Dept of State Hospitals - Metropolitan - Psy

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50669 Based on observation, interview, and record review, the facility failed to ensure care was provided in a safe setting. The facility failed to ensure the use of physical restraints was incorporated into patient’s care plans. The facility failed to ensure restraints were implemented in accordance with safe and appropriate restraint technique per manufacturer’s instructions. The facility failed to ensure that skin integrity and circualtion checks were conducted every 15 minutes, and range of motion exercises were performed every 2 hours. The facility failed to ensure licensed staff received restraint training on an annual basis. The facility failed to ensure patients were informed of their rights by providing the required patients’ rights notification. (Refer to A-0117, A-0144, A-0166, A-0167, A-0175, A-0205) This failure resulted in the facility being unable to ensure compliance with the Conditions of Participation for Patients’ Rights at 42 CFR 482.13.”

“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: 50669 Based on observation, interview, and record review the facility failed to ensure nursing staff developed and maintained active nursing care plans. The facility failed to ensure adequate supervision and evaluation of nursing personnel. The facility failed to ensure staff performed hand hygiene after medication adminstration and between patients. (Refer to A-0396, A-0398, and A-0405) This failure resulted in the facility being unable to ensure compliance with the Conditions of Participation for Nursing Services at 42 CFR 482.23.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 50669 Based on interview, and record review, the facility failed to ensure patients were informed of their rights by providing the required Patients’ Rights Notification for two of 10 sampled patients (Patients 2 and 3). This failure had the potential to affect all patients’ receiving services by limiting their awareness of their rights, including the right to participate in care decisions, voice grievances, and receive care. Findings: 1. During a review of Patient 2’s “Treatment Plan,” dated 6/8/26, the “Treatment Plan” indicated Patient 2 was admitted to the facility on 1/28/26 for diagnosis of schizoaffective disorder, bipolar type (mental health condition involving a disconnection from reality with extreme shifts in emotions). During a concurrent interview and record review on 6/18/26 at 9:25 a.m. with Registered Nurse Auditor (RN Auditor), Patient 2’s “Notification of Patients’ Rights,” undated, was reviewed. The “Notification of Patients’ Rights” indicated, “...patients are to be notified of their Patients and California State Constitutional Rights within 24 hours of Admission. Initial in each box and sign indicating the following information has been received...”. The Notification of Patient’s Rights was not filled out or signed. RN Auditor stated the document should have been filled out within 24 hours of Patient 2’s admission and it was 4 months overdue. During a review of the facility’s policy and procedure (P&P) titled, “Patient’s Rights,” dated 2/11/26, the P&P indicated, “Each person admitted to a state hospital shall be provided with an appropriate patients’ rights handbook... Documentation to the effect that notification, or an attempt to provide notification, has occurred, shall be entered in a patient’s record within 24 hours of admission...” 22069 2. During a review of Patient 3’s clinical record, the record indicated Patient 3 was admitted to the facility on 6/15/26 with diagnosis that included schizoaffective disorder, bipolar type (mental health condition involving a disconnection from reality with extreme shifts in emotions). During a concurrent interview and record review on 6/17/26 at 11:15 a.m. with Unit Supervisor (US), Patient 3’s “Notification of Patients’ Rights,” form, undated, was reviewed. The “Notification of Patients’ Rights” indicated, “...patients are to be notified of their Patients and California State Constitutional Rights within 24 hours of Admission. Initial in each box and sign indicating the following information has been received...”. The form was noted to be completely blank. The US stated staff conducting the admission should have completed the patient’s rights form and provide explanation of rights to the patient. The US confirmed the patient’s rights notification was not done. During a review of the facility’s policy and procedure (P&P) titled, “Patient’s Rights,” dated 2/11/26, the P&P indicated, “Each person admitted to a state hospital shall be provided with an appropriate patients’ rights handbook... Documentation to the effect that notification, or an attempt to provide notification, has occurred, shall be entered in a patient’s record within 24 hours of admission...””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50669 Based on observation, interview, and record review, the facility failed to ensure care was provided in a safe setting for two of 10 sampled patients (Patient 1 and Patient 2) when: 1. Patient 1, who was assessed as a high risk for self-harm by ingestion of foreign objects, swallowed a fork, while in bilateral mitten restraints (a padded, oversized protective glove that covers the patient’s hand used to prevent self-injurious behaviors) and on 1:1 supervision. The facility failed to implement physician orders and adequate supervision for Patient 1. This failure resulted in Patient 1 requiring emergency transfer and surgical intervention. 2. Patient 2 was not provided with adequate supervision for victimization (being mistreated, harmed or taken advantage of by someone else), in accordance with the facility’s policy and procedure, by Psychiatric Technician (PT) 2. This failure had the potential to result in Patient 2 experiencing victimization from other peers. Findings: 1. During a review of Patient 1’s “Treatment Plan,” dated 5/21/26, the “Treatment Plan” indicated Patient 1 was admitted to the facility on 1/7/26 for diagnoses to include borderline personality disorder (mental health condition characterized by severe difficulties regulating emotions and impulsive behaviors) and psychosis (disconnected to reality often resulting in seeing or hearing things that are not happening). The “Treatment Plan” further indicated Patient 1 was at high imminent risk of suicide and self-injurious behaviors with extensive history of swallowing foreign objects. During a review of Patient 1’s “Special Incident Report (SIR),” dated 5/26/26, the “SIR” indicated, “[Patient 1] was transferred to [hospital name] due to diagnosis of gastric foreign body ... [Patient 1] stated to the 1:1 staff that he swallowed a spork and pudding together ... History of DTS [danger to self]/PICA [eating disorder when someone regularly and compulsively eats things that are not food]” During an interview on 6/15/26 at 1:29 p.m. with Unit Supervisor (US), US confirmed with Patient 1’s medical record, on 5/22/26 Patient 1 was in bilateral mitten restraints and had 1:1 supervision provided by Psychiatric Technician Assistant (PTA) 2, when Patient 1 swallowed a plastic fork. US stated Patient 1 was transferred to the local community hospital for an emergency surgery. US further stated since Patient 1 was in bilateral mitten restraints, PTA 2 should have been feeding Patient 1, and Patient 1 should have never had a fork due to having a physician order for no plastic utensils. During an interview on 6/16/26 at 3:09 p.m. with PTA 2, PTA 2 reported that while assigned to provide 1:1 supervision for Patient 1, PTA 2 accompanied Patient 1 to get an evening snack, where Psychiatric Technician (PT) 4 handed the patient pudding and a plastic spork. PTA 2 stated he returned Patient 1 to his room and allowed Patient 1-whose thumbs were outside the mittens-to eat using the plastic spork. PTA 2 stated Patient 1’s thumbs were out of the mittens the entire time he was assigned to the 1:1 supervision. PTA 2 stated he had not been informed that Patient 1 was prohibited from having plastic utensils or that the thumbs were required to remain inside the mittens. PTA 2 further stated he was not watching Patient 1 while eating, and then Patient 1 told him that the spork had been swallowed. During an interview on 6/17/26 at 3:41 p.m. with PT 4, PT 4 stated she was handing out snacks on 5/22/26 when Patient 1 and his 1:1 came to the snack cart, and took a pudding cup, cookies and a spork. PT 4 stated PTA 2 informed her, he would bring the spork back to PT 4. PT 4 further stated she was unaware of Patient 1 not being allowed to have a plastic fork. During a review of Patient 1’s “Return from Outside Hospitalization Note,” dated 6/10/26, the “Return from Outside Hospitalization Note” indicated Patient 1 was sent to a local community hospital on 5/22/26 for foreign body ingestion and underwent an exploratory laparotomy (major open surgery when a doctor makes large cut into the stomach to physically look at the internal organs and removes whatever should not be there). The “Note” further indicated Patient 1 received multiple antibiotics after surgery for intrabdominal (inside the stomach) infection. During a review of Patient 1’s “Physician’s Orders (PO),” dated 1/7/26, the “PO” indicated, “Patient may not use plastic utensils (sporks). Patient to use paper spoons only for all meals PICA precaution.” During a review of Patient 1’s “Physician Order for Behavioral Seclusion or Restraint,” date 5/22/26 at 1600, the “Physician Order for Behavioral Seclusion or Restraint” indicated, “renewal ... bilateral mittens with 1:1 supervision ... specific behavioral criteria for application ... unpredictable DTS/PICA behavior ...” During a review of Patient 1’s “Observation Record for Behavioral Seclusion or Restraint,” dated 5/22/26, the “Observation Record for Behavioral Seclusion or Restraint” indicated PTA 2 assumed responsibility for 1:1 supervision of Patient 1 from 7 p.m. til 8 p.m. and Patient 1 was being observed while in bilateral hand mittens for DTS and PICA behaviors. During a review of the facility’s policy and procedure (P&P) titled, “Staff Supervision of Patients Utilizing 1:1 ...,” dated 5/11/26, the P&P indicated, “One-to-one (1:1) supervision is continuous observation with no barriers (e.g., privacy screen, toilet stall door, blanket, sheet, etc. which interferes with a staff’s ability to visualize a patient’s activity/behavior during observation) between the supervising staff person and the patient ... Monitoring and Documentation of Patients Placed on Enhanced Observation ... Effective observation required that the staff remain vigilant ...” During a review of the facility’s P&P titled, “Care of the Patient in Seclusion and Behavioral Restraints,” dated June 2026, the P&P indicated, “Nutrition/Hydration ... A patient in seclusion or restraints is to be offered nutrition at designated mealtimes and nursing staff is to provide assistance ...” During a review of the Manufacturer’s Instructions “Security Mitts Application Instructions,” dated 8/16/23, the Manufacturer’s Instructions indicated, “Intended use: To protect patients assessed to be at risk ... or in danger of injury to themselves ... Application Instructions: 1. Insert the patient’s hand into the mitt, palm down. 2. Wrap the wrist strap around the smallest part of the patient’s wrist ... ALWAYS monitor patients ... Improper application or use of any restraint may result in serious injury ...” The Manufacturer’s Instructions have a picture to show the final way the mitten restraint should appear once applied properly, noting the thumb fully inside the mitten. 2. During a review of Patient 2’s “Treatment Plan,” dated 6/8/26, the “Treatment Plan” indicated Patient 2 was admitted to the facility on 1/28/26 for diagnosis of schizoaffective disorder, bipolar type (mental health condition involving a disconnection from reality with extreme shifts in emotions). The “Treatment Plan” further indicated Patient 2 was high risk for violence due to extensive history of aggression and intrusiveness towards others. During a review of Patient 2’s “Physician Order (PO),” dated 6/15/26, the “PO” indicated, “Renew 1:1 supervision x 24 hours for AM/PM only for victimization.” During multiple observations on 6/15/26 at 12:10 pm and 12:32-12:41 pm, Patient 2 was lying in bed, which was against the wall on the right side, PT 2 was sitting outside of the room against the wall to the left, facing horizontally with the direction of the hallway. PT 2 had his head down, staring at the floor. PT 2 did not visually observe Patient 2 during any of the surveyor’s observations. During concurrent observation and interview on 6/15/26 at 12:42 pm, outside of Patient 2’s room, PT 2 was sitting back in the chair outside of the room, against the wall. PT 2 confirmed where he was sitting, he was unable to view the patient due to the wall obstructing his view. PT 2 stated Patient 2 was on 1:1 supervision for victimization. During concurrent observation and interview on 6/15/26 at 12:45 pm in the nurses’ station, with Unit Supervisor (US), PT 2 was observed sitting in a chair starring at the ground. US confirmed PT 2 was assigned to 1:1 supervision for Patient 2 and PT 2 was not providing continuous observation to Patient 2. US stated PT 2 was unable to observe Patient 2 because the wall was obstructing his view, and PT 2 needed to move to visualize Patient 2. During a review of the facility’s policy and procedure (P&P) titled, “Staff Supervision of Patients Utilizing 1:1 ...,” dated 5/11/26, the P&P indicated, “One-to-one (1:1) supervision is continuous observation with no barriers (e.g., privacy screen, toilet stall door, blanket, sheet, etc. which interferes with a staff’s ability to visualize a patient’s activity/behavior during observation) between the supervising staff person and the patient ... Monitoring and Documentation of Patients Placed on Enhanced Observation ... Effective observation required that the staff remain vigilant ...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 50669 Based on interview and record review, the facility failed to ensure a care plan was develop for mulitiple physical restraint used for one of 10 sampled patients (Patient 1). This failure had the potential to result in nursing staff not being aware of possible interventions prior to the use of physical restraints. Findings: During a review of Patient 1’s “Treatment Plan,” dated 5/21/26, the “Treatment Plan” indicated Patient 1 was admitted to the facility on 1/7/26 for diagnoses to include borderline personality disorder (mental health condition characterized by severe difficulties regulating emotions and impulsive behaviors) and psychosis (disconnected to reality often resulting in seeing or hearing things that are not happening). The “Treatment Plan” further indicated Patient 1 was at high imminent risk of suicide and self-injurious behaviors with extensive history of swallowing foreign objects. During a concurrent interview and record review on 6/16/26 at 2:59 p.m. with Registered Nurse Auditor (RN Auditor), Patient 1’s full medical record was reviewed. The “Treatment Plan,” dated 5/21/26, indicated Patient 1 was in various types of restraints - 5-point restraints, wrist-to-waist restraints, and bilateral mittens - on 3/2/26, 4/8/26, 4/10/26, 4/13/26, and 5/16/26 to 5/22/26. Although the “Treatment Plan” identified these restraint episodes, it did not include, and no separate care plan reflected, a process of assessment, interventions, and evaluations specific to Patient 1’s restraint use. RN Auditor confirmed Patient 1 had been in restraint frequently since admission for swallowing foreign objects and stated there should have been a care plan. During a review of Patient 1’s “Physician Orders (PO),” dated 5/22/26, the “PO” indicated Patient 1 was in continuous bilateral mitten restraints from 5/16/26 to 5/22/26. During a review of the facility’s policy and procedure (P&P) titled, “Nursing Care Plan/Plan of Care (POC),” dated May 2026, the P&P indicated, “Psychiatric nursing care plans/plans of care ... Once the patient’s initial Treatment Plan has been developed: Psychiatric nursing interventions will be incorporated into the plan of care ... Nursing specific interventions must be included in the Treatment Plan for all conditions identified. Interventions are specific strategies designed to assist the patient meet his/her objectives. Each POC shall include a nursing intervention that addresses monitoring and/or assessment of the condition ...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 50669 Based on interview and record review the facility failed to ensure restraints were implemented in accordance with safe and appropriate restraint technique per manufacturer’s instructions for 1 of 10 sampled patients (Patient 1). This failure resulted in Patient 1 swallowing a foreign object (a spork- a spoon/fork combination) while wearing bilateral mitten restraints (a padded, oversized protective glove that covers the patient’s hand used to prevent self-injurious behaviors). Findings: During a review of Patient 1’s “Treatment Plan,” dated 5/21/26, the “Treatment Plan” indicated Patient 1 was admitted to the facility on 1/7/26 for diagnoses to include borderline personality disorder (mental health condition characterized by severe difficulties regulating emotions and impulsive behaviors) and psychosis (disconnected to reality often resulting in seeing or hearing things that are not happening). The “Treatment Plan” further indicated Patient 1 was at high imminent risk of suicide and self-injurious behaviors with extensive history of swallowing foreign objects. During a review of Patient 1’s “Interdisciplinary Notes (IDN),” dated 5/22/26, the “IDN” indicated Patient 1 was on 1:1 observation, eating a snack and informed his 1:1 staff that he had swallowed a spork. During an interview on 6/16/26 at 3:09 p.m. with Psychiatric Technician Assistant (PTA) 2, PTA 2 confirmed he was assigned to 1:1 supervision for Patient on 5/22/26 when Patient 1 swallowed the fork. PTA 2 stated Patient 1 had bilateral mittens on with both thumbs out of each mitten and was given a fork to eat pudding with. PTA 2 further stated he was not aware the thumbs needed to be in the mitten restraints and he has never received training on mittens. During an interview on 6/17/26 at 11:25 a.m. with Registered Nurse (RN) 1, RN 1 stated he was not working on 5/22/26, the date Patient 1 swallowed the spork, but prior to that incident, he had seen Patient 1 with his thumbs out of the mittens multiple times and had to inform 1:1 staff of Patient 1’s thumb needing to be inside the mittens. RN 1 further stated thumbs should be inside the mittens. During an interview on 6/17/26 at 12:01 p.m. with Senior Psychiatric Technician (SPT), SPT stated prior to Patient 1 swallowing the spork on 5/22/26, she seen Patient 1 with his thumbs out of the mittens frequently and he would use the mitten as a claw to grab things. SPT further stated the whole hand needed to be inside the mittens, but she has never received training on mittens. During an interview on 6/17/26 at 2:30 p.m. with Psychiatric Technician Instructor (PT Instructor), PT Instructor stated he was responsible for training staff on therapeutic strategies and interventions, including restraints. PT Instructor confirmed mittens were a facility-approved restraint but stated he was not familiar with their correct application, including thumb placement, and that training on mittens had not been provided to staff. During a review of Patient 1’s “Physician Orders (PO),” dated 5/22/26 at 1600, the “PO” indicated Patient 1 was ordered bilateral mittens with 1:1 supervision due to unpredictable danger to self/PICA behaviors [mental health condition characterized by swallowing nonfood items]” During a review of the Manufacturer’s Instructions “Security Mitts Application Instructions,” dated 8/16/23, the Manufacturer’s Instructions indicated, “Intended use: To protect patients assessed to be at risk ... or in danger of injury to themselves ... Application Instructions: 1. Insert the patient’s hand into the mitt, palm down. 2. Wrap the wrist strap around the smallest part of the patient’s wrist ... ALWAYS monitor patients ... Improper application or use of any restraint may result in serious injury ...” The Manufacturer’s Instructions have a picture to show the final way the mitten restraint should appear once applied properly, noting the thumb fully inside the mitten. During a review of the facility’s policy and procedure (P&P) titled, “Behavioral Seclusion or Restraint,” dated 3/20/26, the P&P indicated, “Nursing staff shall be current with procedures for the proper application of restraint and nursing care requirements when providing care for patients in seclusion or restraints ...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 34959 Based on observation, interview, and record review, the facility failed to ensure that skin integrity (assess skin for redness, skin tears, and bruising) and circulation (assess skin color, swelling, and ability to move fingers) checks were conducted every 15 minutes, and range of motion exercises were performed every 2 hours for one (1) of 10 sampled patients (Patient 5) while the patient was in wrist to waist restraints (a mechanical device that secures a patient’s wrists to a belt around the waist to restrict arm movement and help prevent unsafe behavior’s). This failure had the potential to result in impaired circulation, compromised skin integrity, and restricted joint mobility. Findings: During a review of Patient 5’s “Treatment Plan” dated 5/14/26, the “Treatment Plan,” indicated Patient 5 was admitted to the facility on 11/14/24 with a diagnosis of schizophrenia (fixed false beliefs that are not based on reality). During a review of Patient 5’s “Physician Order for Behavioral Seclusion (patient in a room or area that the patient is prevented from leaving) or Restraint (mechanical device that immobilizes or reduces a patient’s ability to move their arms, legs, and body freely)” dated 6/16/26 at 8:00 a.m., the “Physician Order for Behavioral Seclusion,” indicated, wrist to waist with 1:1 supervision (continuous patient observation) for unpredictable impulsive (a patient became agitated and exhibited aggressive behavior toward others without warning) Danger to others (DTO) behavior. The maximum duration of order was 4 hours. During a review of Patient 5’s “Physician Order for Behavioral Seclusion or Restraint” dated 6/16/26 at 12 p.m., the “Physician Order for Behavioral Seclusion,” indicated, wrist to waist with 1:1 supervision for unpredictable impulsive DTO behavior. The maximum duration of order was 4 hours. During a review of Patient 5’s “Physician order for Behavioral Seclusion or Restraint” dated 6/17/26 at 8:00 a.m., the “Physician Order for Behavioral Seclusion,” indicated, wrist to waist with 1:1 supervision for unpredictable impulsive DTO behavior. The maximum duration of order was 4 hours. During a review of Patient 5’s “Physician order for Behavioral Seclusion or Restraint” dated 6/17/26 at 12 p.m., the “Physician Order for Behavioral Seclusion,” indicated, wrist to waist with 1:1 supervision for unpredictable impulsive DTO behavior. The maximum duration of order was 4 hours. During an observation on 6/16/26 at 11:03 a.m. in the day room, Psychiatric Technician (PT) 1 assumed responsibility for Patient 5, who was on a 1:1 observation for DTO and in bilateral wrist to waist restraints while seated in a wheelchair. PT 1 was observed first not assessing the wrist to waist restraints and without receiving a handoff report (ensure continuity of care and patient safety by communicating important information about patient) from Psychiatric Technician (PT) 5. During an observation on 6/16/26 at 11:15 a.m. in the day room, PT 1 was observed not performing the required circulation and skin integrity checks due at 11:15 a.m. for Patient 5. PT 1 was subsequently observed documenting on the form titled, “Observation Record for Behavioral Seclusion or Restraint,” that circulation and skin integrity checks had been completed at 11:15 a.m. During a concurrent interview and record review on 6/16/26 at 11:19 a.m. with PT 1, Patient 5’s “Observation Record for Behavioral Seclusion or Restraint,” dated 6/16/26 was reviewed. The “Observation Record for Behavioral Seclusion or Restraint,” indicated, that circulation and skin integrity checks had been completed on 6/16/26 at 11:15 a.m. PT 1 confirmed that he had not performed Patient 5’s circulation and skin integrity checks at 11:15 a.m. PT 1 also stated that circulation and skin integrity checks were to include placing one finger between the patient’s wrist and the restraint and inspecting the wrist to ensure the restraints were not too tight. During a concurrent observation and interview on 6/17/26 at 11:45 a.m. with Unit Supervisor (US) and Psychiatric Technician Assistant (PTA) 1, in the day room, PTA 1 was observed not performing the required circulation and skin integrity checks due at 11:45 a.m. for Patient 5. PTA 1 was subsequently observed documenting on the form titled, “Observation Record for Behavioral Seclusion or Restraint,” that circulation and skin integrity checks had been completed at 11:45 a.m. The Unit Supervisor confirmed that the required circulation and skin integrity checks were not performed at 11:45 a.m. PTA 1 stated that she had checked the patient’s circulation and skin integrity at 11:45 a.m. US informed PTA 1 that the required circulation and skin integrity checks had not been performed. US further stated that the circulation and skin integrity checks included placing two fingers between the patient’s wrist and restraint. During a concurrent observation and interview on 6/17/26 at 12 p.m. with US and PTA 1, in the day room, PTA 1 observed not performing the required range of motion exercises due every 2 hours at 12 p.m. for patient 5 who was in wrist to waist restraints and seated in a wheelchair eating lunch. PTA 1 was subsequently observed documenting on the form titled, “Observation Record for Behavioral Seclusion or Restraint,” that range of motion exercises does not apply at this time. US confirmed that the required range of motion exercises had not been performed at 12 p.m. PTA 1 confirmed that range of motion exercises were not done at 12 p.m. because Patient 5 was having lunch. US stated that PTA 1 should have asked Patient 5 if range of motion exercises could be performed and obtained assistance from another nursing staff member to safely perform range of motion exercises to Patient 5’s bilateral wrists and upper extremities. During a review of the facility’s policy and procedure (P&P) titled, “Care of the Patient in Seclusion and Behavioral Restraints,” dated June 2026, the P&P indicated, “Circulation is to be checked every 15 minutes for loss of skin integrity. Observe skin for chafing (skin breakdown), bruising, redness, abrasions (scraped skin), and edema (swelling) ...All patients in restraints are to receive adequate exercise every 2 hours for a period of not less than 10 minutes. Range of motion exercises shall be performed by removing or loosening the restraint belt while the cuff remains on the patient. Nursing staff will ensure the patient’s limbs are exercised, loosen, or remove the belt and exercise one limb at a time. It is advisable to have another nursing staff available when loosening or removing the restraint belt when providing range of motion ...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(vi) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (vi) Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1-hour face-to-face evaluation. This Standard is not met as evidenced by: 50669 Based on interview and record review, the facility failed to ensure licensed staff received restraint training on an annual basis for eight of eight licensed staff (Psychiatric Technician (PT) 1, PT 2, PT 3, PT 4, Psychiatric Technician Assistant (PTA) 1, PTA 2, Registered Nurse (RN) 2, and RN 3). This failure resulted in the majority of licensed staff providing care to patients requiring restraint, including Patient 1, without current, documented competency in restraint training. Findings: During a concurrent interview and record review on 6/18/26 from 10:15 a.m. to 11:31 a.m. with Human Resources Director (HRD) and Director of Nursing (DON) the following employee files were reviewed and indicated: 1. PT 1 was hired on 6/2/25 and there was no documented evidence that “Seclusions and Restraint Use” training was conducted. 2. PT 2 was hired on 4/1/25 and the “Therapeutic Strategies and Interventions(TSI)” training has not been conducted since 4/7/25. 3. PT 3 was hired on 4/1/25 and the TSI training has not been conducted since 3/24/25. 4. PT 4 was hired on 3/11/22 and there was no documented evidence that “Seclusions and Restraint Use” training was conducted. 5. PTA 1 was hired on 7/2/18 and the “Seclusions and Restraint Use” training has not been conducted since 5/14/21. 6. PTA 2 was hired on 3/2/17 and the “Seclusions and Restraint Use” training has not been conducted since 6/24/21. 7. RN 2 was hired on 6/10/24 and there was no documented evidence that “Seclusions and Restraint Use” training was conducted. 8. RN 3 was hired on 1/31/24 and there was no documented evidence that “Seclusions and Restraint Use” training was conducted. The HRD confirmed PT 1, PT 4, RN 2 and RN 3 never received “Seclusions and Restraint Use” training, PT 2 and PT 3’s training for “Therapeutic Strategies and Interventions” training was expired, and PTA 1 and PTA 2’s training for “Seclusions and Restraint Use” was expired for multiple years. The HRD stated there were two required trainings for restraints, “Seclusions and Restraint Use” and “Therapeutic Strategies Interventions”, and they both needed to be completed annually. The DON stated “Seclusion and Restraint Use” training was a review of the facility’s policy and procedure and “Therapeutic Strategies and Interventions” training was teaching staff how to “take down (stabilizing a patient against a wall and a floor to restrictive movements)” a patient and apply 5-point restraints and wrist to waist restraints. The DON further stated there was no specific training for application and monitoring of mittens. The DON stated and she was unsure why all eight of eight staff were out of compliance with annual restraint trainings. During a review of the facility’s policy and procedure (P&P) titled, “Behavioral Seclusion or Restraint,” dated 3/30/26, the P&P indicated, “...All staff whose responsibilities include the implementation or assessment of seclusion, restraints, psychiatric PRN or STAT medications shall successfully complete competency-based training regarding implementation of associated policies... Employees participating in the stabilization, seclusion or restraint of patients shall be current in required TSI training... Nursing staff shall be current with procedures for the proper application of restraint and nursing care requirements when providing care for patients in seclusion or restraints...””

“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: 50669 Based on interview and record review, the facility failed to ensure nursing staff developed and maintained active nursing care plans for three of 10 sampled patients (Patient 1, Patient 4, and Patient 5). This failure resulted in the absence of an individualized plan to guide nursing staff in identifying and addressing each patient’s nursing care needs, goals, and interventions, and had the potential to result in unmet patient needs and inconsistent, uncoordinated nursing care. Findings: 1. During a review of Patient 1’s “Treatment Plan,” dated 5/21/26, the “Treatment Plan” indicated Patient 1 was admitted to the facility on 1/7/26 for diagnoses to include borderline personality disorder (mental health condition characterized by severe difficulties regulating emotions and impulsive behaviors) and psychosis (disconnected to reality often resulting in seeing or hearing things that are not happening). The “Treatment Plan” further indicated Patient 1 was at high imminent risk of suicide and self-injurious behaviors with extensive history of swallowing foreign objects. During a concurrent interview and record review on 6/16/26 at 2:59 p.m. with Registered Nurse (RN) Auditor, Patient 1’s “Treatment Plan,” dated 5/21/26, and “Nursing Care Plans (NCP),” dated 1/7/26, were reviewed. Patient 1’s “Treatment Plan” indicated “See NCP’s” for the following areas:.. “Gender affirming care ... Failure to thrive ...Vitamin D Deficiency ... Non-compliance with some medical treatment ... Self-inflicted abd [abdominal] wound.” Patient 1 did not have any NCP. RN Auditor stated he should have nursing care plans to correlate with the Treatment plan. During a review of the facility’s policy and procedure (P&P) titled, “Nursing Care Plan/Plan of Care (POC),” dated May 2026, the P&P indicated, “Psychiatric nursing care plans/plans of care...Once the patient’s initial Treatment Plan has been developed: Psychiatric nursing interventions will be incorporated into the plan of care...Nursing specific interventions must be included in the Treatment Plan for all conditions identified. Interventions are specific strategies designed to assist the patient meet his/her objectives. Each POC shall include a nursing intervention that addresses monitoring and/or assessment of the condition ...” 22069 2. During a review of Patient 4’s clinical record, the record revealed Patient 4 was admitted to the facility on 7/11/24 with diagnosis that included schizoaffective disorder, bipolar type (a chronic mental health condition). Patient 4 was identified having a medical problems for Constipation (incomplete bowel movements), Onychomycosis (a fungal infection of the nail bed), Vitamin D Deficiency (low vitamin D levels that can affect bone health) and Hypothyroidism (a condition where your thyroid glands does not produce enough hormones). During a concurrent interview and record review on 6/16/26 at 3:25 p.m. with Registered Nurse Auditor (RN Auditor), Patient 4’s nursing care plans for Constipation, Onychomycosis, Vitamin D Deficiency and Hypothyroidism were reviewed. The nursing care plans indicated they were last evaluated by the Registered Nurse (RN) on 12/26/25, with a reevaluation date of 3/26/26. Further review of the nursing care plans revealed there were no reevaluations done since 12/26/25. The RN Auditor stated the nursing care plans were supposed to be reevaluated on 3/26/26. RN Auditor stated the reevaluation was not done. 34959 3. During a review of Patient 5’s “Treatment Plan” dated 5/14/26, the “Treatment Plan,” indicated, Patient 5 was admitted to the facility on 11/14/24. Patient 5 diagnoses included hypothyroidism (causes fatigue, weight gain, feeling cold, and muscle weakness), dyslipidemia (abnormal level of cholesterol), constipation (incomplete bowel movements), vitamin D deficiency (low vitamin D levels that can affect bone health), and overweight (excess body weight). During a concurrent interview and record review on 6/16/26 at 2:46 p.m. with Registered Nurse Auditor (RN Auditor), Patient 5’s “Medical Conditions Form,” undated, was reviewed. The “Medical Conditions Form,” indicated, the following medical conditions were opened and did not have a nursing care plan on the following dates: a. Hypothyroidism was opened on 11/14/24 b. Dyslipidemia was opened on 11/14/24 c. Constipation was opened on 11/14/24 d. Obesity was opened on 11/14/24 e. Vitamin D was opened on 11/18/24 RN Auditor confirmed that nursing care plans should have been developed and implemented for all of Patient 5’s identified medical conditions to assist the patient in achieving established goals and desired outcomes. During a concurrent interview and record review on 6/16/26 at 2:48 p.m. with RN Auditor, Patient 5’s “Fall Risk Assessment,” dated 5/5/26 was reviewed. The “Fall Risk Assessment,” indicated, Patient 5 had a history of falls. In section B, Patient 5 received a score of 2. A score greater than 1 in either section B or section E indicated Patient 5 was at risk for falls. RN Auditor confirmed Patient 5 did not have an individualized nursing care plan to address risk for falls. During an interview on 6/18/26 at 9:05 a.m. with Supervising Registered Nurse (SRN) 1, SRN 1 stated registered nurses are expected to develop a nursing care plan for each identified medical condition and to initiate nursing care plans within eight hours of identifying risks and alerts. During a review of the facility’s policy and procedure (P&P) titled, “Nursing Care Plan/Plan of Care,” dated May 2026, the P&P indicated, ...”When behaviors/conditions... falls... are identified, the RN will assess the patient and develop a Nursing Care Plan. A Nursing Care Plan will be a. Established within eight (8) hours of identification of risk/alert ...1. Active and Acute Medical Conditions will be identified [opened] under Focus 6 listed on the [facility name] Medical Conditions Form [facility name 9011A] ....4. A Nursing Care Plan is required for each opened medical condition on the [facility name Medical Conditions Form [facility 9011A] ...””

“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: 50669 Based on interview, and record review, the facility’s Director of Nursing (DON) failed to ensure adequate supervision and evaluation of nursing personnel for 8 of 8 licensed staff files reviewed, when: 1. Eight of eight licensed staff files lacked documented training on multiple topics, including PICA [swallowing non-food objects] behaviors and 1:1 supervision, resulting in licensed nursing personnel providing direct care and safety-critical supervision to patients without evidence they were equipped to adhere to the facility’s policies and procedures. 2. Six of eight licensed staff files lacked documentation of an annual performance evaluation, resulting in the facility’s inability to demonstrate ongoing assessment of these staff members’ clinical competency and performance. These failures resulted in the facility’s Director of Nursing being unable to demonstrate that licensed nursing personnel were adequately supervised and evaluated to ensure adherence to hospital policies and procedures, and had the potential to affect all patients receiving care from these 8 licensed staff members. Findings: 1. During a concurrent interview and record review on 6/18/26 at 10:10 a.m. with the Human Resources Director (HRD), Psychiatric Technician (PT) 1’s “Transcript,” undated, was reviewed. The “Transcript” indicated PT 1 was hired on 6/2/25 and had no documented evidence of nursing orientation, annual nursing updates and staff supervision of patients utilizing 1:1 training being conducted. The HRD stated PT 1 should have completed those trainings. During a concurrent interview and record review on 6/18/26 at 10:27 a.m. with the HRD and the DON, PT 3’s “Transcript,” undated, was reviewed. The “Transcript” indicated PT 3 was hired on 7/7/00 and had no documented evidence of staff supervision of patients utilizing 1:1 training being conducted. The “Transcript” further indicated PT 3 has not conducted annual nursing training since 6/5/25. The HRD confirmed PT 3 was out of compliance for both trainings, and the DON stated PT 3 should have had both trainings completed annually. During a concurrent interview and record review on 6/18/26 at 10:39 a.m. with the HRD and the DON, Registered Nurse (RN) 2’s “Transcript,” undated, was reviewed. The “Transcript” indicated RN 2 was hired on 6/10/24 and had no documented evidence of staff supervision of patients utilizing 1:1 training, and nursing orientation being conducted. The DON confirmed with the HRD there was no documented evidence of training being completed and the DON stated RN 2 should have completed both training courses. During a concurrent interview and record review on 6/18/26 at 10:39 a.m. with the HRD and the DON, PT 4’s “Transcript,” undated, was reviewed. The “Transcript” indicated PT 4 was hired on 3/11/22 as a student assistant and became a PT on 1/16/26. The “Transcript” further indicated PT 4 had no documented evidence of staff supervision of patients utilizing 1:1 training being conducted. The DON confirmed with the HRD there was no documented evidence of training being completed and the DON stated PT 4 should have completed the training course. During a concurrent interview and record review on 6/18/26 at 10:51 a.m. with the HRD and the DON, Psychiatric Technician Assistant (PTA) 2’s “Transcript,” undated, was reviewed. The “Transcript” indicated PTA 2 was hired on 3/2/17 and had no documented evidence of staff supervision of patients utilizing 1:1 training, and nursing orientation being conducted. The DON confirmed with the HRD there was no documented evidence of training being completed and the DON stated PTA 2 should have completed both training courses. During a concurrent interview and record review on 6/18/26 at 10:55 a.m. with the HRD and the DON, PTA 1’s “Transcript,” undated, was reviewed. The “Transcript” indicated PTA 1 was hired on 7/2/18 and has not conducted staff supervision of patients utilizing 1:1 training, since 11/28/22. The DON confirmed with the HRD there was no documented evidence of training being completed and the DON stated PTA 1 should have completed the training annually. During a concurrent interview and record review on 6/18/26 at 10:59 a.m. with the HRD and the DON, PT 2’s “Transcript,” undated, was reviewed. The “Transcript” indicated PT 2 was hired on 4/1/25 and had no documented evidence of nursing orientation and nursing annual update trainings being conducted. The DON confirmed with the HRD there was no documented evidence of training being completed and the DON stated PT 2 should have completed both training courses. During a concurrent interview and record review on 6/18/26 at 11:31 a.m. with HRD and DON, RN 3’s “Transcript,” undated, was reviewed. The “Transcript” indicated RN 3 was hired on 1/31/24 and had no documented evidence of nursing annual update training being conducted. The DON confirmed with the HRD there was no documented evidence of training being completed and the DON stated RN 3 should have completed the training annually. During an interview on 6/18/26 at 11:38 a.m. with the DON, the DON stated staff supervision of patients utilizing 1:1 training was important for ensuring patient safety when the patient was deemed high-risk. The DON further stated nursing orientation was over a month long to orient new staff to the facility’s policy and procedures (P&P), ensure competency, and needed to be documented in the employee’s file immediately after completion. The DON stated after nursing orientation, staff were to complete an annual nursing update to review P&P’s and skills. During a review of the facility’s P&P titled, “Staff Supervision of Patients Utilizing 1:1”...dated 5/11/26, the P&P indicated, “Training ... staff training in procedures for Enhanced observation supervision of high-risk patients shall be part of the clinical training during hospital-wide orientation and hospital annual update ...” During a review of the facility’s P&P titled, “Plan for Provision of Nursing Care-Nursing Orientation, Nursing Annual Updates,” dated March 2026, the P&P indicated,” ...a. Annual update classes are mandatory for all nursing personnel and provide staff with the opportunity to update their knowledge and skills. Nursing Annual Update is reviewed and updated on an ongoing basis to provide applicable information regarding patient care and nursing policies and procedures ...” 2. During a concurrent interview and record review on 6/18/26 from 10:15 a.m. to 11:31 a.m. with Human Resources Director (HRD) and Director of Nursing (DON) the following employee files were reviewed: a. Psychiatric Technician (PT) 1’s “Employee Record” indicated PT 1 was hired on 6/2/25 and did not contain documented evidence that performance evaluations had been conducted. b. PT 2’s “Employee Record” indicated PT 2 was hired on 4/1/25 and did not contain documented evidence that performance evaluations had been conducted. c.PT 4’s “Employee Record” indicated PT 4 was hired on 1/16/26 and did not contain documented evidence that performance evaluations had been conducted. d. Psychiatric Technician Assistant (PTA) 2’s “Employee Record” indicated PTA 2 was hired on 3/2/17 has not conducted an annual performance evaluation since 10/31/24. e. Registered Nurse (RN) 2’s “Employee Record” indicated RN 2 was hired on 6/10/24 has not conducted an annual performance evaluation since 6/9/25. f. RN 3’s “Employee Record” indicated RN 3 was hired on 1/31/24 and has not conducted an annual performance evaluation since 2/13/25. The HRD confirmed six licensed staff were not in compliance with facility’s policy and procedure (P&P) for completion of employee evaluations. The HRD stated PT 1, PT 2, and PT 4’s evaluations were supposed to be conducted every four months for the first probationary year and annually thereafter. The HRD further stated PTA 2, RN 2, and RN 3 should have had evaluations completed annually. During a review of the facility’s policy and procedure (P&P) titled, “Performance Appraisal and Employee Development,” dated 12/5/25, the P&P indicated, “At minimum, every employee should receive a Performance Appraisal Summary once every (12) months. All individuals who provide patient care services are required to receive a yearly evaluation to assess current clinical competency...””

“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: 34959 Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene (cleaning hands with soap and water or an alcohol-based hand sanitizer to prevent the spread of infection) after medication administration and between patients during medication administration for four (4) of (ten)10 sampled patients (Patient 7, Patient 8, Patient 9, and Patient 10). This failure had the potential to result in cross-contamination (is the transfer of harmful bacteria from one person to another) and the transmission of infectious organisms (can be spread through contaminated hands) between patients during medication administration. Findings: 1a. During a review of Patient 7’s “Face Sheet (demographic data),” undated, the “Face Sheet,” indicated, Patient 7 was admitted to the facility on 2/13/23 with a diagnosis of schizophrenia (fixed false beliefs that are not based on reality). During a review of Patient 7’s “Physician Orders” dated 6/1/26, the “Physician Orders,” indicated Patient 7’s following medications: * Olanzapine (used to treat schizophrenia) 30 milligrams (mg) tab rapdis (dissolves rapidly in the mouth) po (by mouth) daily at 12 p.m. During an observation on 6/16/26 at 11:05 a.m. in the medication room, Psychiatric Technician (PT) 2 administered the following medication to Patient 7: * Olanzapine 30 mg tab rapdis po daily at 12 p.m. PT 2 did not perform hand hygiene after medication administration and before contact with Patient 8. 1b. During a review of Patient 8’s “Face Sheet,” undated, the “Face Sheet,” indicated, Patient 8 was admitted to the facility on 1/25/18 with a diagnosis of schizoaffective disorder, bipolar type (disorganized thinking, depression, and elevated mood). During a review of Patient 8’s “Physician Orders” dated 6/3/26, the “Physician Orders,” indicated Patient 8’s following medications: * Venlafaxine hydrochloride (used for schizoaffective disorder, bipolar type) (HCL) (salt form) 225 mg Cap Extended-Release (ER) (medication is released gradually over 24 hours) po every 24 hours daily at 12 p.m. During an observation on 6/16/26 at 11:07 a.m. in the medication room, PT 2 administered the following medication to Patient 8: * Venlafaxine HCL 225 mg Cap ER po every 24 hours daily at 12 p.m. PT 2 did not perform hand hygiene after medication administration and before contact with Patient 9. 1c. During a review of Patient 9’s “Face Sheet (demographic data),” undated, the “Face Sheet,” indicated, Patient 9 was admitted to the facility on 8/11/15 with a diagnosis of schizoaffective disorder, bipolar type. During a review of Patient 9’s “Physician Orders” dated 6/1/26, the “Physician Orders,” indicated Patient 9’s following medications: * Calcium carbonate /vitamin D3 /calcium 600 mg-vitamin D3 10 (a supplement used to support bone health calcium and vitamin D deficiencies) microgram (mcg) one (1) tablet po TID (3 times a day). * Folic acid (helps the body make healthy red blood cells)1mg tablet daily po at 12 p.m. * Omega-3/(Docosahexaenoic acid (DHA)/Eicosapentaenoic Acid (EPA)//fish oil (helps the eye, heart, and brain) Enteric Coated (EC) (allows the medication pass through the stomach and dissolve) 1000 mg soft gel 1 capsule po TID. During an observation on 6/16/26 at 11:09 a.m. in the medication room, PT 2 administered the following medications to Patient 9: * Calcium carbonate /vitamin D3 /calcium 600 mg-vitamin D3 10 mcg 1 tablet po TID. * Folic acid 1mg tablet po daily at 12 p.m. * Omega-3/ (DHA)/(EPA)//fish oil EC 1000 mg soft get 1 capsule po TID. PT 2 did not perform hand hygiene after medication administration and before contact with Patient 10. 1d. During a review of Patient 10’s “Face Sheet (demographic data),” undated, the “Face Sheet,” indicated, Patient 10 was admitted to the facility on 5/19/26 with a diagnosis of schizophrenia. During a review of Patient 10’s “Physician Orders” dated 6/3/26, the “Physician Orders,” indicated Patient 10’s following medications: * Midodrine HCL (to treat low blood pressure) 10 mg tablet po TID. * Oxybutynin chloride (to treat frequent urination) 5 mg tablet po TID. * Clonazepam (for schizophrenia) 1.5 mg tablet po TID. During an observation on 6/16/26 at 11:14 a.m. in the medication room, PT 2 administered the following medications to Patient 10: * Midodrine HCL 10 mg tablet po TID. * Oxybutynin chloride 5 mg tablet po TID. * Clonazepam 1.5 mg tablet po TID. PT 2 did not perform hand hygiene after medication administration. During an interview on 6/16/26 at 11:15 a.m. with PT 2, PT 2 stated that she only washes her hands with soap and water after every third patient. During an interview on 6/17/26 at 2:52 p.m. with Public Health Nurse (PHN), PHN stated that the expectation was for the psychiatric technicians to perform hand hygiene using soap and water or an alcohol-based hand sanitizer before and after medication administration and between patient contacts. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration Protocol” dated December 2025, the P&P indicated,”...F.Perform hand hygiene using soap and water or alcohol-based hand sanitizer before and after administration of medications/treatments and between administering medications/treatments to each patient ...””

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 29492 Based on observation, interview and record review, the facility failed to separate three COVID-19 positive patients (Patients 1, 2 & 3) from non COVID-19 patients on Unit 410. This failure had the potential for COVID-19 infection for 37 patients on Unit 410. Findings: During an interview on 4/24/24 at 10 a.m. with Public Health Nurse 1 (PHN 1), PHN 1 stated Unit 410 was on quarantine precautions for COVID-19 and had been for approximately two weeks. PHN 1 stated three new patients had tested positive for COVID-19 that morning. PHN 1 stated the positive patients were being prepared to be transferred to the COVID-19 unit (Unit 702). PHN 1 stated the procedure was to isolate the positive patients and encourage them to wear a surgical mask. During an interview with Registered Nurse 1 (RN 1) on 4/24/24 at 11:15 a.m., RN 1 stated he was preparing transfer paper work for Patients 1, 2 & 3 to go to the covid unit. RN 1 stated they had tested positive around 8:30 a.m. that morning. RN 1 stated transportation could sometimes take up to four hours or longer depending on how busy transport was. RN 1 stated the positive patients were still in their regular assigned rooms. During an observation and interview on 4/24/24 at 11:25 a.m., with Supervising Psychiatric Technician 1 (SPT 1) in room 214, three male patients (Patients 3, 7 & 8) were observed in the room without a mask. SPT 1 stated Patient 3 had tested positive that morning. Patients 7 & 8 had tested negative for covid. During a concurrent observation and interview on 4/24/24, at 11:30 a.m., with SPT 1 in room 205, Patient 1 was observed laying on her bed without a mask on. Three other patients (Patients 4, 5, & 6) were roommates with Patient 1. SPT 1 stated Patient 1 tested positive for COVID-19 that morning at approximately 8:30 a.m. She further stated Patients 4, 5, & 6 (her roommates) had all tested negative. During an observation on 4/24/24, at 11:32 a.m., Patient 5 was observed without a mask wandering in and out of room 205. During an observation on 4/24/24, at 11:39 a.m., Patient 2 was observed in room 206, laying on his bed without a mask on and coughing. Patient 2’s roommate (Patient 9) was not in the room at that time. Patient 9 had tested negative earlier that morning. During an interview with Unit Supervisor 1 (US 1) on 4/24/24, at 11:34 a.m., she stated the covid positive patients were all still in their same rooms with the negative patients while awaiting transportation to the covid unit. US 1 stated they should have been separated, however there was not enough room to do so. During an interview on 4/24/24, at 1:58 p.m., with PHN 2 she stated after a patient tests positive for COVID-19, that patient should wear a surgical mask and be isolated from the rest of the patients while awaiting transfer. A review of the facility’s policy and procedure (P&P) titled, “Care of Patients on Isolation Unit for testing Positive for COVID-19 and Patients Under Investigation for COVID-19,” dated revised June 2021, the P&P indicated, “...C. Patient Placement 1. Only patients with the same respiratory pathogen may be housed (cohort) in the same room (e.g., a patient with COVID-19 should not be housed in the same room as a patient with an undiagnosed respiratory infection or PUI [person under investigation]...””