Glendora Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient’s Rights was met, as evidenced by: 1. The facility failed to ensure its nursing staff addressed a patient concern and notified a physician for one (1) of 30 sampled patients (Patient 13), when Patient 13 verbalized concern with right knee and requested to have an X ray (an imaging procedure to create detailed image of the body’s internal structure such as bones, tissues and organs) on 1/3/2026, in accordance with the facility’s policy on patient rights pertaining to prompt medical care and treatment. This deficient practice resulted in a violation in Patient 13’s right for requesting medical treatment and had the potential to cause delay in evaluation and treatment that Patient 13 needed. (Refer to A-0129) 2. The facility failed to ensure two of 30 sampled patients (Patient 1 and Patient 2), who were on involuntary holds (a legal process where a person is held against their will in a mental health facility for evaluation and treatment due to concerns about their mental state and potential risk to themselves or others) and with physician order of line of sight (LOS, high level safety protocol requiring staff to maintain direct, continuous, and unobstructed visual contact with a patient), received care in a safe environment when: 2.a. Staff did not maintain adequate constant visual monitoring for Patient 1 who required LOS observation when Patient 1 was able to force a locked door (Door 2) open and eloped (a person leaves a safe, supervised area without permission due with behavioral issues) from the facility on 3/22/2025 at 4:05 p.m. Patient 1 eloped from the facility on 3/22/2025 and did not return. This deficient practice resulted in Patient 1’s elopement from the facility hence putting Patient 1’s safety at risk including but not limited to various dangers outside of the facility, self-harm or injury. (Refer to A-0144) 2.b. The facility failed to ensure the staff were assigned to remain at Door 2 (Door that was forcibly opened by Patient 1 and was used for eloping on 3/22/2025) at all times to prevent elopement, given that Door 2 could be opened in the same manner as Patient 1 used during the elopement incident on 3/22/2025. This deficient practice had the potential to compromise other patients’ safety including but not limited to another patient using the same door again to elope from the facility. (Refer to A-0144) 2.c. The facility failed to implement an audit mechanism to verify that all staff received the in-service training on the line-of-sight (LOS) and failed to ensure compliance among staff in following line-of-sight precautions, after the incident involving Patient 1’s elopement from the facility on 3/22/2025. This deficient practice had the potential to place other patients’ safety at risk by not being adequately observed by staff, preventing timely intervention when necessary. (Refer to A-0144) 2.d. Staff failed to maintain constant unobstructed view on Patient 2, who required LOS observation, when Patient 2 was left in the room (Patient 2’s room) with door closed, while a Mental Health Worker sat outside Patient 2’s room with no direct line of sight of Patient 2, on 1/20/2026. This deficient practice had the potential to put Patient 2’s safety at risk including but not limited to danger to self or danger to others for not being observed, which may delay necessary intervention when needed. (Refer to A-0144) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Quality Assessment and Performance Improvement Program (QAPI) was met, as evidenced by: 1. The facility’s Quality Assessment and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) team failed to collect, track and trend data on critical patient safety indicators, implement comprehensive action plan, and measure the success of actions taken and track performance to ensure improvements are sustained, in accordance with the facility’s performance improvement plan, when the QAPI team: 1.a. Failed to collect, track, and report patient mortality (patient death occurred in the hospital) data including one (1) of 30 sampled patient’s (Patient 12), which happened on 3/2/2025, to the QAPI team during the QAPI meetings, Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital) and the Governing Board (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making). This deficient practice had the potential for the facility being unable to identify safety gaps, analyze factors that may have contributed to Patient 12’s death, and identify and address potential problems which had the potential to affect quality of patient care and safety. (Refer to A-0273) 1.b. Failed to verify accurate AWOL (absent without official leave, elopement, leaving the hospital without discharge order from physician) data and did not include one (1) of 30 sampled patient’s (Patient 1) AWOL incident in the QAPI, MEC and GB reports. This deficient practice led to inaccurate AWOL data being reported to medical staff and GB and prevented the QAPI team from analyzing Patient 1’s elopement and addressing potential issues which had the potential to affect the quality of patient care and safety. (Refer to A-0273) 2. The facility’s Quality Assurance Performance Improvement team (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) failed to analyze an adverse patient event (preventable, serious and unambiguous occurrence or error at a healthcare facility that is universally or largely preventable and should never occur) when it failed to conduct a comprehensive root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution ) regarding patient elopement (leaving the hospital without authorization or physician order), involving one of 30 sampled patients (Patient 1), and failed to implement appropriate corrective actions and compliance audit mechanisms in a timely manner, in accordance with the facility’s performance improvement plan, in order to ensure there was proper observation or monitoring provided for patients who are placed on line-of-sight (LOS, a straight line along which an observer had unobstructed vision) monitoring in the Unit 2 (inpatient unit that provided treatment and therapy for patients who have mental, emotional and behavioral disorders). This deficient practice regarding the lack of a comprehensive analysis of an adverse patient event had the potential for another incident of elopement to occur which puts other patients at risk for injury or harm. (Refer to A-0286) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by: 1. The facility failed to ensure that one of 30 sampled patient’s (Patient 29), observation-type safety precautions (specific safety measures implemented to monitor patients at risk, such as fall risk [potential for a patient to fall and sustain injury, often due to mobility issues, medication effects, or cognitive impairment]), were properly documented and implemented for Patient 29. This would include specific measures such as fall precautions, reflecting what safety measures were in place and observations made for Patient 29 during the Q 15-minute patient rounds (a structured, proactive process where healthcare staff visit patients at regular intervals to address patient needs and improve safety). In addition, the Q15-minute round sheets (records used by staff to document patient checks every 15 minutes to ensure continuous safety monitoring) were not always signed by the appropriate staff members (Mental Health Workers and Supervising Licensed Nursing Staff) as required by the facility’s care expectations and procedures regarding Q15-minute observation rounding sheets (Q15 refers to checks performed every 15 minutes to monitor patient safety and behavior). This deficient practice had the potential to compromise Patient 29’s safety when required fall precautions (specific safety measures designed to prevent injury from falls) and patient observations/monitoring were either not followed/implemented or not verifiable, potentially leading to Patient 29’s multiple falls. (Refer to A-0395) 2. The facility failed to ensure that three (3) Mental Health Workers ([MHW] 7, 8, and 9) performed rounding on patients every fifteen (15) minutes (Q15min), as assigned by Registered Nurse (RN), for 12 out of 30 sampled patients (Patient 8, 11, 14, 15, 16, 17, 18, 22, 24, 25, 26, and 27) on 1/20/2026 from 2 a.m. to 3 a.m., to monitor each patient’s location and behavior, in accordance with the facility’s policy regarding patient safety rounds (patient safety rounds refer to scheduled checks performed by staff at regular intervals, such as every 15 minutes, to monitor patient location, behavior, and overall safety, ensuring that precautions are in place to prevent harm to the patient or others). This deficient practice had the potential to result in delay in identifying patients’ risk behavior including harming self and harming others, putting the safety of Patients 8, 11, 14, 15, 16, 17, 18, 22, 24, 25, 26, and 27 at risk. (Refer to A-0395) 3. The facility failed to ensure three (3) MHWs (MHW 7, 8, and 9) maintained constant visual monitoring on patients as assigned by Registered Nurse for three (3) of 30 sampled patients (Patient 2, 20, and 21) requiring line of sight observation (a straight line along which an observer had unobstructed vision) on 1/20/2026 from 2 a.m. to 3 a.m., in accordance with the facility’s policy regarding patient safety rounds (patient safety rounds refer to scheduled checks performed by staff at regular intervals, such as every 15 minutes, to monitor patient location, behavior, and overall safety, ensuring that precautions are in place to prevent harm to the patient or others). This deficient practice had the potential to result in delay in identifying patients’ risk behavior including harming self and harming others and providing interventions in a timely manner, putting the safety of Patients 2, 20, 21 and other patients at risk. (Refer to A-0395) 4. The facility failed to ensure staff maintained a line-of-sight (LOS, a straight line along which an observer had unobstructed vision) monitoring, in accordance with the facility’s policy and procedure (P&P) titled, “Precaution Protocol and Risk Levels,” for one of 30 sampled patients (Patient 1), when Patient 1 was able to force open a locked door (Door 2) and eloped (leaving the hospital without authorization or physician order). This deficient practice regarding inadequate line of sight monitoring had the potential to compromise patient safety for Patient 1 such as involvement in traffic accidents, falls, and exposure to extreme weather when eloped and may also result in other incidents of elopement, self-harm, or harm to other patients due to lack of patient monitoring. (Refer to A-0395) 5. The facility failed to ensure one of 30 sampled patient’s (Patient 29) neurological assessment (a systematic evaluation of a patient’s nervous system function, including level of consciousness, motor and sensory function, reflexes, and cranial nerve responses), was completely performed and documented in Patient 29’s electronic medical record (EMR, a digital version of a patient’s medical chart that contains health information, treatment history, and clinical documentation), in accordance with the facility’s policy and procedure regarding assessments and reassessments, after Patient 29 sustained an unwitnessed fall (an incident where a patient falls without anyone observing the event, making it unclear whether there was head trauma or loss of consciousness) and had an order to be monitored for neurological function for 24 hours after the fall. This deficient practice had the potential to place Patient 29 at an increased risk for missed signs of neurological worsening, such as changes in motor weakness (a decrease in muscle strength or inability to move a limb effectively, which can indicate damage to the brain or spinal cord) or abnormal reflexes (unexpected or absent automatic responses to stimuli, such as the knee-jerk reaction, which can signal neurological impairment), and of delayed recognition of bleeding inside the skull (intracranial hemorrhage), which can be life-threatening if not promptly identified and treated. (Refer to A-0398) 6. The facility failed to ensure one of 30 sampled patient’s (Patient 3) pain assessment (a systematic evaluation of a patient’s pain, including location, intensity, duration, and characteristics, often using a standardized pain scale), was completely performed (pain assessment must include pain location, intensity, and characteristics of pain) and documented in Patient 3’s EMR (electronic medical record), in accordance with the facility’s policy and procedure regarding pain assessment and intervention (intervention refers to the actions or treatments taken to alleviate or manage pain based on the assessment findings, such as administering medication or repositioning). This deficient practice had the potential to result in delayed and inadequate pain management for Patient 3 because the location, intensity, and characteristics of pain were not described, placing Patient 3 at risk of worsening pain and psychological distress (such as anxiety). (Refer to A-0398) 7. The facility failed to ensure one of 30 sampled patient’s (Patient 3) detailed neurological assessment (a systematic evaluation of the nervous system, including motor, sensory reflexes [rapid, involuntary motor responses to specific sensory stimuli, acting as protective or functional mechanisms without requiring conscious thought], and cognitive functions [the ability to perceive and react, process and understand, make decisions and produce appropriate responses to the environment]) and NIH Stroke Scale (NIHSS, a standardized tool used to measure the severity of stroke symptoms and guide treatment decisions), was performed after Patient 3 complained of weakness (loss of strength in muscles) and one-sided pain (pain localized to one side of the body), as per the physician’s order and the facility’s policy regarding assessment, reassessment, and documentation. This deficient practice had the potential to result in a serious safety event for Patient 3, which could lead to permanent neurological damage, and/or delayed or missed diagnosis of stroke (brain attack). (Refer to A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 50594 Based on observation, interview and record review, the facility’s governing body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to provide oversight to the facility’s Quality Assurance Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) team to ensure that a thorough investigation was completed for one of 30 sampled patients (Patient 1) and to implement proper action plan and monitoring after Patient 1 eloped (a person leaves a safe, supervised area without permission) from the facility on 3/22/2025, in accordance with the facility’s Governing Body bylaws (laws and regulations that establish the internal structure, operations, and decision-making processes of an organization) pertaining to overseeing performance improvement activities, ensuring patient safety, and provision of quality patient care. This deficient practice had the potential to compromise patient safety and quality of care and puts other involuntary hold (a legal process where a person is held against their will in a mental health facility for evaluation and treatment due to concerns about their mental state and potential risk to themselves or others) patients requiring line of sight observation (LOS, a straight line along which an observer had unobstructed vision) to remain in an unsafe setting and at risk for injury due to lack of appropriate staff monitoring, resulting from the facility’s inadequate action plan that outlines necessary patient safety measures. Findings: During a review of Patient 1’s, History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 3/18/2025, the “H&P” indicated, Patient 1 was admitted on 3/18/2025 on 5150 hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment), for suicidal ideation (thoughts of taking one’s own life) with a plan to overdose on pills and jump from a bridge. During a review of Patient 1’s, “Patient Monitoring,” record, dated 3/21/2025, the records indicated Patient 1 had a physician’s order for LOS (a straight line along which an observer had unobstructed vision) level of monitoring for being a Danger to Others (DTO, where an individual poses a risk of harm to others) and AWOL (Absent Without Leave, patient who has left a hospital, treatment facility or care setting without permission or vanishes while under care). During a concurrent interview and record review on 1/21/2026 at 12:52 p.m. with the Director of Psychiatric Service (DIR 1), Patient 1’s “Progress Notes non-physician (nurses notes),” dated from 3/19/2025 to 3/22/2025, was reviewed. The record indicated the following: -On 3/19/2025 at 2:40 p.m., Patient 1 was agitated, attempted to AWOL (Absent Without Leave, leaving the facility without authorization), wanted to transfer to another facility and to smoke. -On 3/20/2025 at 7:10 a.m., Patient 1 tried to walk out of the facility. -On 3/21/2025 at 10:00 a.m., Patient 1 informed staff, “I’m not good, I can’t spend another night in the psych (Psychiatric) ward I want to smoke and go to groups,” Patient 1 also punched the wall and run toward the door.” -On 3/22/2025 at 6:50 a.m., Patient 1 did not like to be at the facility. Patient 1 attempted to AWOL. Patient exited the Unit 2 door (another door closer to the courtyard per staff interview) and was held down by the security and staff. -On 3/22/2025 at 4:05 p.m. “patient (Patient 1) AWOL by slamming his body on the double door (Door 2 in Unit 2) leading to the outside hallway.” -DIR 1 confirmed Patient 1 had made multiple AWOL attempts throughout the stay. DIR 1 also confirmed LOS observation was only in place after Patient 1’s AWOL attempt (3rd attempt) on 3/21/2025 in the morning. DIR 1 stated nursing staff should have escalated the observation level to 1:1 (one-to one observation where a staff member is assigned to maintain continuous direct or arm’s length supervision of a patient to ensure safety ) for Patient 1 after AWOL attempt on 3/22/2025 at 6:50 a.m. DIR 1 stated, “he (Patient 1) should be put on 1:1.” During an interview on 1/21/2026 at 1:04 p.m. with the Quality Supervisor (QS), QS stated a root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution) was conducted on 3/23/2025, the root cause analysis identified that staff could have approached Patient 1 when Patient 1 was ramming the unit exit door (Door 2) with his body. QS stated RCA did not identify any other issue during the RCA (The QAPI team did not identify the issue with monitoring/auditing of LOS following the incident of 3/22/2025 to ensure compliance with LOS interventions). During an interview on 1/22/2026 at 10:03 a.m. with the Quality Specialist (QS), QS stated the following: after the elopement incident (on 3/22/2025), an in-service on Code Green and AWOL Precautions was reportedly conducted; however, details about who provided the education were unclear. QS further noted that the staff roster for the training started on 3/23/2025, but there was no set deadline, and the roster remained incomplete with many missing signatures. During an interview on 1/22/2026 at 10:06 a.m. with QS, QS stated the following: previously, there was trust in nursing to manage corrective actions independently, but moving forward, closer monitoring would be necessary. QS admitted not monitoring the education component and confirmed that auditing for line of sight (LOS) compliance had not been performed. According to the QS, nursing did not monitor LOS observation compliance either, or there was no system in place for compliance tracking. During an interview on 1/22/2026 at 10:13 a.m. with QS, QS stated the following: there was no paper trail regarding the expectation for Mental Health Workers (MHWs) to remain at the doors (Door 1 and Door 2 [Door 2 was where Patient 1 left]). QS recalled that an employee had been stationed at the door for at least a couple of months but could not confirm exact details. QS further stated that they did not believe a formal in-service was conducted; rather, the topic appeared to have been discussed informally during nursing departmental meetings and said that it was unclear whether these discussions were prompted by the elopement incident [on 3/22/2025] or by other patient attempts to elope. QS did not have specific details regarding those incidents of elopement or whether they occurred. During an interview on 1/23/2026 at 4:17 p.m. with the Quality Supervisor (QS), QS stated the following: patient elopement was considered as an adverse event (preventable, serious and unambiguous occurrence or error at a healthcare facility that is universally or largely preventable and should never occur). QAPI was responsible for investigating and discussing adverse events in the QAPI (Quality Assurance Performance Improvement, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital), MEC (Medical Executive Committee, representing a hospital’s medical staff, responsible for overseeing patient care quality, safety, and performance. It acts as a bridge between physicians and hospital administration, enforcing bylaws, approving policies, and making recommendations on staff credentialing, privileges, and peer reviews) and GB meetings so that everyone would provide feedback and determine if the action plan that was implemented was appropriate or not. QS further stated Patient 1’s elopement on 3/22/2025 should have been reported to GB. QS stated, “they were the leadership. They needed to be aware.” During a review of the facility’s list of “Governing Board of Directors,” dated 7/1/2021, the list indicated the Chief Executive Officer (CEO) was a member of the GB. During an interview on 1/26/2026 at 3:37 p.m. with the Chief Executive Officer (CEO), the CEO stated the following: GB delegated the QAPI team to perform investigations on any adverse event including AWOL. Adverse events would be reported in QAPI meetings and either department of medicine or department of psychiatry, then reported to MEC then to GB on a quarterly basis. CEO further stated GB needed to know all adverse events, what caused the adverse events, what could be done differently in order to prevent the adverse events from happening again. During a concurrent interview and record review on 1/26/2026 at 3:54 p.m. with the Chief Executive Officer (CEO), the facility’s “Department of Psychiatry Meeting (psych dept minutes)” meeting minutes, dated 7/17/2025 and “Governing Board of Directors Meeting (GB minutes)” meeting minutes, dated 8/27/2025, were reviewed. Both minutes (psych dept minutes and GB minutes) indicated, “First Quarter of 2025 ... AWOLs - zero (0) cases.” CEO stated the data was presented by the nursing department, but the Quality department was responsible to provide oversight on data accuracy. CEO further stated since the wrong AWOL data was presented to Department of Psychiatry, the same wrong data was presented to GB. During an interview on 1/26/2026 at 3:58 p.m. with CEO, CEO stated without documenting in the meeting minutes, there was no proof that GB was made aware of Patient 1’s elopement incident and had discussion about the incident. During an interview on 1/26/2026 at 4:02 p.m. with the CEO, the CEO stated that the manner by which LOS was being conducted was a significant issue. The CEO also stated that staff education alone was insufficient to address the issue and that proper monitoring or auditing for compliance was also necessary to be put in place. The CEO further stated they knew LOS was a problem, but they did not have a current PI (Performance Improvement plan, a method for analyzing performance problems and setting up systems to ensure good performance) plan for patient rounding audits in the facility. During review of facility’s policy and procedure (P&P) titled, “Precaution Protocol and Risk Levels,” dated 3/2025, the P&P indicated, “Precautions are instituted whenever a patient is at risk for acting on suicidal, assaultive, or runaway impulses... The attending physician will determine the appropriate precaution level of their patient based on patient behaviors and need with the input of members of the interdisciplinary team. 1. Suicide, assault, AWOL precautions: A. An RN may institute any precaution level subsequently notifying the physician and obtaining a doctor’s order. B. Upon initiation of precaution, the RN must document, in the EMR, the patient behaviors warranting the precaution ... 2. Risk levels: one-to-one, line of sight and Q15 minute check. A. One-to one (1:1): 1. Highest intensity of level of observation... B. LOS (line-of-sight): 1. LOS observation is when a patient is in LOS of staff at all times including bathroom privileges... C. Q15 minutes close observation: 1. Suicide precaution 1 (SP 1), Assault precautions (AS 1), AWOL precaution (AWOL 1). 2. Patients are checked every 15 minutes. 3. Patients are evaluated for safety in the milieu at each check.” During a review of facility’s policy and procedure (P&P) titled, “Rights for Individual In Mental Health Facilities,” undated, the P&P indicated, “You also have the right to be free from potential harmful situations or conditions.” During a review of the facility’s GB bylaws (laws and regulations that establish the internal structure, operations, and decision-making processes of an organization), dated 7/1/2021, the bylaws indicated, “The primary function of the Governing Board is to assure that the Hospital and it’s Medical Staff provide quality medical care that meets the needs of the community. For this purpose, the Board of Directors has delegated to the Governing Board the authority to receive and evaluate periodic reports from the Medical Staff and its officers, to make decisions regarding Medical Staff appointment and Clinical Privileges, to oversee performance improvement, utilization review, risk management, patient safety, identification and reduction of medical errors and similar matters regarding the provision of quality patient care at the hospital and to establish policies regarding these matters.””

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its nursing staff addressed a patient concern and notified a physician for one (1) of 30 sampled patients (Patient 13), when Patient 13 verbalized concern with right knee and requested to have an X ray (an imaging procedure to create detailed image of the body’s internal structure such as bones, tissues and organs) on 1/3/2026, in accordance with the facility’s policy on patient rights pertaining to prompt medical care and treatment. This deficient practice resulted in a violation in Patient 13’s right for requesting medical treatment and had the potential to cause delay in evaluation and treatment that Patient 13 needed. Findings: During a review of Patient 13’s “Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 12/17/2025, the psych eval indicated, Patient 13 was admitted to the facility on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to concerns of grave disability (means the person is unable to provide for their basic needs such as food, clothing, or shelter because of a mental disorder) with admitting diagnosis of major depressive disorder (MDD, a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Patient 13’s “Progress Note Non-Physician (nurses notes, nursing narrative notes),” dated 1/3/2026, the “nurses notes” indicated, Patient 13 informed Registered Nurse (RN) 8 that Patient 13 needed an X ray (an imaging procedure to create detailed image of the body’s internal structure such as bones, tissues and organs) on Patient 13’s right knee because sometime ago someone kicked Patient 13. The nurses notes further indicated RN 8 would follow up with medical doctor. During an interview on 1/20/2026 at 11:18 a.m. with the Director (DIR 1) of Psychiatric Services (inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders), DIR 1 stated nursing staff would communicate with physicians and would get order to address a patient’s medical complaint. During an interview on 1/22/2026 at 4:09 p.m. with Nurse Manager (NM) 1, NM 1 stated there was no evidence of nursing communication with physician regarding Patient 13’s right knee concern and no medical physician progress notes found in Patient 13’s medical record. During an interview on 1/23/2026 at 11:49 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated there was no X ray ordered for Patient 13 during hospitalization. During an interview on 1/23/2026 at 12:54 p.m. with a physician (MD 2), MD 2 stated nurses should communicate with physician if patient had any medical concern. MD 2 further stated if a patient had medical concern and wanted an X ray, he (MD 2) would order an X ray for the patient. During an interview on 1/23/2026 at 12:55 p.m. with RN 8, RN 8 stated the following: Patient 13 informed her (RN 8) that the right knee pain was from long time ago prior to hospitalization. RN 8 did not inform the medical doctor. RN 8 endorsed Patient 13’s concern to the following shift for follow up. RN 8 stated, “I trust the nurse to follow up with the physician.” During a review of the facility’s patient handbook titled, “Rights for Individuals in Mental Health Facilities,” dated 5/2014, the patient handbook indicated, “Medical Treatment ... While you are staying in a facility, you have the right to prompt medical care and treatment. Helpful Hints: if you do not feel well or are in pain, let your doctor or a treatment staff member know right away. If you have any question about your treatment, talk to your doctor or a treatment staff member or ask you advocate for help.””

“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: 50594 Based on observation, interview and record review the facility failed to ensure two of 30 sampled patients (Patient 1 and Patient 2), who were on involuntary holds (a legal process where a person is held against their will in a mental health facility for evaluation and treatment due to concerns about their mental state and potential risk to themselves or others) and with physician order of line of sight (LOS, high level safety protocol requiring staff to maintain direct, continuous, and unobstructed visual contact with a patient), received care in a safe environment when: 1.a. Staff did not maintain adequate constant visual monitoring for Patient 1 who required LOS observation when Patient 1 was able to force a locked door (Door 2) open and eloped (a person leaves a safe, supervised area without permission due with behavioral issues) from the facility on 3/22/2025 at 4:05 p.m. Patient 1 eloped from the facility on 3/22/2025 and did not return. This deficient practice resulted in Patient 1’s elopement from the facility hence putting Patient 1’s safety at risk including but not limited to various dangers outside of the facility, self-harm or injury. 1.b. The facility failed to ensure the staff were assigned to remain at Door 2 (Door that was forcibly opened by Patient 1 and was used for eloping on 3/22/2025) at all times to prevent elopement, given that Door 2 could be opened in the same manner as Patient 1 used during the elopement incident on 3/22/2025. This deficient practice had the potential to compromise other patients’ safety including but not limited to another patient using the same door again to elope from the facility. 1.c. The facility failed to implement an audit mechanism to verify that all staff received the in-service training on the line-of-sight (LOS) and failed to ensure compliance among staff in following line-of-sight precautions, after the incident involving Patient 1’s elopement from the facility on 3/22/2025. This deficient practice had the potential to place other patients’ safety at risk by not being adequately observed by staff, preventing timely intervention when necessary. 2. Staff failed to maintain constant unobstructed view on Patient 2 who required LOS observation, when Patient 2 was left in the room (Patient 2’s room) with door closed, while a Mental Health Worker sat outside Patient 2’s room with no direct line of sight of Patient 2, on 1/20/2026. This deficient practice had the potential to put Patient 2’s safety at risk including but not limited to danger to self or danger to others for not being observed, which may delay necessary intervention when needed. On 1/22/2026 at 1:59 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Quality Supervisor (QS), Quality Supervisor (QS 2), Director of Psychiatric Services (DIR 1), Nurse Manager (NM 1) and Policy and Procedure Quality Coordinator (PPQC). The facility failed to provide a safe environment for involuntary hold (a legal process where a person is held against their will in a mental health facility for evaluation and treatment due to concerns about their mental state and potential risk to themselves or others) patients, who were at risk for AWOL (Absent Without Leave, leaving the facility without authorization), requiring line-of-sight (LOS, a straight line along which an observer had unobstructed vision) monitoring, when the facility’s staff failed to provide continuous visual monitoring for Patient 1 on 3/22/2025, which resulted in Patient 1 successfully forcing a locked unit (Unit 2) exit door (Door 2) open and then eloped (a person leaves a safe, supervised area without permission due with behavioral issues) from the facility on 3/22/2025. The Facility continued failing to ensure staff performed constant, unobstructed visual monitoring on other patients requiring LOS observation during the survey team’s onsite observation (which began on 1/20/2026), when facility’s staff failed to maintain visual contact on a patient (Patient 2) on LOS observation, by allowing Patient 2’s door to remain closed despite Patient 2 being inside the room on 1/20/2026 (The closed door did not allow for constant unobstructed visual monitoring of Patient 2). The facility also failed to implement monitoring mechanisms to ensure corrective action was implemented consistently to prevent patients from eloping. These deficient practices continued to pose risks for patients requiring line of sight observation. These different safety risks include danger to self, danger to others and elopement due to lack of adequate monitoring. On 3/18/2025, Patient 1 was admitted to the facility on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal (harming self or ending own’s life) ideation with plan to overdose on pills and to jump off the bridge. Throughout the hospitalization, Patient 1 made multiple AWOL attempts. Physician ordered a line of sight (LOS) observation for Patient 1 on 3/21/2025. On 3/22/2025, Patient 1 eloped from the facility by forcing a locked unit (Unit 2) exit door (Door 2) open. During a security video footage review on 1/21/2026 at 11:40 a.m., it was observed that on 3/22/2025 at 4:07 p.m., Patient 1 was pacing alone in the hallway, then ran into the locked unit exit door (Door 2) to force it open and escaped. There was no staff providing line of sight observation or to stop Patient 1 at the time of Patient 1’s elopement. Facility performed a root case analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution) shortly after the incident and decided to re-enforce line of sight education for staff and placing a staff member at unit exit door (Door 2). During an observation on 1/20/2026 at 11:28 a.m., Patient 2, who had a line-of-sight observation order, was found inside the patient (Patient 2’s) room with door closed while a mental health worker was sitting outside Patient 2’s room. Further security video footage reviewed on 1/22/2026, indicated observations on 1/17/2026 and 1/20/2026 in which there were multiple times where there were no staff sitting at or monitoring Door 2 to prevent patients from being AWOL. In addition, the facility did not have any audit mechanism to ensure LOS observation compliance. The failure to maintain constant visual monitoring on involuntary hold (a legal process where a person is held against their will in a mental health facility for evaluation and treatment due to concerns about their mental state and potential risk to themselves or others) patients requiring line of sight monitoring by staff, places current patients at risk for dangers to self, danger to others and elopement. On 1/26/2026 at 4:24 p.m., the IJ was removed in the presence of the CEO, DIR 1, PPQC, CNO, QS, QS 2, LVN 1, DIR 4. The elements of the IJ Removal Plan (interventions to correct the deficient practice) were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that for immediate action taken by the facility, the facility provided training on LOS procedures for staff at the start of each shift, before patient care began, and would continue until all staff had completed the training in all patient care units. The staff education included mandatory in-service education and attestation of “Line of Sight (LOS) - Zero Tolerance Attestation” for proper LOS protocol, emphasizing continuous visual monitoring, accurate every fifteen (15) minute documentation, keeping LOS patient doors open, getting staff coverage for break and zero tolerance for non-compliance. LOS monitoring assignment would be indicated on daily assignment sheet. Staff responsibilities are clearly defined: Charge RNs must assign and communicate observation levels (Q15 [every fifteen minute rounding], LOS [line of sight], 1:1 [one to one]) at shift start and huddles, and conduct audits; RNs must obtain physician orders for LOS/1:1, reassess every shift, and request discontinuation when appropriate; Mental Health Workers (MHWs) must document rounds, maintain visual contact for LOS/1:1, and immediately report AWOL behaviors to the nurse; Staffing Coordinators ensure adequate coverage per orders and patient acuity (a measurement of the intensity of care, nursing time, and resources a patient requires based on the severity of their illness, stability, and complexity); all staff must report escalating behaviors promptly for possible upgrade in monitoring. Leadership oversight includes multiple audits per shift and twice-weekly video reviews, while a mental health worker would be assigned to perform environmental safety checks to verify door functionality each shift. A new policy titled, “AWOL Risk Identification and Mitigation” would be developed along with the above measures aim to reduce AWOL risk, strengthen patient safety, and support. Findings: 1.a. During a review of Patient 1’s “Application For Up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment, (5150 hold paperwork, a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be danger to themselves, to others, or gravely disabled [unable to take care of themselves]),” dated 3/17/2025, the 5150 hold paperwork indicated, Patient 1 was detained for being a danger to self with a plan to commit suicide (killing self) by overdosing on pills and to jump from a bridge. During a review of Patient 1’s “Face Sheet (front page of the chart that contains a summary of basic information about the patient),” not dated, the face sheet indicated, Patient 1 was admitted to the facility’s behavioral health service (treatment for mental health conditions and behaviors that impact overall well-being, including emotional, psychological, and social aspects) on 3/18/2025. During a review of Patient 1’s History and Physical (H&P, a formal and complete an assessment of the patient and the problem), dated 3/18/2025, the H&P indicated, Patient 1 was admitted on 3/18/2025 on 5150 hold for suicidal ideation (thoughts of taking one’s own life) with a plan to overdose on pills and to jump from a bridge. During a review of Patient 1’s record, the record indicated Patient 1 weighed 84.1 kilogram (kg, the system unit of mass equivalent to approximately 2.2 lbs [pounds, a unit of weight or mass]). During a review of Patient 1’s, “Patient Monitoring” record, dated 3/21/2025, the record indicated, Patient 1 had a physician’s order for LOS (a straight line along which an observer had unobstructed vision) for Danger to Others (DTO, where an individual poses a risk of harm to others) and AWOL (Absent Without Leave, leaving the facility without authorization). During a concurrent observation and interview on 1/21/2026 at 11:40 a.m. with the Director of Psychiatric Services (DIR) 1, the surveillance footage from 3/22/2025, was reviewed. The security camera was pointed at the hallway and double door of (Door 2). The following events were observed at the indicated timestamps in the video: -at 4:07 p.m. on 3/22/2025: Patient 1 was pacing alone in the hallway between the nursing station and unit exit (Door 2). Patient 1 was walking towards the unit exit door (Door 2). There was a staff standing at the nursing station; -at 4:08 p.m.: Patient 1 went to the unit exit door (Door 2) and pushed the unit exit door once. The unit exit door remained closed. Patient 1 then backed up and slammed his body into the door, but the door remained closed. Patient 1 backed up again and slammed his body into the door again. Unit exit door (Door 2) was opened. Patient 1 went through the unit exit door (Door 2). There was no one around to stop Patient 1. Two staff members were seen walking to the unit exit door after Patient 1 left. -DIR 1 stated the staff did not look at Patient 1. There was no line of sight of Patient 1. DIR 1 further stated LOS means the patients should always be within visual range of the staff (This ensures continuous monitoring and immediate response if needed). During a concurrent interview and record review on 1/21/2026 at 12:52 p.m. with DIR 1. Patient 1’s, “Progress Notes non-physician (nurses notes),” dated from 3/19/2025 to 3/22/2025, was reviewed. The record indicated the following: -3/19/2025 at 2:40 p.m., Patient 1 was agitated, attempted to AWOL from the unit, wanted to transfer to another facility and wanted to smoke, posturing (adoption of unusual or bizarre body positions) and threatening staff. -3/20/2025 at 7:10 a.m., Patient 1 tried to walk out of the facility. Patient 1 was aggressive and kicking at staff. -3/21/2025 at 10:00 a.m., Patient 1 informed staff, “I’m not good, I can’t spend another night in the psych (Psychiatry) ward I want to smoke and go to groups,” patient (Patient 1) also punched the wall and run toward the door (Door 2). -3/22/2025 at 6:50 a.m., Patient 1 attempted to AWOL. Patient 1 exited the door (Door 2) but was held down by security and other staff members. -3/22/2025 at 4:05 p.m., “patient (Patient 1) AWOL by slamming his body on the double door (Door 2) leading to the outside hallway.” -DIR 1 confirmed Patient 1 had made multiple AWOL attempts throughout the stay. DIR 1 also confirmed LOS observation was only put in place after Patient 1’s AWOL attempt (3rd attempt) on 3/21/2025 in the morning. DIR 1 stated nursing staff should have escalated the observation level to 1:1 (one-to-one observation where a staff member is assigned to maintain continuous direct or arm’s length supervision of a patient to ensure safety) for Patient 1 after AWOL attempt on 3/22/2025 at 6:50 a.m. DIR 1 stated, “he (Patient 1) should be put on 1:1.” During an interview on 1/21/2026 at 1:04 p.m. with the Quality Supervisor (QS), QS stated a root cause analysis (method used in healthcare to systematically identify and address underlying causes of adverse or sentinel events [an unexpected occurrence in a healthcare setting that results in patient death, permanent harm, or severe temporary harm] to enhance patient safety and mitigate risks) was conducted on 3/23/2025, the root cause analysis identified staff could have approached Patient 1 when Patient 1 was ramming the unit exit door with his body. QS stated RCA did not identify any other issue. During an interview on 1/22/2026 at 8:54 a.m. with Registered Nurse (RN 2), RN 2 stated MHW 5 had gone to get something for Patient 1. RN 2 added that there should have been another staff member watching Patient 1 for LOS to ensure patient safety and to prevent injury to self or risk to others. RN 2 stated that Patient 1 was identified as an AWOL risk and had a history of AWOL attempts during hospitalization. RN 2 stated LOS was not being carried out properly. RN 2 stated if someone had been watching Patient 1, he (Patient 1) could have been stopped and would not have been able to get through the door. During an interview on 1/21/2026 at 4:14 p.m. with DIR 1, DIR 1 stated there was no AWOL prevention policy or elopement screening assessment tool. Patient 1’s AWOL risk was identified through report when Patient 1 first came into the facility on 3/18/2025 and based on Patient 1’s behavior such as verbalization of wanting to leave and attempting to open doors. During a concurrent interview and record review on 1/21/2026 at 5:09 p.m. with DIR 1, the facility’s in-service material titled, “CODE GREEN (elopement) and AWOL Precaution,” dated 3/2025 and an in-service sign-in sheet titled, “Staff Roster,” undated, were reviewed. The In-service material indicated the following: “How to prevent a Code Green: Be alert and aware of your surroundings, ensure the unit door fully closes and red sensors light up, assign appropriate observation level: Q15 min check, line-of-sight, 1:1 observation (when indicated), ensure rounding times match charting ...” The “Staff Roster” indicated, missing signatures from multiple staff. DIR 1 stated the following: the in-service material was provided to nursing staff after the elopement incident on 3/22/2025. The in-service material did not address how to provide and maintain line of sight. DIR 1 also confirmed in-service sign-in sheet was incomplete. DIR 1 stated staff was supposed to sign after receiving the education. During review of the facility’s policy and procedure (P&P) titled, “Precaution Protocol and Risk Levels,” dated 3/2025, the P&P indicated, “Precautions are instituted whenever a patient is at risk for acting on suicidal, assaultive, or runaway impulses... The attending physician will determine the appropriate precaution level of their patient based on patient behaviors and need with the input of members of the interdisciplinary team. 1. Suicide, assault, AWOL precautions: A. An RN may institute any precaution level subsequently notifying the physician and obtaining a doctor’s order. B. Upon initiation of precaution, the RN must document, in the EMR (Electronic Medical Record), the patient behaviors warranting the precaution ... 2. Risk levels: one-to-one, line of sight and Q15 minute check. A. One-to one (1:1): 1. Highest intensity of level of observation... B. LOS (line-of-sight): 1. LOS observation is when a patient is in LOS of staff at all times including bathroom privileges... C. Q15 minutes close observation: 1. Suicide precaution 1 (SP 1), Assault precautions (AS 1), AWOL precaution (AWOL 1). 2. Patients are checked every 15 minutes. 3. Patients are evaluated for safety in the milieu at each check.” During a review of facility’s policy and procedure (P&P) titled, “Rights for Individual In Mental Health Facilities,” undated, the P&P indicated, “You also have the right to be free from potential harmful situations or conditions.” 1.b. During an observation on 1/20/2026 at 10:15 a.m., upon entering the facility’s Unit 1, there was an empty chair located by the entrance to the unit, but no staff were observed at the entrance to the (Unit 1). During an observation on 1/20/2026 at 11:34 a.m., upon leaving the facility’s Unit 1, there was no staff observed at the exit from Unit 1. During an interview on 1/20/2026 at 10:50 a.m. with a Mental Health Worker (MHW 1), MHW 1 stated that they were staying by Door 2 (unit exit door located in the Unit 2 where Patient 1 eloped) to prevent anyone from escaping the unit. During a concurrent observation and interview on 1/21/2026 at 12:16 p.m. with the DIR 1 and Director of Plant Operations (DIR 2), DIR 2 reviewed the video footage of Patient 1 eloping through Door 2 on 3/22/2025 and stated that Patient 1 used momentum to overcome the magnetic lock on the door. DIR 2 explained that if enough force or momentum was applied to exceed the magnetic holding force, the door would open. DIR 2 further stated that after the incident (involving Patient 1’s elopement), the vendor inspected Door 2 and recommended certain replacements, which were completed in March 2025. DIR 2 also noted that there was no way to determine whether the replaced parts were damaged as a result of the patient (Patient 1) slamming into Door 2 or if they were compromised, prior to the incident. DIR 2 confirmed that maintenance on Door 2 was last performed on 3/14/2025 (prior to Patient 1 slamming his body through the door and eloping), and the door (Door 2) passed inspection at that time (3/14/2025). During an interview on 1/21/2026 at 12:57 p.m. with DIR 1, DIR 1 stated that it was decided staff should remain by the Unit 2 door (Door 2) at all times to prevent elopement. DIR 1 also stated that it seemed safer to keep someone stationed at the exit (Door 2), and if the staff member needed to leave, they were supposed to be replaced. DIR 1 added that there was no assigned MHW to remain at the Unit 1 door (Door 1) because they did not believe patients on the (Unit 1) were capable of eloping. The main concern for elopement was with (Unit 2, where Door 2 was located and used by patient to elope on 3/22/2025) patients, as they (referring to the Unit 2 patients) were faster and more aggressive than those on Unit 1. During an interview on 1/22/2026 at 9:15 a.m. with Registered Nurse (RN 2), RN 2 stated the following regarding the Mental Health Worker (MHW) assigned to remain by the doors (Door 1 and Door 2): RN 2 said that there must be at least one assigned MHW at Door 1 and Door 2 at all times, and this practice was implemented a few months ago. RN 2 could not recall any official in-service or memo regarding this practice, nor the exact date it was implemented or the reason why. During an interview on 1/22/2026 at 10:13 a.m. with the Quality Specialist (QS), the QS stated: The QS said that there was no paper trail regarding the expectation for Mental Health Workers (MHWs) to remain at the doors. The QS recalled that an employee had been stationed at the doors (Door 1 and Door 2 [door used by patient 1 to elope]) for at least a couple of months but could not confirm exact details. The QS further stated that they did not believe a formal in-service was conducted; rather, the topic appeared to have been discussed informally during nursing departmental meetings and said that it was unclear whether these discussions were prompted by the elopement incident on 3/22/2025 or by other patient attempts to elope. The QS did not have specific details regarding those incidents of other elopement or whether they occurred. During an observation on 1/22/2026 at 11:08 a.m., the facility’s security video footage, date-stamped 1/20/2026, was reviewed, the security video view showed the unit exit door from the Unit 2 (Door 2), there was no Mental Health Worker (MHW) observed sitting by the door (Door 2) on 1/20/2026 from 8:28 a.m. to 8:34 a.m. During an observation on 1/22/2026 at 11:15 a.m., the facility’s security video footage, date-stamped 1/20/2026, was reviewed, the security video view showed exit from the Unit 2 (Door 2). There was no Mental Health Worker (MHW) observed sitting by the door (Door 2) on 1/20/2026 from 3:08 a.m. to 3:12 a.m. During an observation on 1/22/2026 at 11:41 a.m., the facility’s security footage, date-stamped 1/17/2026, was reviewed, the security video view showed exit from the Unit 2 (Door 2). There was no Mental Health Worker (MHW) observed sitting by the door on 1/17/2026 from 11:33 a.m. to 11:38 a.m. During review of facility’s policy and procedure (P&P) titled, “Precaution Protocol and Risk Levels,” dated 3/2025, the P&P indicated, “Precautions are instituted whenever a patient is at risk for acting on suicidal, assaultive, or runaway impulses... The attending physician will determine the appropriate precaution level of their patient based on patient behaviors and need, with the input of members of the interdisciplinary team. 1. Suicide, assault, AWOL precautions: A. An RN may institute any precaution level subsequently notifying the physician and obtaining a doctor’s order. B. Upon initiation of precaution, the RN must document, in the EMR, the patient behaviors warranting the precaution ... 2. Risk levels: one-to-one, line of sight and Q15 minute check. A. One-to one (1:1): 1. Highest intensity of level of observation... B. LOS (line-of-sight): 1. LOS observation is when a patient is in LOS of staff at all times including bathroom privileges... C. Q15 minutes close observation: 1. Suicide precaution 1 (SP 1), Assault precautions (AS 1), AWOL precaution (AWOL 1). 2. Patients are checked every 15 minutes. 3. Patients are evaluated for safety in the milieu at each check.” During a review of facility’s policy and procedure (P&P) titled, “Rights for Individual In Mental Health Facilities,” undated, the P&P indicated, “You also have the right to be free from potential harmful situations or conditions.” 1.c. During a concurrent interview and record review on 1/21/2026 at 5:09 p.m. with DIR 1, the facility’s in-service material titled, “CODE GREEN and AWOL Precaution,” dated 3/2025 and an in-service sign-in sheet titled, “Staff Roster,” undated, were reviewed. The In-service material indicated the following: “How to prevent a Code Green: Be alert and aware of your surroundings, ensure the unit door fully closes and red sensors light up, assign appropriate observation level: Q15min check, line-of-sight, 1:1 observation (when indicated), ensure rounding times match charting ...” The “Staff Roster” indicated, missing signatures from multiple staff. DIR 1 stated the following: the in-service material was provided to nursing staff after the elopement incident on 3/22/2025. The in-service material did not address how to provide and maintain line of sight. DIR 1 also confirmed in-service sign-in sheet was incomplete. DIR 1 stated staff was supposed to sign after receiving the education. During an interview on 1/22/2026 at 10:03 a.m. with the Quality Specialist (QS), QS stated the following: after the elopement incident (on 3/22/2025), an in-service on Code Green and AWOL Precautions was reportedly conducted; however, details about who provided the education were unclear. QS further noted that the staff roster for the training started on 3/23/2025, but there was no set deadline, and the roster remained incomplete with many missing signatures. During an interview on 1/22/2026 at 10:06 a.m. with QS, QS stated the following: previously there was trust in nursing to manage corrective actions independently, but moving forward, closer monitoring would be necessary. QS admitted not monitoring the education component and confirmed that auditing for line of sight (LOS) compliance had not been performed. According to the QS, nursing does not monitor LOS observation compliance either, or there was no system in place for compliance tracking. During an interview on 1/22/2026 at 10:13 a.m. with QS, QS stated the following: there was no paper trail regarding the expectation for Mental Health Workers (MHWs) to remain at the doors. QS recalled that an employee had been stationed at the door (Door 2) for at least a couple of months but could not confirm exact details. QS further stated that they do not believe a formal in-service was conducted; rather, the topic appears to have been discussed informally during nursing departmental meetings and said that it was unclear whether these discussions were prompted by the elopement incident [on 3/22/2025] or by other patient attempts to elope. QS did not have specific details regarding those incidents of elopement or whether they occurred. During review of facility’s policy and procedure (P&P) titled, “Precaution Protocol and Risk Levels,” dated 3/2025, the P&P indicated, “Precautions are instituted whenever a patient is at risk for acting on suicidal, assaultive, or runaway impulses... The attending physician will determine the appropriate precaution level of their patient based on patient behaviors and need, with the input of members of the interdisciplinary team. 1. Suicide, assault, AWOL precautions: A. An RN may institute any precaution level subsequently notifying the physician and obtaining a doctor’s order. B. Upon initiation of precaution, the RN must document, in the EMR, the patient behaviors warranting the precaution ... 2. Risk levels: one-to-one, line of sight and Q15 minute check. A. One-to one (1:1): 1. Highest intensity of level of observation... B. LOS (line-of-sight): 1. LOS observation is when a patient is in LOS of staff at all times including bathroom privileges... C. Q15 minutes close observation: 1. Suicide precaution 1 (SP 1), Assault precautions (AS 1), AWOL precaution (AWOL 1). 2. Patients are checked every 15 minutes. 3. Patients are evaluated for safety in the milieu at each check.” During a review of facility’s policy and procedure (P&P) titled, “Rights for Individual In Mental Health Facilities,” undated, the P&P indicated, “You also have the right to be free from potential harmful situations or conditions.” 2. During a review of Patient 2’s “Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 1/13/2026, the “psych eval” indicated, Patient 2 was admitted to the facility on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to being extremely aggressive (behavior that is forceful, assertive, and potentially hostile or threatening), agitated (feeling of irritability or severe restlessness), and confrontational with violent outbursts and with admitting diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During a review of Patient 2’s physician order, dated 1/14/2026, the physician order indicated, Patient 2 was on line of sight (LOS, a straight line along which an observer had unobstructed vision, a type of observation performed by health worker to monitor patients for safety) observation for AWOL (absent without official leave, elopement, leaving the hospital without discharge order from physician) risk. During a concurrent observation and interview on 1/20/2026 at 11:28 a.m. with the Director (DIR 1) of Psychiatric (inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) Services, Patient 2 was in the patient room with door closed with a staff sitting outside the door. DIR 1 stated there was no line of sight for Patient 2. Patient 2’s door should remain open (in order for the assigned staff to maintain direct constant patient observation). During an interview on 1/20/2026 at 3:18 p.m. with Registered Nurse (RN 1), RN 1 stated the following: patients could be on line of sight (LOS) observation if they made multiple AWOL attempts, was sexually inappropriate to others, was danger to self or danger to others. Line of sight observation was everyone’s responsibility. Staff did not need to maintain visual contact on patients with line-of-sight observation. Staff just need to pay more attention and check patients frequently because they had some behavioral issues. During an interview on 1/21/2026 at 2:29 p.m. with the nurse manager (NM 1), NM 1 stated that for patients with line-of-sight observation order, staff must maintain visual contact at all times with the patient. During an interview on 1/21/2026 at 3:30 p.m., with DIR 1, DIR 1 stated the risk for patients eloping from the facility would include the risk of running into traffic and injuring themselves for patients who were danger to self. For patients who were a danger to others, the eloped patient might harm others. For patients who were gravely disabled, the eloped patient would be in unsafe circumstances and danger to themselves. DIR 1 stated, “if they are on a hold (involuntary hold such as 5150-hold), they are deemed by the psychiatrist that they are not mentally stable to be on their own.” During a review of the facility’s policy and procedure (P&P) titled, “Precaution Protocol and Risk Levels,” dated 3/2025, the P&P indicated, “Precautions are instituted whenever a patient is at risk for acting on suicidal, assaultive, or runaway impulses... The attending physician will determine the appropriate precaution level of their patient based on patient behaviors and need, with the input of members of the interdisciplinary team. 1. Suicide, assault, AWOL precautions: A. An RN may institute any precaution level subsequently notifying the physician and obtaining a doctor’s order. B. Upon initiation of precaution, the RN must document, in the EMR, the patient behaviors warranting the precaution ... 2. Risk levels: one’-to-one, line of sight and Q15 minute check. A. One-to one (1:1): 1. Highest intensity of level of observation... B. LOS (line-of-sight): 1. LOS observation is when a patient is in LOS of staff at all times including bathroom privileges... C. Q15 minutes close observation: 1. Suicide precaution 1 (SP 1), Assault precautions (AS 1), AWOL precaution (AWOL 1). 2. Patients are checked every 15 minutes. 3. Patients are evaluated for safety in the milieu at each check.” During a review of the facility’s patient handbook titled, “Rights for Individuals in Mental Health Facilities,” dated 5/2014, the patient handbook indicated, “You also have the right to be free from potentially harmful situations or conditions.””

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility’s Quality Assessment and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) team failed to collect, track and trend data on critical patient safety indicators, implement comprehensive action plan, and measure the success of actions taken and track performance to ensure improvements are sustained, in accordance with the facility’s performance improvement plan, when the QAPI team: 1. Failed to collect, track, and report patient mortality (patient death occurred in the hospital) data including one (1) of 30 sampled patient’s (Patient 12), which happened on 3/2/2025, to the QAPI team during the QAPI meetings, Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital) and the Governing Board (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making). This deficient practice had the potential for the facility being unable to identify safety gaps, analyze factors that may have contributed to Patient 12’s death, and identify and address potential problems which had the potential to affect quality of patient care and safety. 2. Failed to verify accurate AWOL (absent without official leave, elopement, leaving the hospital without discharge order from physician) data and did not include one (1) of 30 sampled patient’s (Patient 1) AWOL incident in the QAPI, MEC and GB reports. This deficient practice led to inaccurate AWOL data being reported to medical staff and GB and prevented the QAPI team from analyzing Patient 1’s elopement and addressing potential issues which had the potential to affect the quality of patient care and safety. Findings: 1. During a review of Patient 12’s “Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 2/27/2025, the “psych eval” indicated, Patient 12 was admitted to the facility on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to increased paranoia (intense, irrational suspicion, persecution delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]), being aggressive (behavior that is forceful, assertive, and potentially hostile or threatening) and delusional with admitting diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During an interview on 1/26/2026 at 10:50 a.m. with the Director (DIR 1) of Psychiatric (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Services, DIR stated the following: on 3/2/2025, Patient 12 was found unresponsive (means the patient is unconscious, not waking up, and not reacting to sound, touch, or pain) by Mental Health Worker. Staff initiated chest compression (involving rhythmic, high-force pushes on the center of the chest to manually pump blood to vital organs when the heart stops), activated Code Blue (hospital emergency code used to summon help when a patient is in need of resuscitation [process hospital personnel followed to revive someone from cardiac (when the heart stops beating) or respiratory arrest-when a patient stops breathing]) and called 911. Emergency Medical Services (EMS, paramedics) arrived and took over the resuscitation effort, but Patient 12 passed away despite resuscitation effort. DIR 1 stated this incident was an adverse occurrence (any unexpected or harmful medical occurrence) and it was reported to Quality Department. During an interview on 1/26/2026 at 3:03 p.m. with the Quality Supervisor (QS), QS stated the following: QAPI (Quality Assessment and Performance Improvement, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) monitored and tracked all mortality (patient death occurred in the hospital) data. Any inpatient death would be considered as an adverse event (any unexpected or harmful medical occurrence) as the facility did not expect any inpatient death. Quality department would investigate all inpatient death and report in quarterly QAPI meeting and Department of Medicine (a medical staff committee), then it would be reported to Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital) and eventually to Governing Board (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making). QS further stated Patient 12’s death would count as a mortality case. During a concurrent interview and record review on 1/26/2026 at 3:16 p.m. with Quality Supervisor (QS) 2, the facility’s “Department of Medicine Meeting (medicine dept minutes)” minutes (the official written record of discussions, decisions, and action items from a meeting, serving as a formal, objective document), dated 6/11/2025, 9/10/2025 and 11/13/2025, were reviewed. All three (3) medicine department minutes indicated, there was no report of and discussion of Patient 12’s death. QS 2 confirmed no mortality data was found in the minutes reviewed. During a concurrent interview and record review on 1/26/2026 at 3:20 p.m. with QS, the facility’s “Performance Improvement/ Patient Safety Meeting (QAPI minutes)” minutes, dated 4/29/2025, 6/3/2025, 9/2/2025, and 11/4/2025, were reviewed. All four (4) QAPI minutes indicated, there was no report of and discussion of Patient 12’s death. QS stated no mortality data was found in all 4 meeting minutes. QS stated the QAPI team was required to collect, analyze, present the data and to be able to show trend, in order to get a bigger picture of what was going on, catch problems quicker and evaluate the effectiveness of current action plan. QS further stated, MEC and Governing Body would not be able to provide oversight and give feedback if data were not presented. During an interview on 1/26/2026 at 3:37 p.m. with the Chief Executive Officer (CEO), CEO stated the following: QAPI collected data for adverse events including AWOL (absent without official leave, elopement, leaving the hospital without discharge order from physician) and patient death. Adverse events data would be reported in QAPI meeting and either department of medicine (a medical staff committee) or department of psychiatry (a medical staff committee), then reported to MEC then to GB on a quarterly basis. CEO further stated GB needed to know all adverse events, what caused the adverse events, what could be done differently in order to prevent the adverse events from happening again. During a concurrent interview and record review on 1/26/2026 at 3:44 p.m. with the Chief Executive Officer (CEO), the facility’s “Governing Board of Directors Meeting (GB minutes)” minutes, dated 8/27/2025, was reviewed. The GB minutes indicated, there was no discussion about Patient 1’s death. CEO confirmed there was no record that Patient 12’s death was discussed in GB meeting. The CEO further stated that there was no mention of Patient 12’s death in the QAPI or Department of Medicine meeting minutes, hence it did not reach the governing body meeting. During a review of the facility’s Performance Improvement Plan 2025, dated 5/2025, the QAPI plan indicated, “The intent of the [QAPI] plan is to increase the probability of desired patient outcomes, including patient and physician satisfaction, by assessing and improving the processes that most affect health outcomes; establish priorities for the investigation of problems by focusing on those with the greatest potential impact on patient care outcome ... [the facility] departmental review is accomplished through data collection and identification of any opportunities for improvement. Their PI (performance improvement) activities will be reported quarterly to the Performance Improvement/ Patient Safety Committee ... the Performance Improvement/ Patient Safety Committee is directly accountable/reportable to the Medical Staff, Senior Leadership/Administration of [the facility] ... Performance processes that involves risk to the patient or may result in a never/serious event ... adverse patient events ... data collection should focus on areas of prevalence and the severity of identified problems, giving consideration to patient safety and quality of care ... data collected will be used to monitor the effectiveness and safety of services, quality of care, identify opportunities for improvement, and changes that will lead to improvement ...” 2. During a review of Patient 1’s History and Physical (H&P, a formal and complete an assessment of the patient and the problem), dated 3/18/2025, the H&P indicated, Patient 1 was admitted on 3/18/2025 on 5150 hold for suicidal ideation (thoughts of taking one’s own life) with plan to overdose on pills and jump from a bridge. During an interview on 1/21/2026 at 11:39 a.m. with the Director (DIR 1) of Psychiatric (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Services, DIR 1 stated Patient 1 eloped (same as AWOL [absent without official leave], leaving the hospital without discharge order from physician) from the facility on 3/22/2025. DIR 1 also stated Patient 1 did not return to the facility after the elopement. During an interview on 1/26/2026 at 3:22 p.m. with the Quality Supervisor (QS), QS stated the following: Quality department would collect AWOL data and present in Performance Improvement/ Patient Safety meeting on a quarterly basis. The AWOL data would also be presented to the department of Psychiatry (a medical staff committee), then to MEC and eventually to the Governing Board (GB). During a concurrent interview and record review on 1/26/2026 at 3:23 p.m. with QS, the facility’s “Department of Psychiatry Meeting (psych dept minutes)” meeting minutes, dated 7/17/2025, was reviewed. The psych dept minutes indicated, “First Quarter (January to March) of 2025 ... AWOLs - zero (0) cases.” QS stated the data was inaccurate because Patient 1 eloped on 3/22/2025, which should be included in the first quarter of 2025 data. QS further stated Quality Department should have the oversight on AWOL data to make sure its accuracy before the data was presented. During an interview on 1/26/2026 at 3:37 p.m. with the Chief Executive Officer (CEO), CEO stated the following: QAPI collected data for adverse events including AWOL and patient death. Adverse events data would be reported in QAPI meeting and either department of medicine or department of psychiatry, then reported to MEC then to GB on a quarterly basis. CEO further stated the GB needed to know all adverse events, what caused the adverse events, what could be done differently in order to prevent the adverse events from happening again. During a concurrent interview and record review on 1/26/2026 at 3:54 p.m. with the Chief Executive Officer (CEO), the facility’s “Department of Psychiatry Meeting (psych dept minutes)” minutes, dated 7/17/2025 and the “Governing Board of Directors Meeting (GB minutes)” minutes, dated 8/27/2025, were reviewed. Both minutes (psych dept minutes and GB minutes) indicated, “First Quarter of 2025 ... AWOLs - zero (0) cases.” CEO stated the data was presented by nursing department, but the Quality department was responsible for providing oversight on data accuracy. The CEO further stated that since the wrong AWOL data was presented to Department of Psychiatry, the same inaccurate data was presented to the GB. During a review of the facility’s Performance Improvement Plan 2025, dated 5/2025, the QAPI plan indicated, “The intent of the [QAPI] plan is to increase the probability of desired patient outcomes, including patient and physician satisfaction, by assessing and improving the processes that most affect health outcomes; establish priorities for the investigation of problems by focusing on those with the greatest potential impact on patient care outcome ... [the facility] departmental review is accomplished through data collection and identification of any opportunities for improvement. Their PI (performance improvement) activities will be reported quarterly to the Performance Improvement/ Patient Safety Committee ... the Performance Improvement/ Patient Safety Committee is directly accountable/reportable to the Medical Staff, Senior Leadership/Administration of [the facility] ... Performance processes that involves risk to the patient or may result in a never/serious event ... adverse patient events ... data collection should focus on areas of prevalence and the severity of identified problems, giving consideration to patient safety and quality of care ... data collected will be used to monitor the effectiveness and safety of services, quality of care, identify opportunities for improvement, and changes that will lead to improvement ... data had a defined source, frequency, and intensity appropriate to the activity or process being studied. Examples of data sources include valid and reproducible databases.””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 50594 Based on observation, interview and record review, the facility’s Quality Assurance Performance Improvement team (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) failed to analyze an adverse patient event (preventable, serious and unambiguous occurrence or error at a healthcare facility that is universally or largely preventable and should never occur) regarding patient elopement when it failed to conduct a comprehensive root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution ) regarding patient elopement (leaving the hospital without authorization or physician order), involving one of 30 sampled patients (Patient 1), and failed to implement appropriate corrective actions and compliance audit mechanisms in a timely manner, in accordance with the facility’s performance improvement plan, in order to ensure there was proper observation or monitoring provided for patients who are placed on line-of-sight (LOS, a straight line along which an observer had unobstructed vision) monitoring in the Unit 2 (inpatient unit that provided treatment and therapy for patients who have mental, emotional and behavioral disorders). This deficient practice regarding the lack of a comprehensive analysis of an adverse patient event had the potential for another incident of elopement to occur which puts other patients at risk for injury or harm. Findings: During a review of Patient 1’s History and Physical (H&P, a formal and complete an assessment of the patient and the problem), dated 3/18/2025, the H&P indicated, Patient 1 was admitted on 3/18/2025 on 5150 hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thoughts of taking one’s own life) with plan to overdose on pills and jump from a bridge. During a review of Patient 1’s “Patient Monitoring” record, dated 3/21/2025, the records indicated Patient 1 had a physician’s order for Line of Sight (LOS, a straight line along which an observer had unobstructed vision) monitoring for being a Danger to Others (DTO, where an individual poses a risk of harm to others) and AWOL (Absent Without Leave, leaving the facility without authorization). During a concurrent observation, interview, and record review on 1/21/2026 at 11:40 a.m. with the Director of Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Services (DIR) 1, the facility’s video footage, with date stamped 3/22/2025, was observed and reviewed. The following was observed: -at 4:07 p.m. Patient 1 was observed pacing alone in the hallway between the nursing station and unit exit (Door 2). Patient 1 was walking towards the unit exit door (Door 2). There was a staff member standing at the nursing station. -at 4:08 p.m. Patient 1 went to the unit exit door (Door 2) and pushed the unit exit door once. The unit exit door remained closed. Patient 1 then backed up and slammed his body into the door, but the door remained closed. Patient 1 backed up again and slammed his body into the door again. Unit exit door (Door 2) was opened. Patient 1 went through the unit exit door. There was no one around to stop Patient 1. Two staff were seen walking to the unit exit door after Patient 1 left. DIR 1 stated the staff did not look at Patient 1. There was no line of sight of Patient 1. During the same observation and interview on 1/21/2026 at 11:40 a.m. DIR 1 further stated LOS meant the patients should always be within visual range of the staff (This ensures continuous monitoring and immediate response if needed). During a review on 1/21/2026 at 12:52 p.m. with DIR 1. Patient 1’s, “Progress Notes non-physician (nurses notes),” dated from 3/19/2025 to 3/22/2025, was reviewed. The record indicated the following: -3/19/2025 at 2:40 p.m., Patient 1 was agitated (a feeling of irritability or severe restlessness), attempted to AWOL and wanted to transfer to another facility and to smoke. -3/20/2025 at 7:10 a.m., Patient 1 tried to walk out of the facility. -3/21/2025 at 10:00 a.m., Patient 1 informed staff, “I’m not good, I can’ spend another night in psych (psychiatric) ward I wanted to smoke and go to groups,” patient (Patient 1) also punched the wall and run toward the door (Door 2). -3/22/2025 at 6:50 a.m., Patient 1did not like to be at the facility. Patient 1 attempted to AWOL. -3/22/2025 at 4:05 p.m., “patient (Patient 1) AWOL by slamming his body on the double door (Door 2) leading to the outside hallway.” -DIR 1 confirmed Patient 1 had made multiple AWOL attempts throughout the stay. DIR 1 also confirmed LOS observation was only in place after Patient 1’s AWOL attempt (3rd attempt) on 3/21/2025 in the morning. DIR 1 stated nursing staff should have escalated the observation level to 1:1 (one-to one observation where a staff member is assigned to maintain continuous direct or arm’s length supervision of a patient to ensure safety) for Patient 1 after AWOL attempt on 3/22/2025 at 6:50 a.m. DIR 1 stated, “he (Patient 1) should be put on 1:1.” During an interview on 1/21/2026 at 1:04 p.m. with the Quality Supervisor (QS), QS stated a root cause analysis (the process of discovering the root causes of problems in order to identify appropriate solution) was conducted on 3/23/2025, the root cause analysis identified staff could have approached Patient 1 when Patient 1 was ramming the unit exit door with his body. QS stated the RCA did not identify any other issues. QS further stated Patient 1’s entire chart was not reviewed, and Patient 1’s multiple attempts to leave the unit were not identified (during the RCA). During an interview on 1/22/2026 at 10:03 a.m. with the Quality Specialist (QS), QS stated the following: after the elopement incident (on 3/22/2025), an in-service on Code Green and AWOL Precautions was reportedly conducted; however, details about who provided the education were unclear. QS further noted that the staff roster for the training started on 3/23/2025, but there was no set deadline (of training completion), and the roster remained incomplete with many missing signatures. During an interview on 1/22/2026 at 10:06 a.m. with QS, QS stated the following: previously, there was trust in nursing to manage corrective actions independently, but moving forward, closer monitoring would be necessary. QS admitted not monitoring the education component and confirmed that auditing for line of sight (LOS) compliance had not been performed. According to the QS, nursing did not monitor LOS observation compliance either, or there was no system in place for compliance tracking. During an interview on 1/22/2026 at 10:13 a.m. with QS, QS stated the following: there was no paper trail regarding the expectation for Mental Health Workers (MHWs) to remain at the doors (Door 1 and Door 2 [where Patient 1 escaped]). QS recalled that an employee had been stationed at the door for at least a couple of months but could not confirm exact details. QS further stated that they did not believe a formal in-service was conducted; rather, the topic appeared to have been discussed informally during nursing departmental meetings and said that it was unclear whether these discussions were prompted by the elopement incident [on 3/22/2025] or by another patient attempts to elope. QS did not have specific details regarding those incidents of elopement or whether they occurred. During a review of the facility’s policy and procedure (P&P) titled, “Performance Improvement Plan 2025,” last reviewed 5/2025, the P&P indicated, “The primary goal is to provide a comprehensive Performance Improvement Program that will coordinate and integrate ALL performance improvement activities hospital wide. This will ensure that the highest achievable safety and quality of care is delivered through out [facility name] at reduced costs and improved outcomes ...by assessing and improving the processes that most affect health outcomes; establish priorities for the investigation of problems by focusing on those with the greatest potential impact on patient care outcome and patient satisfaction... Medical staff performance improvement activities will be carried out collaboratively; using aggregated data, relative to performance improvement, patient safety ...This will be accomplished through the ongoing and systematic objective assessment and documentation of hospital-wide and medical documentation of corrective action plans, improvements and/ or resolutions ...Provide reports to appropriate medical staff committees, MEC and Governing Board.” During a review of the facility’s Performance Improvement Plan 2025, dated 5/2025, the QAPI plan indicated, “The intent of the [QAPI] plan is to increase the probability of desired patient outcomes, including patient and physician satisfaction, by assessing and improving the processes that most affect health outcomes; establish priorities for the investigation of problems by focusing on those with the greatest potential impact on patient care outcome ... [the facility] departmental review is accomplished through data collection and identification of any opportunities for improvement. Their PI (performance improvement) activities will be reported quarterly to the Performance Improvement/ Patient Safety Committee ... the Performance Improvement/ Patient Safety Committee is directly accountable/reportable to the Medical Staff, Senior Leadership/Administration of [the facility] ... Performance processes that involves risk to the patient or may result in a never/serious event ... adverse patient events ... data collection should focus on areas of prevalence and the severity of identified problems, giving consideration to patient safety and quality of care ... data collected will be used to monitor the effectiveness and safety of services, quality of care, identify opportunities for improvement, and changes that will lead to improvement ... data had a defined source, frequency, and intensity appropriate to the activity or process being studied. Examples of data sources include valid and reproducible databases.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to: 1. Ensure that one of 30 sampled patient’s (Patient 29), observation-type safety precautions (specific safety measures implemented to monitor patients at risk, such as fall risk [potential for a patient to fall and sustain injury, often due to mobility issues, medication effects, or cognitive impairment]), were properly documented and implemented for Patient 29. This would include specific measures such as fall precautions, reflecting what safety measures were in place and observations made for Patient 29 during the Q 15-minute patient rounds (a structured, proactive process where healthcare staff visit patients at regular intervals to address patient needs and improve safety). In addition, the Q15-minute round sheets (records used by staff to document patient checks every 15 minutes to ensure continuous safety monitoring) were not always signed by the appropriate staff members (Mental Health Workers and Supervising Licensed Nursing Staff) as required by the facility’s care expectations and procedures regarding Q15-minute observation rounding sheets (Q15 refers to checks performed every 15 minutes to monitor patient safety and behavior). This deficient practice had the potential to compromise Patient 29’s safety when required fall precautions (specific safety measures designed to prevent injury from falls) and patient observations/monitoring were either not followed/implemented or not verifiable, potentially leading to Patient 29’s multiple falls. 2. Ensure that three (3) Mental Health Workers ([MHW] 7, 8, and 9) performed rounding on patients every fifteen (15) minutes (Q15min), as assigned by Registered Nurse (RN), for 12 out of 30 sampled patients (Patient 8, 11, 14, 15, 16, 17, 18, 22, 24, 25, 26, and 27) on 1/20/2026 from 2 a.m. to 3 a.m., to monitor each patient’s location and behavior, in accordance with the facility’s policy regarding patient safety rounds (patient safety rounds refer to scheduled checks performed by staff at regular intervals, such as every 15 minutes, to monitor patient location, behavior, and overall safety, ensuring that precautions are in place to prevent harm to the patient or others). This deficient practice had the potential to result in delay in identifying patients’ risk behavior including harming self and harming others, putting the safety of Patients 8, 11, 14, 15, 16, 17, 18, 22, 24, 25, 26, and 27 at risk. 3. Ensure three (3) MHWs (MHW 7, 8, and 9) maintained constant visual monitoring on patients as assigned by Registered Nurse for three (3) of 30 sampled patients (Patient 2, 20, and 21) requiring line of sight observation (a straight line along which an observer had unobstructed vision) on 1/20/2026 from 2 a.m. to 3 a.m., in accordance with the facility’s policy regarding patient safety rounds (patient safety rounds refer to scheduled checks performed by staff at regular intervals, such as every 15 minutes, to monitor patient location, behavior, and overall safety, ensuring that precautions are in place to prevent harm to the patient or others). This deficient practice had the potential to result in delay in identifying patients’ risk behavior including harming self and harming others and providing interventions in a timely manner, putting the safety of Patients 2, 20, 21 and other patients at risk. 4. Ensure staff maintained a line-of-sight (LOS, a straight line along which an observer had unobstructed vision) monitoring, in accordance with the facility’s policy and procedure (P&P) titled, “Precaution Protocol and Risk Levels,” for one of 30 sampled patients (Patient 1), when Patient 1 was able to force open a locked door (Door 2) and eloped (leaving the hospital without authorization or physician order). This deficient practice regarding inadequate line of sight monitoring had the potential to compromise patient safety for Patient 1 such as involvement in traffic accidents, falls, and exposure to extreme weather when eloped and may also result in other incidents of elopement, self-harm, or harm to other patients due to lack of patient monitoring. Findings: 1. During a review of Patient 29’s Psychiatric Evaluation (a comprehensive assessment conducted by a mental health professional to determine a patient’s mental status, diagnosis, risk factors, and treatment needs, often including history, current symptoms, and safety concerns), dated 8/16/2025, the psychiatric evaluation indicated that Patient 29 was admitted on a 5150 hold for danger to self (a 72-hour involuntary psychiatric hold under California law for individuals who, due to mental illness, pose a danger to themselves, others, or are gravely disabled [unable to take care of themselves]). During a review of the facility’s fall log (a record maintained by the facility to document all incidents of patient falls, including details such as date, time, location, and any injuries sustained), dated 9/2025, the record indicated that Patient 29 sustained two unwitnessed falls (falls that occur without being seen by anyone) on 9/2/2025 and 9/8/2025. During a review of Patient 29’s Nursing Progress Note, dated 9/2/2025, the note indicated that Patient 29 had an unwitnessed fall around 11:40 a.m. and was found on the floor by the Mental Health Worker. The note also indicated that Patient 29 reported falling backwards and hitting the back of the head and reported pain. The note indicated that the physician was notified and neurological checks (a series of clinical assessments to evaluate nervous system function) were ordered. During a review of Patient 29’s Nursing Progress Note dated 9/8/2025, the note indicated that Patient 29 had an unwitnessed fall at 8:00 a.m. The note further indicated that Patient 29 reported hitting the left side of the head on the wall, complained of “a little” pain, and expressed a desire to sleep. During a concurrent interview and record review on 1/20/2026 at 2:52 p.m. with the Director of Nursing (Dir 1), Patient 29’s fall risk assessment (a medical evaluation to determine the likelihood of a patient falling, based on various factors such as balance, medication, and history of falls), dated 9/2/2025 and 9/8/2025, were reviewed. Patient 29’s fall risk assessment record indicated that Patient 29’s Fall Risk score was at 25 on 9/2/2025 and 40 on 9/8/2025. Dir 1 stated that both scores, 25 and 40, indicated that Patient 29 was at no risk of falling. During the same concurrent interview and record review on 1/20/2026 at 2:52 p.m. with the Director of Nursing (Dir 1), Dir 1 stated that a score of 0-44 indicated a “normal” finding, and a score of 45 and above indicated a high risk for fall. Dir 1 also mentioned that the score of 40 on 9/8/2025, the day Patient 29 sustained the second unwitnessed fall, must not have been accurately calculated. Dir 1 said that a score of 40 was too low for a person who had previously sustained a fall within the last three months. During a concurrent interview and record review on 1/20/2026 at 2:52 p.m. with the Director of Nursing (Dir 1), Patient 29’s physician orders, dated 8/15/2025, were reviewed. Dir 1 stated that a “fall precaution order (a directive to implement specific safety measures designed to prevent injury from falls)” was placed on 8/15/2025 at 4:52 p.m. on the day of Patient 29’s admission to the facility. During an interview on 1/20/2026 at 2:11 p.m. with the Director of Nursing (Dir 1), Dir 1 stated that if a patient was identified as at risk for falls, fall precautions should be implemented. Dir 1 identified several fall precautions such as applying a yellow armband to the wrist (a visual indicator for staff), placing a yellow star on the patient’s name and door (to alert staff of the fall risk), providing yellow non-skid socks (to prevent slipping), and performing patient checks every 15 minutes as ordered to ensure close observation (to monitor the patient closely). During an interview on 1/20/2026 at 2:11 p.m. with Dir 1, Patient 29’s observation and patient rounding sheets, dated 9/2/2025 and 9/8/2025, were reviewed. Dir 1 stated the following: -Marking fall precautions on the observation and patient rounding sheets (used for every 15-minute checks) was one way to ensure fall precautions were implemented and that staff was monitoring the patient for falls. Dir 1 then said that the rounding sheet for Patient 29 on 9/2/2025 had the fall precaution circled (indicating it was selected), but the sheet lacked signatures of the Mental Health Workers (MHWs) for the entire day and night shifts and had no nurse signature attesting to it. -The patient rounding sheet for 9/8/2025 had no fall precautions marked or circled, even though all staff involved in rounding on Patient 29 signed the sheet and the assigned licensed nurse co-signed it, attesting to its accuracy. Dir 1 then stated that both records were questionable as to whether staff actually monitored Patient 29 for falls on 9/2/2025 and 9/8/2025. During an interview on 1/21/2026 at 2:24 a.m. with Nurse Manager (NM 1), NM 1 stated that nurses should communicate with Mental Health Workers (MHWs) regarding the precautions and observation levels that patients required to ensure that the correct level of observation and precautions were followed. NM 1 further stated that nursing staff were responsible to ensure that the appropriate type of precaution and level of observation was implemented for their assigned patients. During an interview on 1/21/2026 at 3:30 p.m. with Nurse Manager (NM 1), NM 1 said that fall precautions should be marked on the observation rounds sheets (a form used by healthcare staff to record regular checks on patients’ location, behavior, and safety). NM 1 stated, “We mark to ensure we are monitoring for anything that can increase the risk for falls or if the patient needs assistance.” During a review of Patient 29’s Observation and Rounding sheets, dated 9/1/2025 through 9/8/2025, the record indicated the following: -On 9/1/2025, fall precautions were indicated to be monitored for Patient 29, but the record lacked signature by the licensed nurse. -On 9/2/2025, the record had fall precautions circled for Patient 29 but lacked signatures of the Mental Health Workers (MHWs) and had no nurse signature for the entire day and night shifts. -On 9/3/2025, there were no precautions circled or marked for Patient 29, yet the record was signed by both MHWs and the licensed nurse for the day. -On 9/4/2025, no fall precautions were marked on the record, although all signatures attested to monitoring. -On 9/5/2025, fall precautions were marked, but no signature of the licensed nurse was affixed to attest to the monitoring. -On 9/6/2025, no fall precautions were marked, and on 9/7/2025, no signature by the licensed nurse was recorded on the rounding sheets. During a review of the facility’s policy and procedures (P&P) titled “Fall Precaution Program,” dated 4/2024, the P&P indicated that the purpose of the program was to identify patients who were potentially at a high risk of falling during hospitalization and to institute measures to anticipate risk factors for falls and implement strategies to reduce those risks and limit injuries to people who fall. If the patient is determined to be a fall risk (score of 25 or greater), fall precautions will be implemented. Fall-prone patients may be placed on fall precautions requiring LOS (Line of Sight, continuous visual observation of the patient by staff to ensure safety) or 1:1 (One-to-One, direct, uninterrupted supervision by a dedicated staff member assigned solely to that patient). For all patients identified as at risk for falls, a yellow armband will be placed on the wrist to indicate fall risk ...Provide Q15 (every 15 minutes) minutes rounds on close observation as ordered...” During a review of the facility’s position description for Registered Nurse, dated 7/2022, the position description indicated, “Job Specific Accountabilities ... demonstrate effective leadership skills of delegation, organization, and coordination in managing assigned unit; delegates responsibilities to unit staff as appropriate ... monitors all patients ... demonstrate appropriate delegation of tasks and duties in the direction and coordination of the work of nursing team members, patient care and unit activities.” During a review of the facility’s policy and procedure (P&P) titled, “Scope of Services and Nursing Staffing Plan,” dated 4/2024, the P&P indicated, “The goal of the Nursing Services Department is to provide direct and indirect patient care services that ensure safety, comfort, personal hygiene, and protection of patients ... A minimum of one (1) registered nurse shall be on the hospital premises providing or supervising nursing services 24 hours a day, seven (7) days a week ... each unit or area where patient care is provided will have a staffing matrix to provide for enough professional nursing staff ... to carry out the following activities ... appropriate healthcare interventions as specified in standards, policies and procedures, protocols or as determined by professional judgement ... Nursing care is provided by Registered Nurses, Licensed Vocational Nurses, Mental Health Workers and Unit Secretary.” 2. During an interview on 1/20/2026 at 10:33 a.m. with a Mental Health Worker (MHW) 2, MHW 2 stated the following: MHWs received assignment from Registered Nurse (RN) to perform rounding every fifteen (15) minutes on the assigned patients. MHWs would check on the assigned patients for their location and behavior every 15 minutes (Q15min), and document on the rounding sheet. MHW 2 further stated the purpose of Q15min rounding was to make sure patients were safe. During an interview on 1/21/2026 at 2:24 a.m. with the Nurse Manager (NM) 1, NM 1 stated nurses would communicate with the MHWs what precaution and observation level that patients required to ensure the correct level of observation was being followed. NM 1 stated it was the nursing responsibility to ensure the correct type of precaution and observation was implemented. During a review of the facility’s night shift (work hours from 7 p.m. to 7 a.m. next morning) unit assignment titled, “Unit East - PM,” dated 1/29/2026, the unit assignment indicated the following: -MHW 7 was assigned to perform Q15min rounding on Patient 14 and Patient 15 (both in Room 1), and Patient 22 and Patient 24 (both in Room 3); -MHW 8 was assigned to perform Q15min rounding on Patient 16 and Patient 17 (both in Room 4), Patient 18 (in Room 5); -MHW 9 was assigned to perform Q15min rounding on Patient 25 (in Room 7), Patient 26 and Patient 8 (both in Room 8), and Patient 11 and Patient 27 (in Room 9). During a concurrent observation and interview on 1/22/2026 at 11:15 a.m. with the Regional Security Manager (RSM) and the Quality Supervisor (QS) 2, the facility’s security video footage with date stamp 1/20/2026 from 2 a.m. to 3:08 a.m., was reviewed. The following was observed in the security video footage with video view of the hallway including three patients’ rooms (Rooms 3, 4 and 5) leading to the unit exit door (Door 2): -MHW 7 was sitting in a chair by Door 2 from 2 a.m. to 3:08 a.m. and did not get up to make any rounds for his (MHW 7’s) assigned patients (Patient 14, 15, 22, and 24) while MHW 8 did not walk down the hallway and enter Room 4 and Room 5 to round on Patients 16, 17, and 18 from 2 a.m. to 3:08 a.m.. In addition, Room 5’s (where Patient 18 was located) door remained closed in the security video footage from 2 a.m. to 3:08 a.m. -QS 2 stated MHW 7 and MHW 8 did not perform any Q15min rounding from 2 a.m. to 3:08 a.m. for their (MHW 7’s and MHW8’s) assigned patients (Patient 14, 15, 16, 17, 18, 22, and 24). During a concurrent observation and interview on 1/26/2026 at 1:15 p.m. with the Director (DIR 1) of Psychiatric Services (inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders), the facility’s security video footage, with date stamp 1/20/2026 from 2 a.m. to 3 a.m., was reviewed. The following was observed in the security video footage with video view of the hallway including three patients’ rooms (Rooms 7, 8 and 9): -MHW 9 was sitting in a chair in the middle of the hallway but did not enter any of her (MHW 9’s) assigned rooms: Rooms 7, 8 and 9 to check on Patients 8, 11, 25, 26 and 27, from 2 a.m. to 3 a.m. -DIR 1 stated MHW 9 did not make any Q15min rounding for MHW 9’s assigned patients (Patient 8, 11, 25, 26 and 27) on 1/20/2026 from 2 a.m. to 3 a.m. During a review of Patient 8’s “Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 12/20/2025, the “psych eval” indicated, Patient 8 was admitted to the facility on a 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to danger to others and gravely disabled (inability to care for oneself) with admitting diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During a review of Patient 8’s physician order, dated 1/19/2026, the physician order indicated, Patient 8 was on standard Q 15-minute rounding. During a review of Patient 11’s “Psychiatric Evaluation (psych eval),” dated 1/19/2026, the “psych eval” indicated, Patient 11 was admitted to the facility on 5250-hold due to endangering other people’s safety and gravely disabled with admitting diagnosis of paranoid schizophrenia (a chronic mental illness characterized by intense, irrational suspicion, persecution delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary] and auditory hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste]). During a review of Patient 11’s physician order, dated 1/19/2026, the physician order indicated, Patient 11 was on standard Q 15-minute rounding for assault (threat or attempt to cause physical harm) or harm to others. During a review of Patient 14’s “Psychiatric Evaluation (psych eval),” dated 12/29/2025, the “psych eval” indicated, Patient 14 was admitted to the facility on 5250-hold due to increased confusion agitation (feeling of irritability or severe restlessness) and delusions with admitting diagnosis of schizophrenia paranoid type. During a review of Patient 14’s physician order, dated 1/19/2026, the physician order indicated, Patient 14 was on standard Q 15-minute rounding for history of wandering into patients’ rooms and taking their belongings. During a review of Patient 15’s “Psychiatric Evaluation (psych eval),” dated 1/9/2026, the “psych eval” indicated, Patient 15 was admitted to the facility on 5250-hold due to danger to self and grave disability with admitting diagnoses of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), generalized anxiety disorder (a group of mental disorders characterized by significant feelings of fear) and seizure order (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness). During a review of Patient 15’s physician order, dated 1/8/2026, the physician order indicated, Patient 15 was on standard Q 15-minute rounding for assault harm to others. During a review of Patient 16’s “Psychiatric Evaluation (psych eval),” dated 1/18/2026, the “psych eval” indicated, Patient 16 was admitted to the facility on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to inability to care for self with admitting diagnosis of major depression (MDD, a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) severe recurrent without psychotic features (delusions and hallucinations). During a review of Patient 16’s physician order, dated 1/17/2026, the physician order indicated, Patient 16 was on standard Q 15-minute rounding for assault harm to others. During a review of Patient 17’s “Psychiatric Evaluation (psych eval),” dated 1/19/2026, the “psych eval” indicated, Patient 17 was admitted to the facility with complaint of suicidal (act of intentionally ending self’s life) thoughts with plan of slitting wrist and with admitting diagnosis of schizophrenia. During a review of Patient 17’s physician order, dated 1/19/2026, the physician order indicated, Patient 17 was on standard Q 15-minute rounding for suicide harm to self. During a review of Patient 18’s “Psychiatric Evaluation (psych eval),” dated 1/17/2026, the “psych eval” indicated, Patient 18 was admitted to the facility due to increased confusion, agitation, irritability with delusions of paranoia, and making verbal threats to strike out with admitting diagnosis of schizoaffective disorder (a mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]), bipolar type. During a review of Patient 18’s physician order, dated 1/16/2026, the physician order indicated, Patient 18 was on standard Q 15-minute rounding for assault harm to others. During a review of Patient 22’s “Psychiatric Evaluation (psych eval),” dated 12/31/2025, the “psych eval” indicated, Patient 22 was admitted to the facility on 5150-hold due to danger to others for being extremely aggressive, agitated (a feeling of irritability or severe restlesness) and violent towards others with admitting diagnosis of schizoaffective disorder, bipolar type. During a review of Patient 22’s physician order, dated 12/30/2025, the physician order indicated, Patient 22 was on standard Q 15-minute rounding for assault harm to others. During a review of Patient 24’s “Psychiatric Evaluation (psych eval),” dated 1/12/2026, the “psych eval” indicated, Patient 24 was admitted to the facility due to having manic episodes (a sustained period of abnormally elevated or irritable mood and intense, increase energy featuring racing thoughts, impulsivity and risky behavior) and suicidal thoughts with admitting diagnosis of bipolar type 1 disorder, manic episode. During a review of Patient 24’s physician order, dated 1/14/2026, the physician order indicated, Patient 24 was on standard Q 15-minute rounding for suicide harm to self. During a review of Patient 25’s “Psychiatric Evaluation (psych eval),” dated 1/13/2026, the “psych eval” indicated, Patient 25 was admitted to the facility on 5150-hold due to danger to self for suicidal attempt of overdosing with admitting diagnosis of major depression, recurrent, severe, without psychotic features. During a review of Patient 25’s physician order, dated 1/12/2026, the physician order indicated, Patient 25 was on standard Q 15-minute rounding for assault harm to others. During a review of Patient 26’s “Psychiatric Evaluation (psych eval),” dated 1/16/2026, the “psych eval” indicated, Patient 26 was admitted to the facility on 5150-hold due to danger to others and gravely disabled and reported increased aggression and assaultive behavior towards Patient 26’s family member and with admitting diagnosis of schizoaffective, bipolar. During a review of Patient 26’s physician order, dated 1/16/2026, the physician order indicated, Patient 26 was on standard Q 15-minute rounding for assault harm to others. During a review of Patient 27’s “Psychiatric Evaluation (psych eval),” dated 1/20/2026, the “psych eval” indicated, Patient 27 was admitted to the facility on 5150-hold for danger to self for suicidal plans to drive a bus off a bridge and cut Patient 27’s throat with knife and bleed to death and with admitting diagnosis of major depression. During a review of Patient 27’s physician order, dated 1/19/2026, the physician order indicated, Patient 27 was on standard Q 15-minute rounding for suicide harm to self. During a review of the facility’s policy and procedure (P&P) titled, “Scope of Services and Nursing Staffing Plan,” dated 4/2024, the P&P indicated, “The goal of the Nursing Services Department is to provide direct and indirect patient care services that ensure safety, comfort, personal hygiene, and protection of patients ... A minimum of one (1) registered nurse shall be on the hospital premises providing or supervising nursing services 24 hours a day, sever (7) days a week ... each unit or area where patient care is provided will have a staffing matrix to provide for enough professional nursing staff ... to carry out the following activities ... appropriate healthcare interventions as specified in standards, policies and procedures, protocols or as determined by professional judgement ... Nursing care is provided by Registered Nurses, Licensed Vocational Nurses, Mental Health Workers and Unit Secretary.” During a review of the facility’s policy and procedure (P&P) titled, “Precaution Protocol and Risk Levels,” dated 3/2025, the P&P indicated, “Purpose: to protect the high-risk patient from harm and to ensure the safety of other patients, staff and visitors ... 1. Suicide, assault, AWOL precaution: A. An RN may institute any precaution level subsequently notifying the physician and obtaining a doctor’s order ... 2. Risk Levels: one-to-one (1:1), line of sight (LOS) and Q 15-minute checks ...C. Q 15-minute close observations ... 2. Patients are checked every 15 minutes. 3. Patients are evaluated for safety in the milieu (community) at each check.” During a review of the facility’s position description for Registered Nurse, dated 7/2022, the position description indicated, “Job Specific Accountabilities ... demonstrate effective leadership skills of delegation, organization, and coordination in managing assigned unit; delegates responsibilities to unit staff as appropriate ... monitors all patients for evidence of danger to self or others ... demonstrate appropriate delegation of tasks and duties in the direction and coordination of the work of nursing team members, patient care and unit activities.” During a review of the facility’s position description for Mental Health Worker, dated 1/2026, the position description indicated, “Job Specific Accountabilities ... Monitors all patients for evidence of danger to self or others and reports immediately to Registered Nurse ... Practices impeccable close observation techniques for all levels of observation, i.e. Q15 (Q15min rounding), LOS, 1:1.” 3. During an interview on 1/20/2026 at 10:41 a.m. with a Mental Health Worker (MHW) 4, MHW 4 stated the following: on the unit assignment, it would indicate which patient required line of sight (LOS, a straight line along which an observer had unobstructed vision, a type of observation performed by health worker to monitor patients for safety) observation and type of precaution. The staff needed to maintain visual contact on LOS patients and be aware of where these patients were. During an interview on 1/20/2026 at 11:28 a.m. with the Director (DIR 1) of Psychiatric Services (inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders), DIR 1 stated patient door should remain open when a LOS patient was in the room to maintain visual contact with the LOS patient. During an interview on 1/20/2026 at 3:18 p.m. with a Registered Nurse (RN) 1, RN 1 stated patients could be placed on line of sight observation in cases such as patients making multiple AWOL (attempt without official leave, same as elopement [patient leaving the facility without authorization]) attempts, acting sexually inappropriately, and/or being dangers to self or to others. During an interview on 1/21/2026 at 2:24 p.m. with the Nurse Manager (NM) 1, NM 1 stated nurses would communicate with the MHWs what precaution and observation level patients required to ensure that the correct level of observation was being followed. NM 1 stated it was the nursing responsibility to ensure the correct type of precaution and observation was implemented. During a review of the facility’s night shift unit assignment titled, “Unit East - PM,” dated 1/29/2026, the unit assignment indicated the following: -MHW 7 was assigned to Patient 21 (in Room 2) who required line of sight observation; -MHW 8 was assigned to Patient 20 (in Room 5) who required line of sight observation; -MHW 9 was assigned to Patient 2 (in Room 7) who required line of sight observation. During a concurrent observation and interview on 1/22/2026 at 11:15 a.m. with the Regional Security Manager (RSM) and the Quality Supervisor (QS) 2, the facility’s security video footage, with date stamp 1/20/2026 from 2 a.m. to 3:08 a.m., was reviewed. The following was observed in the security video footage with video view of the hallway including three (3) patients’ rooms (Rooms 3, 4 and 5) leading to the unit exit door (Door 2): -MHW 7 was sitting in a chair by Door 2 from 2 a.m. to 3:08 a.m. and did not get up to make any rounds for his (MHW 7’s) assigned patients including Patient 21, while MHW 8 did not walk down the hallway and enter Room 5 to round on Patient 20 from 2 a.m. to 3:08 a.m. In addition, Room 5 door remained closed in the security video footage from 2 a.m. to 3:08 a.m. -QS 2 stated MHW 7 and MHW 8 did not perform any Q15min rounding from 2 a.m. to 3:08 a.m. for their (MHW 7’s and MHW8’s) assigned patients. QS 2 further stated the line of sight observation was not maintained for Patient 20 and Patient 21. During a concurrent observation and interview on 1/26/2026 at 1:15 p.m. with the DIR 1, the facility’s security video footage, with date stamp 1/20/2026 from 2 a.m. to 3 a.m., was reviewed. The following was observed in the security video footage with video view of the hallway including three patients’ rooms (Rooms 7, 8 and 9): -MHW 9 was sitting in a chair in the middle of the hallway but did not enter any of her (MHW 9’s) assigned room to check on Patient 2 from 2 a.m. to 3 a.m. -DIR 1 stated MHW 9 did not make any Q15min rounding on 1/20/2026 from 2 a.m. to 3 a.m. for MHW 9’s assigned patients. DIR 1 further stated there was no line-of-sight observation provided for Patient 2 from 2 a.m. to 3:08 a.m. During a review of Patient 2’s “Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 1/13/2026, the “psych eval” indicated, Patient 2 was admitted to the facility on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to being extremely aggressive (behavior that is forceful, assertive, and potentially hostile or threatening), agitated (feeling of irritability or severe restlessness), and confrontational with violent outbursts with admitting diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During a review of Patient 2’s physician order, dated 1/14/2026, the physician order indicated Patient 2 was on line of sight observation for AWOL risk. During a review of Patient 20’s “Psychiatric Evaluation (psych eval),” dated 1/1/2026, the “psych eval” indicated, Patient 20 was admitted to the facility on 5150-hold for disrupting the peace and threatening to harm others with admitting diagnosis of schizophrenia. The psych eval also indicated Patient 20 talked about being groomed as a child to have sex with older women. During a review of Patient 20’s physician order, dated 1/14/2026, the physician order indicated Patient 20 was on line of sight observation for sexually acting out behavior. During a review of Patient 21’s “Psychiatric Evaluation (psych eval),” dated 3/6/2024, the “psych eval” indicated, Patient 21 was admitted to the facility on a 5150-hold due to dangers to others and gravely disabled for homicidal threats to chop off [Patient 21’s family] head then ship it to China. Patient 21’s psych eval also indicated an admitting diagnosis of schizoaffective (a mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]), bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Patient 21’s physician order, dated 12/8/2025, the physician order indicated, Patient 21 was on line of sight observation for being confused and requiring staff re-direction and re-orientation. During a review of the facility’s policy and procedure (P&P) titled, “Scope of Services and Nursing Staffing Plan,” dated 4/2024, the P&P indicated, “The goal of the Nursing Services Department is to provide direct and indirect patient care services that ensure safety, comfort, personal hygiene, and protection of patients ... A minimum of one (1) registered nurse shall be on the hospital premises providing or supervising nursing services 24 hours a day, seven (7) days a week ... each unit or area where patient care is provided will have a staffing matrix to provide for enough professional nursing staff ... to carry out the following activities ... appropriate healthcare interventions as specified in standards, policies and procedures, protocols or as determined by professional judgement ... Nursing care is provided by Registered Nurses, Licensed Vocational Nurses, Mental Health Workers and Unit Secretary.” During a review of the facility’s policy and procedure (P&P) titled, “Precaution Protocol and Risk Levels,” dated 3/2025, the P&P indicated, “Purpose: to protect the high-risk patient from harm and to ensure the safety of other patients, staff and visitors ... 1. Suicide, assault, AWOL precaution: A. An RN may institute any precaution level subsequently notifying the physician and obtaining a doctor’s order ... 2. Risk Levels: one-to-one (1:1), line of sight (LOS) and Q 15-minute checks ... B. LOS: 1. LOS observation is when patient is in LOS of staff at all times including bathroom privileges 2. Patients are charted on Q 15 minutes.” During a review of the facility’s position description for Registered Nurse, dated 7/2022, the position description indicated, “Job Specific Accountabilities ... demonstrate effective leadership skills of delegation, organization, and coordination in managing assigned unit; delegates responsibilities to unit staff as appropriate ... monitors all patients for evidence of danger to self or others ... demonstrate appropriate delegation of tasks and duties in the direction and coordination of the work of nursing team members, patient care and unit activities.” During a review of the facility’s position description for Mental Health Worker, dated 1/2026, the position description indicated, “Job Specific Accountabilities ... Monitors all patients for evidence of danger to self or others and reports immediately to Registered Nurse ... Practices impeccable close observation techniques for all levels of observation, i.e. Q15 (Q15min rounding), LOS, 1:1.” 4. During a review of Patient 1’s, “History and Physical (H&P, a formal and complete an assessment of the patient and the problem),” dated 3/18/2025, the “H&P” indicated Patient 1 was admitted on 3/18/2025 on 5150 hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thoughts of taking one’s own life) with plan to overdose on pills and jump from a bridge. During a review of Patient 1’s “Patient Monitoring” record, dated 3/21/2025, the records indicated Patient 1 had a physician’s order for Line-of-Sight (LOS, a straight line along which an observer had unobstructed vision) monitoring for being a Danger to Others (DTO, where an individual poses a risk of harm to others) and AWOL (Absent Without Leave, leaving the facility without authorization). During a concurrent observation, interview, and record review on 1/21/2026 at 11:40 a.m. with the Director of Psychiatric Services (DIR) 1, the facility’s video footage, with date stamped 3/22/2025, was observed and reviewed. On 3/22/2025 at 4:07 p.m., Patient 1 was observed pacing alone in the hallway between the nursing station and the unit exit door (Door 2). Patient 1 was observed walking towards the unit exit door (Door 2) and pushed the unit exit door once. The unit exit door remained closed. Patient 1 then backed up and slammed his body into the door, but the door remained closed. Patient 1 backed up again and slammed his body into the door again. Unit exit door was opened. There was no one around to stop Patient 1. Patient 1 eloped from the facility and did not return. DIR 1 stated the staff did not look at Patient 1. There was no line of sight for Patient 1. DIR 1 stated MHW 5 was responsible for Patient 1’s LOS observation (MHW 5 was only seen in the video frame after Patient 1 eloped). DIR 1 stated LOS means the patients should always be within visual range of the staff (This ensures continuous monitoring and immediate response if needed). During an interview on 1/22/2026 at 8:54 a.m. with Registered Nurse (RN) 2, RN 2 stated that there should have been another staff member watching Patient 1 for LOS observation to ensure patient safety and to prevent injury to self or risk to others. RN 2 stated that Patient 1 was identified as an AWOL risk and had a history of AWOL attempts during hospitalization. RN 2 stated that LOS was appropriate, but there was a lack of communication between staff, and that somebody needed to have eyes on Patient 1. RN 2 stated LOS was not being carried out properly. RN 2 stated if someone had been watching Patient 1, he (Patient 1) could have been stopped and would not have been able to get through the door (Door 2). During review of facility’s policy and procedure (P&P) titled, “Precaution Protocol and Risk Levels,” dated 3/2025, indicated, “Precautions are instituted whenever a patient is at risk for acting on suicidal, assaultive, or runaway impulses... The attending physician will determine the appropriate precaution level of their patient based on patient behaviors and need with the input of members of the interdisciplinary team. 1. Suicide, assault, AWOL precautions: A. An RN may institute any precaution level subsequently notifying the physician and obtaining a doctor’s order. B. Upon initiation of precaution, the RN must document, in the EMR, the patient behaviors warranting the precaution ... 2. Risk levels: one-to-one, line of sight and Q15 minute check. A. One-to one (1:1): 1. Highest intensity of level of observation... B. LOS (line-of-sight): 1. LOS observation is when a patient is in LOS of staff at all times including bathroom privileges... C. Q15 minutes close observation: 1. Suicide precaution 1 (SP 1), Assault precautions (AS 1), AWOL precaution (AWOL 1). 2. Patients are checked every 15 minutes. 3. Patients are evaluated for safety in the milieu at each check.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure that nursing staff adhered to the facility’s policies and procedures when: 1. One of 30 sampled patient’s (Patient 29) neurological assessment (a systematic evaluation of a patient’s nervous system function, including level of consciousness, motor and sensory function, reflexes, and cranial nerve responses), was not completely performed and documented in Patient 29’s electronic medical record (EMR, a digital version of a patient’s medical chart that contains health information, treatment history, and clinical documentation), in accordance with the facility’s policy and procedure regarding assessments and reassessments, after Patient 29 sustained an unwitnessed fall (an incident where a patient falls without anyone observing the event, making it unclear whether there was head trauma or loss of consciousness) and had an order to be monitored for neurological function for 24 hours after the fall. This deficient practice had the potential to place Patient 29 at an increased risk for missed signs of neurological worsening, such as changes in motor weakness (a decrease in muscle strength or inability to move a limb effectively, which can indicate damage to the brain or spinal cord) or abnormal reflexes (unexpected or absent automatic responses to stimuli, such as the knee-jerk reaction, which can signal neurological impairment), and of delayed recognition of bleeding inside the skull (intracranial hemorrhage), which can be life-threatening if not promptly identified and treated. 2. One of 30 sampled patient’s (Patient 3) pain assessment (a systematic evaluation of a patient’s pain, including location, intensity, duration, and characteristics, often using a standardized pain scale), was not completely performed (pain assessment must include pain location, intensity, and characteristics of pain) and documented in Patient 3’s EMR (electronic medical record), in accordance with the facility’s policy and procedure regarding pain assessment and intervention (intervention refers to the actions or treatments taken to alleviate or manage pain based on the assessment findings, such as administering medication or repositioning). This deficient practice had the potential to result in delayed and inadequate pain management for Patient 3 because the location, intensity, and characteristics of pain were not described, placing Patient 3 at risk of worsening pain and psychological distress (such as anxiety). 3. One of 30 sampled patient’s (Patient 3) detailed neurological assessment (a systematic evaluation of the nervous system, including motor, sensory reflexes [rapid, involuntary motor responses to specific sensory stimuli, acting as protective or functional mechanisms without requiring conscious thought], and cognitive functions [the ability to perceive and react, process and understand, make decisions and produce appropriate responses to the environment]) and NIH Stroke Scale (NIHSS, a standardized tool used to measure the severity of stroke symptoms and guide treatment decisions), was not performed after Patient 3 complained of weakness (loss of strength in muscles) and one-sided pain (pain localized to one side of the body), as per the physician’s order and the facility’s policy regarding assessment, reassessment, and documentation. This deficient practice had the potential to result in a serious safety event for Patient 3, which could lead to permanent neurological damage, and/or delayed or missed diagnosis of stroke (brain attack). Findings: 1. During a review of Patient 29’s Psychiatric Evaluation (a comprehensive assessment conducted by a mental health professional to determine a patient’s mental status, diagnosis, risk factors, and treatment needs, often including history, current symptoms, and safety concerns), dated 8/16/2025, the psychiatric evaluation indicated that Patient 29 was admitted on a 5150 hold for danger to self (a 72-hour involuntary psychiatric hold under California law for individuals who, due to mental illness, pose a danger to themselves, others, or are gravely disabled). During a review of Patient 29’s nursing progress note (a written entry in the patient’s medical record by nursing staff that documents observations, assessments, interventions, and the patient’s response to care), dated 9/2/2025, the note indicated that Patient 29 sustained an unwitnessed fall (an incident where a patient falls without anyone observing the event, making it unclear whether there was head trauma or loss of consciousness) on 9/2/2025 around 11:40 a.m. after a Mental Health Worker (MHW, a staff member responsible for monitoring and supporting patients with mental health needs) informed the nurse that Patient 29 was found on the floor. Per the note: “Patient (Patient 29) was assessed ... patient (Patient 29) was attempting to go to the restroom and missed the wheelchair and fell backwards, hitting the back of the head ... Patient reported pain but did not give it a rating ... Medical Doctor (MD) and psychiatrist were informed of the fall ... Order received for neuro checks (neurological checks refer to a series of assessments performed to monitor brain and nervous system function, including level of consciousness, pupil [black, circular opening in the center of the eye] response, motor strength, and speech; every 2 hours for 24 hours means these checks must be conducted at two-hour intervals for a full day to detect early signs of neurological deterioration such as bleeding or swelling in the brain) every 2 hours for 24 hours.” During an interview on 1/21/2026 at 2:27 p.m. with the Director of Nursing (Dir 1), Dir 1 stated that the order for Patient 29’s neurological assessment was placed on 9/2/2025 at 1:01 p.m. and indicated that it was to be performed every 2 hours for 24 hours. During a concurrent interview and record review on 1/21/2026 at 2:35 p.m. with the Director of Nursing (Dir 1), Patient 29’s neurological assessment record, dated 9/2/2025 through 9/3/2025, was reviewed. The record indicated that neurological assessment included four distinct parts involving the assessment of: -Glasgow Coma Scale (GCS, a standardized tool used to assess a patient’s level of consciousness [mental status] based on three components: eye opening, verbal response, and motor response [muscle movement]; scores range from 3 to 15, with lower scores indicating more severe impairment) to monitor neurological stability or worsening. -Neurological Detailed Assessment (a comprehensive evaluation of nervous system function, including pupil response, facial symmetry [where both sides of the face, left and right, are alike], speech characteristics, motor strength in all extremities, gait [walking pattern], and aspiration risk [the likelihood of foreign materials such as food, accidentally entering the airway]). -NIH Stroke Scale (NIHSS, a systematic scoring tool used to measure the severity of stroke-related (brain attack) neurological deficits [impairments in body function], including consciousness, vision, motor function, sensation, language, and attention). -Vital Signs (basic physiological measurements such as temperature, pulse, respiration rate, and blood pressure, which help monitor overall health and detect changes in condition). During the same concurrent interview and record review on 1/21/2026 at 2:35 p.m. with the Director of Nursing (Dir 1), the record also indicated that there was no documented detailed neurological assessment; only vital signs (VS) and Glasgow Coma Scale (GCS) were assessed and documented every two hours. Dir 1 stated that the expectation when a neurological assessment was ordered was to perform and document the full detailed neurological assessment (including pupil response, facial symmetry, speech characteristics, motor strength, gait, and aspiration risk) in addition to GCS and vital signs. Dir 1 acknowledged that staff were not completing the detailed neurological assessment as required by physician orders. During an interview on 1/21/2026 at 3:30 p.m. with the Nurse Manager (NM 1), NM 1 stated: “We perform a neurological assessment after any type of head injury or suspected head injury, such as an unwitnessed fall. A proper neuro check includes Glasgow Coma Scale (GCS), pupil assessment, vital signs (VS), and a detailed neurological assessment.” NM 1 also said that these checks were done to help find any problems with the brain or nerves and make sure to catch a head injury that might not be obvious. During a review of the facility’s policy and procedures (P&P) titled “Assessment and Reassessment,” dated 5/2024, the P&P indicated that “ ...Assessment activities are directed by the physician ...All assessments and reassessments are documented in the patient’s medical record ...Neurological Detailed Assessment should include documentation of PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation, a test to evaluate pupil size, shape, and response to light and focus), Pupil Assessment (evaluation of pupil size, symmetry, and reactivity to light), Facial Symmetry (observation to ensure both sides of the face move equally, which can indicate normal cranial nerve function), Characteristics of Speech (assessment of clarity, fluency, and coherence of speech, which can reveal neurological deficits), Aspiration Risk (the likelihood of food or liquid entering the airway during swallowing, which can lead to choking or pneumonia), Neuro Strength in all four extremities (testing muscle strength in both arms and legs to detect weakness or paralysis), and Gait (the manner or style of walking, which can indicate balance, coordination, and neurological integrity). 2. During a review of Patient 3’s Psychiatric Evaluation (a comprehensive assessment conducted by a mental health professional to determine a patient’s mental status, diagnosis, risk factors, and treatment needs, often including history, current symptoms, and safety concerns), dated 12/9/2025, the record indicated that Patient 3’s admitting diagnosis was schizophrenia, paranoid type (a chronic mental health disorder characterized by distorted thinking, hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste], and delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary], often involving feelings of persecution [often irrational belief that one is being targeted, threatened, plotted against, or harmed by others, despite a lack of evidence] or paranoia) and that Patient 3 was admitted on a 5150 hold for grave disability (a 5150 hold is a 72-hour involuntary psychiatric hold for individuals who, due to mental illness, pose a danger to themselves, others, or are gravely disabled; grave disability means the person is unable to provide for their basic needs such as food, clothing, or shelter because of a mental disorder). During a concurrent interview and record review on 1/22/2026 at 1:55 p.m. with the Director of Nursing (Dir 1), Patient 3’s pain assessment record, dated 12/08/2025 through 12/26/2025, was reviewed. The record indicated that Patient 3 complained of pain on the following dates: -12/08/2025 at 8:53 p.m. - pain was 3/10 (mild pain on a numeric rating scale where 0 = no pain and 10 = worst possible pain). -12/11/2025 at 1:30 a.m. - pain was 6/10 (moderate pain on the numeric rating scale). -12/19/2025 at 12:45 a.m. - pain was 6/10 (moderate pain). -12/26/2025 at 1:10 a.m. - pain was 5/10 (moderate pain). -The record indicated that there was no other information documented regarding Patient 3’s pain location (where the pain was felt), intensity (degree of pain beyond numeric score), characteristics (type of pain such as sharp, dull, throbbing), and/or patient’s acceptable pain level (the pain level the patient considers tolerable). -Dir 1 verified that pain characteristics and location were not documented in Patient 3’s record but did not provide a comment regarding the implications of not assessing and documenting a thorough pain assessment that included the following information: (Location [where the pain is felt], Characteristics [sharp, dull, throbbing], Intensity [numeric score and descriptive terms, Acceptable pain level [patient’s goal for relief]), as per the facility’s policy regarding pain assessment. During a review of the facility’s policy and procedures (P&P) titled “Pain Assessment and Intervention,” dated 4/2024, the P&P indicated that “ ...The patient will be asked if they are experiencing pain. If yes, they will be asked to: a. Define the location and type of pain b. Specify the pain score c. Establish the current pain goal.” 3. During a review of Patient 3’s Psychiatric Evaluation (a comprehensive assessment conducted by a mental health professional to determine a patient’s mental status, diagnosis, risk factors, and treatment needs, often including history, current symptoms, and safety concerns), dated 12/9/2025, the record indicated that Patient 3’s admitting diagnosis was schizophrenia, paranoid type (a chronic mental health disorder characterized by distorted thinking, hallucinations, and delusions, often involving feelings of persecution or paranoia) and that Patient 3 was admitted on a 5150 hold for grave disability (a 5150 hold is a 72-hour involuntary psychiatric hold for individuals who, due to mental illness, pose a danger to themselves, others, or are gravely disabled; grave disability means the person is unable to provide for their basic needs such as food, clothing, or shelter because of a mental disorder). During a review of the facility’s policy and procedures (P&P) titled “Assessment and Reassessment,” dated 5/2024, the P&P indicated that “ ...Assessment activities are directed by the physician ...All assessments and reassessments are documented in the patient’s medical record ...Neurological Detailed Assessment should include documentation of PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation, a test to evaluate pupil size, shape, and response to light and focus), Pupil Assessment (evaluation of pupil size, symmetry, and reactivity to light), Facial Symmetry (observation to ensure both sides of the face move equally, which can indicate normal cranial nerve function), Characteristics of Speech (assessment of clarity, fluency, and coherence of speech, which can reveal neurological deficits), Aspiration Risk (the likelihood of food or liquid entering the airway during swallowing, which can lead to choking or pneumonia), Neuro Strength in all four extremities (testing muscle strength in both arms and legs to detect weakness or paralysis), and Gait (the manner or style of walking, which can indicate balance, coordination, and neurological integrity). During a review of Patient 3’s nursing progress note (a written record created by a nurse to document a patient’s condition, symptoms, interventions, and responses over time) dated 12/26/2025 at 1:00 a.m., per note, “Patient 3 complained of severe left-sided pain 7/10 (pain score on a numeric scale from 0 to 10, where 0 = no pain and 10 = worst possible pain; 7 indicates severe pain) and weakness. Patient was given Tylenol 650 mg (Tylenol is the brand name for acetaminophen, a medication used to relieve mild to moderate pain and reduce fever; mg stands for milligrams, a metric unit of weight equal to one-thousandth of a gram). Patient 3 stated she had sharp pain in the left foot and that she was having a stroke [brain attack]. Medical doctor (MD) ordered neuro checks every 4 hours: Neuro assessment for 2:00 a.m.: GCS 15 (Glasgow Coma Scale, a standardized tool to assess level of consciousness based on eye opening, verbal response, and motor response; scores range from 3 to 15, with 15 indicating full alertness); neuro assessment at 6:00 a.m.: GCS 15.” During a concurrent interview and record review on 1/22/2026 at 3:33 p.m. with the Director of Nursing (Dir 1), Patient 3’s neurological assessment record, dated 12/26/2025, was reviewed. The record indicated that neurological assessment included four distinct parts involving the assessment of: -Glasgow Coma Scale (GCS) (a standardized tool used to assess a patient’s level of consciousness (mental status) based on three components: eye opening, verbal response, and motor response; scores range from 3 to 15, with lower scores indicating more severe impairment) to monitor neurological stability or worsening. -Neurological Detailed Assessment (a comprehensive evaluation of nervous system function, including pupil response, facial symmetry, speech characteristics, motor strength in all extremities, gait, and aspiration risk). -NIH Stroke Scale (NIHSS) (a systematic scoring tool used to measure the severity of stroke-related (brain attack) neurological deficits, including consciousness, vision, motor function, sensation, language, and attention). -Vital Signs (basic physiological measurements such as temperature, pulse, respiration rate, and blood pressure, which help monitor overall health and detect changes in condition). During the same concurrent interview and record review on 1/22/2026 at 3:33 p.m. with the Director of Nursing (Dir 1), the record also indicated that there was no documented detailed neurological assessment; only Glasgow Coma Scale (GCS) were assessed and documented every 4 hours on 12/26/2025. Dir 1 stated that the expectation when a neurological assessment was ordered was to perform and document the full detailed neurological assessment (including pupil response, facial symmetry, speech characteristics, motor strength, gait, and aspiration risk) in addition to GCS and vital signs. Dir 1 acknowledged that staff were not completing and documenting the detailed neurological assessment and NIH Stroke Scale (NIHSS). Dir 1 also did not provide a comment regarding the possible implications of not conducting a detailed neurological assessment, including the NIH Stroke Scale (NIHSS) (a systematic scoring tool used to measure the severity of stroke-related neurological deficits), for Patient 3, who complained of having a stroke. During an interview on 1/22/2026 at 4:33 p.m. with psychiatrist (MD 1), MD 1 stated: -“If the patient has an immediate need, I can order a neuro check. A neuro check should include: vital signs (basic physiological measurements such as temperature, pulse, respiration rate, and blood pressure), alertness (patient’s level of consciousness), cognitive functioning (ability to think, reason, and remember), muscle functioning (strength and coordination), and if the patient had head trauma or fell down, we need to check the muscle strength in the hand. Also assess A/O (alert and oriented, meaning the patient is aware of person, place, time, and situation) and GCS (Glasgow Coma Scale, a standardized tool to assess level of consciousness based on eye opening, verbal response, and motor response; scores range from 3 to 15, with 15 indicating full alertness). The medical doctor should be notified so they can assess the patient.” -“The medical doctor needs to be aware and give suggestions if the patient has a previous history (hx) of conditions such as HTN (hypertension, high blood pressure), DM (diabetes mellitus), CVA (cerebrovascular accident, also known as stroke), or other medical conditions. This allows the physician to give directions to nursing staff on what to do. A neuro check order will include the frequency to ensure vital signs and cognitive function remain stable. If they are not stable, the patient needs to be sent out for medical clearance.” During a review of the facility’s policy and procedures (P&P) titled “Assessment and Reassessment,” dated 5/2024, the P&P indicated that “ ...Assessment activities are directed by the physician ...All assessments and reassessments are documented in the patient’s medical record ...Neurological Detailed Assessment should include documentation of PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation, a test to evaluate pupil size, shape, and response to light and focus), Pupil Assessment (evaluation of pupil size, symmetry, and reactivity to light), Facial Symmetry (observation to ensure both sides of the face move equally, which can indicate normal cranial nerve function), Characteristics of Speech (assessment of clarity, fluency, and coherence of speech, which can reveal neurological deficits), Aspiration Risk (the likelihood of food or liquid entering the airway during swallowing, which can lead to choking or pneumonia), Neuro Strength in all four extremities (testing muscle strength in both arms and legs to detect weakness or paralysis), and Gait (the manner or style of walking, which can indicate balance, coordination, and neurological integrity).”