a limited period) hold for grave disability (when a person is unable to provide for his own basic needs). A facility document titled, “PRACTITIONER ORDER SHEET,” dated July 24, 2025, was reviewed. The document indicated, “...Lexapro 20 [twenty] mg [milligrams, unit of measurement] PO [by mouth] q [every] daily for mood...ordered on 7/24/25 [July 24, 25] at 1100 [11 a.m.]...” A facility document titled, “MEDICATION ADMINISTRATION RECORD,” dated July 23, 2025, at 9 a.m., was reviewed. The document indicated, “...LEXAPRO TAB [tablet] 10 MG PO QDAY [daily]...GIVE 1 [one] TAB PO QDAY FOR DEPRESSION [a mood disorder characterized by persistent feelings of sadness and loss of interest]...NEED CONSENT...” The document indicated the medication nurse placed her initials on the document on July 23, 2025, at 9 a.m., to indicate the medication nurse administered Lexapro to Patient 3. A facility document titled, “MEDICATION ADMINISTRATION RECORD,” dated July 24, 2025, at 9 a.m., was reviewed. The document indicated, “...LEXAPRO TAB 10 MG PO QDAY...GIVE 1 TAB PO QDAY FOR DEPRESSION, NEED CONSENT...” The document indicated the medication nurse placed her initials on the document on July 23, 2025, at 9 a.m., to indicate the medication nurse administered Lexapro to Patient 3. A facility document titled, “MEDICATION ADMINISTRATION RECORD,” dated July 25, 2025, at 9 a.m., was reviewed. The document indicated, “...LEXAPRO TAB 10 MG PO QDAY...GIVE 1 TAB PO QDAY FOR DEPRESSION, NEED CONSENT...” The document indicated the medication nurse placed her initials on the document on July 23, 2025, at 9 a.m., to indicate the medication nurse administered Lexapro to Patient 3. A facility document titled, “MEDICATION ADMINISTRATION RECORD,” dated July 26, 2025, at 9 a.m., was reviewed. The document indicated, “...LEXAPRO TAB 10 MG PO QDAY...GIVE 1 TAB PO QDAY FOR DEPRESSION, NEED CONSENT...” The document indicated the medication nurse placed her initials on the document on July 23, 2025, at 9 a.m., to indicate the medication nurse administered Lexapro to Patient 3. There was no documented evidence a psychotropic medication consent for Lexapro was obtained from Patient 3. On September 3, 2025, at 11: 23 a.m., an interview was conducted with the CNO. The CNO stated there is no documentation Patient 3 provided her consent to receive Lexapro. The CNO stated the medication nurse should have verified the consent was signed before administering Lexparo to Patient 3. The CNO stated the medication consent for Lexapro should have been obtained from Patient 3 prior to the administration of Lexapro to Patient 3 since Patient 3 was prescribed the medication. 2. On September 3, 2025, at 9:30 a.m., a review of Patient 6’s record was conducted with the CNO. A facility document titled, “INITIAL PSYCHIATRIC EVALUATION,” dated May, 30 2025, was reviewed and indicated Patient 6 was admitted to the facility on May 30, 2025, for worsening psychosis (a mental health condition characterized by a loss of contact with reality), bizarre (acting strange or unusual) behaviors and not eating and sleeping. A facility document titled, “PRACTITIONER ORDER SHEET,” dated May 31, 2025, was reviewed. The document indicated, “...Latuda 40 mg PO q PM [referring to the time period after noon] with food...order given on 5/31/25 [May 31, 25] at 1445 [2:45 p.m.]...” A facility document titled, “MEDICATION ADMINISTRATION RECORD,” dated May 31, 2025, was reviewed. The document indicated, “...Latuda TAB 40 MG PO Q PM...” There was no documented evidence a psychotropic medication consent for Latuda was obtained from Patient 6. On September 3, 2025, at 11: 30 a.m., an interview was conducted with the CNO. The CNO stated there is no documentation showing Patient 6 provided a medication consent which will include the explaination about Latuda. The CNO further stated the Latuda should have been included on the medication consent-psychotropic drug form since Patient 6 was prescribed the medication. 3. On September 3, 2025, at 9:40 a.m., a review of Patient 8’s record was conducted with the CNO. A facility document titled, “INITIAL PSYCHIATRIC EVALUATION,” dated July, 2 2025, was reviewed and indicated Patient 8 was admitted to the facility on July 2, 2025, for “relapsed on alcohol” and becoming intoxicated and depressed. A facility document titled, “Medication Orders & [and] Prior Medication Reconciliation,” dated July 2, 2025, was reviewed. The document indicated, “...Vistaril...anxiety...50 [fifty] mg PO q 4 [four] PRN [as needed...order given on 7/2/25 [July 2, 25] at 0933 [9:33 a.m.]...” A facility document titled, “MEDICATION ADMINISTRATION RECORD,” dated July 4, 2025, was reviewed. The document indicated, “...Ativan TAB 2 [two] MG PO Q4H...Trazadone TAB 100 MG PO QHS [every night]...Vistaril CAP [capsule] 50MG PO Q4H [every four hours]...” There was no documented evidence a medication consent was obtained from Patient 8 for the psychotropic medications Trazadone, Vistaril, and Ativan. On September 3, 2025, at 11:40 a.m., an interview was conducted with the CNO. The CNO stated there is no documentation showing Patient 8 received an explanation about Trazadone, Vistaril, and Ativan. The CNO further stated a psychotropic medication consent for Trazadone, Vistaril, and Ativan should have been obtained from Patient 8. 4. On September 3, 2025, at 9:50 a.m., a review of Patient 9’s record was conducted with the CNO. A facility document titled, “INITIAL PSYCHIATRIC EVALUATION,” dated July 30, 2025, was reviewed and indicated Patient 9 was admitted to the facility on July 30, 2025, for bizarre behavior. Patient 8 stated she heard voices telling her to hurt herself. A facility document titled, “Medication Orders & Prior Medication Reconciliation,” dated July 30, 2025, was reviewed. The document indicated, “...Vistaril...mood...50 mg PO PRN q4...” A facility document titled, “PRN NOTES DOCUMENTATION REQUIRED,” was reviewed. The document indicated, Patient 6 received Vistaril 50mg PO PRN on July 31, 2025, at 3:05 p.m., August 1, 2025, at 7:05 a.m., August 1, 2025, at 8:18 p.m., and August 2, 2025, at 9:02 p.m. There was no documented evidence a psychotropic medication consent was obtained from Patient 9 for Vistaril. On September 3, 2025, at 11:50 a.m., an interview was conducted with the CNO. The CNO stated there was no documentation showing Patient 9 received an explanation about Vistaril. The CNO further stated a psychotropic medication consent for Vistaril should have been obtained from Patient 9 . On September 3, 2025, at 5 p.m., an interview was conducted with Psychiatrist (Psych, a physician who specialized in the diagnosis and treatment of mental illness) 1. Psych 1 stated the providers fill out the consent form indicating the prescribed medication and explain the psychotropic drugs to the patient before the patients receive their first dose of the medication. Psych 1 stated the nurse is responsible for obtaining the patient’s signature prior to giving the first dose of medication to the patient. Psych 1 stated there must be a signed medication consent from the patient for the prescribed medication for the nurse to administer the psychotropic medication. Psych 1 further stated the medication consent should be obtained whenever a psychotropic medication is prescribed regardless if the patient receives the medication or not. On September 4, 2025, at 1:59 p.m., an interview was conducted with the Registered Nurse (RN) 1. RN 1 stated if there is no consent for a medication, the nurse is supposed to pause and inform the charge nurse. RN 1 stated patients should not be given a psychotropic medication if there is no signed medication consent from the patient. The facility P&P titled, “MEDICATION ADMINISTRATION AND RECORDS,” dated July 2024, was reviewed. The P&P indicated, “...To establish procedures for timely, accurate, and safe administration of medication...All patient who are able to provide expressed and informed consent for psychotropic medications will do so prior to the initial dose...Documentation of expressed and informed consent will be verified by the Nursing Staff and recorded...the log is placed in the MAR [Medication Administration Record]. In addition, the MAR will reflect that consent has been documented...””