Summitridge Center- Psychiatry & Addictive Med

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 45841 Based on observation, interview, record review, and facility document and policy review, it was determined that the facility Governing Body failed to ensure that patients were informed of their patient rights for four (Patient #1, #2, #3, and #4) patients; failed to ensure that patients were free from abuse from peers for one (P#2) patient; and failed to ensure that three (P#7, #8, #9) patients were free from restraints. This failure had the potential to affect all patients who received services at the facility: Findings included: The facility failed to ensure patients’ rights information was provided. (Refer to A0117) The facility failed to ensure a patient was free from patient-to-patient physical abuse. (Refer to A0145) The facility failed to identify geriatric chairs as physical restraints when attached tray tables impacted the patients’ ability to move their bodies, for patients who were unable to remove the tray without assistance in the same manner in which the tray tables were applied by staff. Additionally, the facility failed to ensure an escort physical restraint was not utilized without a physician’s order or associated assessments and documentation. (Refer to A0159)”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45841 Based on observation, interviews, record review, and facility document and policy review, it was determined that the facility failed to protect and promote each patient’s rights. This failure had the potential to affect all patients who received services at the facility. Findings included: The facility failed to ensure patients’ rights information was provided. (Refer to A0117). The facility failed to ensure a patient was free from patient-to-patient physical abuse. (Refer to A0145). The facility failed to identify geriatric chairs as physical restraints when attached tray tables impacted the patients’ ability to move their bodies, for patients who were unable to remove the tray without assistance in the same manner in which the tray tables were applied by staff. Additionally, the facility failed to ensure an escort physical restraint was not utilized without a physician’s order or associated assessments and documentation. (Refer to A0159).”

“Special Medical Record Requirements CFR(s): Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals The medical records maintained by a psychiatric hospital must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution. This Condition is not met as evidenced by: 45841 Based on observation, interview, record review, and facility document and policy review, the facility failed to meet the condition of participation for special medical record requirements. This failure affected 3 (Patients #7, #8, and #9) of 7 patients reviewed for physical restraints. Findings included: The facility failed to identify geriatric chairs as physical restraints when attached tray tables greatly impacted the patients’ ability to move their bodies for patients who were unable to remove the tray without assistance and in the same manner the tray tables were applied by staff. Failure to identify the tray tables as restraints resulted in the staff’s failure to perform assessments, obtain orders, and conduct the monitoring required when physical restraints were utilized for Patients #7, #8, and #9. (Refer to A0159)”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 45841 Based on interview, record review, and facility document and policy review, it was determined that the facility failed to ensure patient rights information was provided to 4 (Patient #1, #2, #3, and #4) of 6 patients reviewed, including information about the right to receive care in a safe setting, rights to be free from abuse and restraints, and the right to access their medical record. In addition, the facility failed to ensure that 2 (Patient #5 and Patient #6) of 6 patients reviewed received their rights on admission to the facility. Findings included: The facility’s policy, titled, “Patients’ Rights,” revised 01/2023, indicated, “1.0 Prior to admission, each individual shall be provided with a copy of the Patient’s Rights form and a verbal explanation of those rights in their primary language in simple non¿technical language. The minor’s parent, managing conservator or legal guardian will be given the Patient’s Rights form. If a family member, legal guardian, or friend is available, he or she shall be asked to be present during the explanation. This shall be done with both voluntary and involuntary patients.” The policy also indicated, “3.0 The individual and/or the parent, conservator, or guardian shall be requested to sign and date a statement of receipt of the Patient’s Rights form prior to admission to acknowledge receiving a written and verbal explanation of those rights. The signed statement shall be witnessed by a family member, legal guardian, or friend (if available) and in the patient’s medical record. The staff member who explains the rights shall also sign and date the statement of receipt of the Patient’s Rights. This signed statement shall be filed in the patient’s medical record. 4.0 When the individual receiving services is unable or unwilling to sign the document which confirms that rights have been orally communicated, a brief explanation of the reason should be entered onto that document along with the signatures of the person who explained the rights and a third-party witness, preferably by a family member, legal guardian or friend (if available) or by another staff member.” An undated facility document titled, “Patient Rights and Responsibilities,” indicated, “The listing is not intended to be and should not be relied on as an all-inclusive restatement of Georgia patients’ rights statutes. An unabridged copy of the Georgia patients’ rights statutes and regulations is available upon request to any staff member.” The patient’s rights information provided to patients as part of their admission packet did not include the patient’s rights to: receive care in a safe setting, to be free from abuse and harassment, to have access to medical records, and to be free from the use of restraints or seclusion. 1. Patient #1’s “History and Physical Report,” dated 08/01/2024, revealed the facility admitted the patient for major depression. Patient #1’s “Receipt of Patient Rights Acknowledgement,” signed 07/31/2024, revealed the patient received their facility packet of patient rights. During an interview on 02/03/2026 at 2:48 PM, the Director of Risk (DR) stated that he was unable find the right to care in a safe setting, the right to be free from abuse, the right to be free from restraints, and the right to access medical records included in the rights the facility provided to patients. The DR stated the right to care in a safe setting, the right to be free from abuse, the right to be free from restraints, and the right to access medical records were Centers for Medicare and Medicaid Services (CMS) rights and needed to be added to the rights the facility provided 2. Patient #2’s “History and Physical Reports” dated 11/21/2025, revealed the facility admitted the patient for psychosis. Patient #2’s “Assessments and Treatments,” record dated 11/21/2025, revealed patient rights information had been provided. During an interview on 02/03/2026 at 2:48 PM, the Director of Risk (DR) stated that he was unable find the right to care in a safe setting, the right to be free from abuse, the right to be free from restraints, and the right to access medical records included in the rights the facility provided to patients. The DR stated the right to care in a safe setting, the right to be free from abuse, the right to be free from restraints, and the right to access medical records were Centers for Medicare and Medicaid Services (CMS) rights and needed to be added to the rights the facility provided. 3. Patient #3’s “Psychiatric Discharge Orders and Summary,” revealed the facility admitted the patient on 08/21/2024 for unspecified psychosis and unspecified mood disorder. Patient #3’s “Receipt of Patient Rights Acknowledgement,” signed 08/21/2024, revealed the patient received their facility packet of patient rights. During an interview on 02/03/2026 at 2:48 PM, the Director of Risk (DR) stated that he was unable find the right to care in a safe setting, the right to be free from abuse, the right to be free from restraints, and the right to access medical records included in the rights the facility provided to patients. The DR stated the right to care in a safe setting, the right to be free from abuse, the right to be free from restraints, and the right to access medical records were Centers for Medicare and Medicaid Services (CMS) rights and needed to be added to the rights the facility provided. 4. Patient #4’s “History and Physical Reports” dated 11/17/2025 at 8:58 AM, revealed facility admitted the patient for suicidal ideation and paranoid delusions. Patient #4’s “Statement That You Have Received Written Notice of Your Patient Rights” was signed by the patient on 11/19/2025 at 10:42 AM. During an interview on 02/03/2026 at 2:48 PM, the Director of Risk (DR) stated that he was unable find the right to care in a safe setting, the right to be free from abuse, the right to be free from restraints, and the right to access medical records included in the rights the facility provided to patients. The DR stated the right to care in a safe setting, the right to be free from abuse, the right to be free from restraints, and the right to access medical records were Centers for Medicare and Medicaid Services (CMS) rights and needed to be added to the rights the facility provided. 5. A demographic record revealed the facility admitted Patient #5 on 12/20/2025 for psychosis and the facility discharged the patient on 01/07/2026 at 5:00 PM. Patient #5’s “Statement That You Have Received Written Notice of Your Patient Rights” revealed the patient signed the form and a registered nurse signed as a witness on 01/07/2026, the day the patient was discharged. During an interview on 02/02/2026 at 11:35 AM, Nurse Leader (NL) #8 stated that Patient #5’s record only showed the acknowledgement of patient rights that was dated 01/07/2026. Per NL #8, there was no documentation from the patient’s admission date. 6. A demographic record revealed the facility admitted Patient #6 on 12/24/2025 for aggression and the facility discharged the patient on 01/01/2026. Patient #6’s medical record revealed no documented evidence that the facility provided the patient with a copy of patient’s rights or that a statement of receipt of the patient’s rights was completed during Patient #6’s admission from 12/24/2025 to 01/01/2026. During an interview on 02/02/2026 at 11:39 AM, Nurse Leader (NL) #8 stated that Patient #6’s medical record did not show any acknowledgement that the patient was notified of their rights. During an interview on 02/02/2026 at 1:43 PM, the Assistant Director of Intake (ADI) stated that once the admission process started, there was a mix of paper and electronic forms. The ADI stated that the acknowledgement form for patient rights was electronic, and the patient could decline to sign the form. Per the ADI, the patient also received a copy of patient rights in a purple admission folder. The ADI stated that if they could not provide patient rights information on admission, they provided it later. During an interview on 02/03/2026 at 12:01 PM, the Chief Nursing Officer (CNO) stated that the expectation was that the facility provides patient rights information when the patient came to the hospital for intake. The CNO stated the patient could either sign or decline to sign acknowledging receipt. The CNO also stated that they provided a copy of the patient’s rights in the patient’s admission folder.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 45841 Based on interview, record review, and facility document and policy review, it was determined that the facility failed to ensure a patient was free from patient-to-patient physical abuse for 1 (Patient #2) of 7 sampled patients reviewed for abuse. Specifically, Patient #12 punched Patient #2 in the face resulting in a laceration above Patient #2’s right eyebrow. Findings included: A facility policy titled, “Alleged Patient Abuse, Neglect, and Exploitation,” dated 11/2023, indicated, “The definition for “Abuse” includes: 4.1 Any act or failure to act by an employee of a hospital which was performed or which was failed to be performed knowingly, recklessly or intentionally and which caused or may have caused, [sic] injury or death to a patient, [sic] and includes such acts as: 4.1.1 rape or sexual assault or a patient; 4.1.2 the striking of a patient; 4.1.3 the use of excessive force when placing a patient in bodily restraints; 4.1.4 the use of bodily or chemical restraints on a patient which is not in compliance with federal and state laws and regulations, and 4.2 Coercive or restrictive actions which are illegal or not justified by the condition of the patient and that are in response to the patient’s request for discharge or refusal of medication therapy or treatment.” The policy did not address patient to patient abuse. A facility policy titled, “Assault Precautions,” revised 08/2023, indicated, “2.0 During hospitalization, all patients will be monitored for behavior that increases assaultive potential.” The policy also indicated, “3.0 Any changes in behavior or events that may impact on a patients [sic] assaultive potential will be reported to the RN [registered nurse] in charge of the unit. 4.0 The RN in charge of the unit will contact the patient’s physician to request appropriate order. 5.0 The RN will alert all staff working with the patient via chart identification and treatment plan of the patient being placed on assault precautions. The RN will initiate a problem in the treatment plan for the potential for assaultive behavior, with appropriate immediate interventions.” Hospital demographic “Encounter Information,” revealed the facility admitted Patient #2 on 11/20/2025 at 11:26 PM and discharged the patient on 11/27/2025 at 4:00 PM. The Encounter Information revealed Patient #2 was admitted to the facility for psychosis. Hospital demographic “Encounter Information,” revealed the facility admitted Patient #12 on 11/11/2025 at 10:12 PM and discharged the patient on 11/26/2025 at 5:18 PM. The Encounter Information revealed Patient #12 was admitted to the facility for psychosis. A hospital incident report, dated 11/22/2025, revealed that on 11/22/2025 at 7:00 AM an incident of aggression by another patient occurred. The hospital incident report revealed Patient #2 was combative and aggressive, and Patient #12 responded by “physical altercation” causing a bleeding laceration to Patient #2’s right eyebrow. The hospital incident report revealed Patient #2 was sent to an emergency department where they were cleared and returned to the hospital with no stitches or sealant used. A nurse’s “Progress Note[s],” dated 11/22/2025 at 7:02 AM, revealed Patient #2 was involved in a physical altercation with another patient. The Progress Note revealed Patient #2 was verbally aggressive toward another patient, and the other patient physically impacted Patient #2 resulting in a bleeding laceration above Patient #2’s right eyebrow. A nurse’s “Progress Note[s],” dated 11/22/2025 at 4:05 PM, revealed Patient #2 was attacked by another patient, and a punch was thrown to Patient #2’s face resulting in a right eye laceration that was not witnessed by the writer of the Progress Note. A nurse practitioner’s “Progress Note[s],” dated 11/22/2025 at 10:34 PM, revealed Patient #2 was in a physical altercation with a peer and sustained a laceration to the right eyebrow. The Progress Note indicated Patient #2 was sent to an emergency room for evaluation and returned to the hospital. Patient #12’s “BH [Behavioral Health] Initial Nursing Treatment Plan,” initiated 11/11/2025 at 11:51 PM, revealed the patient had aggressive behavior related to psychosis and a history of aggressive behavior. The Nursing Treatment Plan did not indicate an update to the plan after the incident on 11/22/2025. On 02/19/2026 at 3:45 PM, Nurse Leader (NL) #8 stated physician notification after an incident should be included in the incident report. NL #8 reviewed the incident report dated 11/22/2025 for Patient #12 and Patient #2 and stated information regarding notifications was missing, and the report was not a complete report. On 02/19/2026 at 3:54 PM, Nurse Leader (NL) #8 stated that there had to be an update to the treatment after a patient was aggressive with another patient. NL #8 stated that the only update she saw to Patient #12’s treatment plan was from 11/18/2025, and there was no update after the incident on 11/22/2025. On 02/20/2026 at 10:09 AM the Director of Risk (DR) stated examples of patient-to-patient abuse included anything sexual and physical. The DR stated physical altercations were looked at to determine what kind of altercation it was. The DR stated a lot of physical altercations were fights, but abuse was more targeted from one patient to another. The DR stated that if both patients were swinging, it was a fight; however, if one patient were beating the other, that would be considered battery and abuse. The DR stated staff were encouraged to report anything right away and not to try to get all the details because that was his job. The DR stated he reached out to the regional director of clinical services if there was a question about what should be reported. On 02/20/2026 at 10:40 AM the DR stated the situation with Patient #2 and Patient #12 was an unwitnessed physical altercation, not abuse, and it was not reported. The DR stated Patient #12 was sitting in a chair in the dayroom. The DR stated Patient #12 said something to Patient #2, Patient #2 ended up in Patient #12’s face, and Patient #12 punched Patient #2. On 02/20/2026 at 11:05 AM the Chief Nursing Officer (CNO) stated if two patients had a fight that was considered abuse, because it was abuse of each other. The CNO stated the expectation was that staff would report anything that could be considered abuse, and the supervisor would inform the risk manager. The CNO stated treatment plans were to be updated if abuse happened. On 02/20/2026 at 2:54 PM, the Chief Operating Officer (COO) stated the DR was not assigned abuse training, but the CNO was assigned abuse training as she was a part of nursing. The COO stated the expectation was that treatment plans were updated as things happened with the patient, and the treatment plan was a “living, breathing” document.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(A) Definitions. (i) A restraint is- (A) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or This Standard is not met as evidenced by: 45841 Based on observation, interview, record review, and facility document and policy review, it was determined that the facility failed to identify geriatric chairs as physical restraints when attached tray tables impacted the patients’ ability to move freely. Specifically, patients who were unable to remove the tray without assistance in the same manner in which the tray tables were applied by staff. Failure to identify the tray tables as restraints resulted in the staff’s failure to perform assessments, obtain orders, and conduct the monitoring required when physical restraints were utilized for 3 (Patients #7, #8, and #9) of 7 patients reviewed for physical restraints. The failure had the likelihood to result in a patient ending up in improper restraints. In addition, the facility failed to ensure an escort physical restraint was not utilized without a physician order or associated assessments and documentation for 1 (Patient #5) of 7 patients reviewed for physical restraints. Findings included: The facility’s policy, titled, “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion,” dated 03/2023, indicated, “Physical Restraints: The application of any manual method that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely (also named therapeutic hold, protective hold, or manual restraint).” The policy also indicated, “Restraint or seclusion shall be used in emergency situations only and requires an order from a physician.” “Geri [Geriatric] Chair: If a patient requires the use of a Geri Chair with the tray locked in place in order for the patient to safely be out of bed. Given that a patient may be out of bed several times a day, it is not necessary to obtain a new order each time.” The policy also indicated, “Fluids and an opportunity for toileting shall be offered at least every 2 hours. 4.9 Vital signs shall be taken upon initiation and as clinically indicated but at least every 2 hours. 4.10 Medications shall be administered as ordered by the physician. Effectiveness of prn [as needed] or stat [immediate] medications shall be documented. 4.11 Meals shall be offered at regular meal times. 4.12 Any patient in restraint or seclusion will be assisted with a bath every 24 hours.” An undated facility document titled, “Patient Rights and Responsibilities” indicated, “The listing is not intended to be and should not be relied on as an all-inclusive restatement of Georgia patients’ rights statutes. An unabridged copy of the Georgia patients’ rights statutes and regulations is available upon request to any staff member.” The patient rights document provided to patients as part of their admission packet did not include the patient’s right to be free from restraint, seclusion, mental abuse, and corporal punishment. During a tour on 02/02/2026, at 10:16 AM, the geriatric psychiatric unit was toured, and there were patients observed in geriatric chairs with the tray tables attached. 1. A demographic record revealed the facility admitted Patient #7 on 01/30/2026 for schizophrenia. A “BH [Behavioral Health] Admission History” dated 01/30/2026 revealed that prior to admission, Patient #7 was independent with mobility and required minimum assistance with activities of daily living. Per the BH Admission History, a functional assessment revealed the patient was independent with transferring from/to bed or a chair. The admission history indicated that Patient #7 was at risk for falls. A “History and Physical Reports” dated 02/01/2026, revealed that Patient #7 had a past medical history of gout, hyperlipidemia, asthma, diabetes, and hypertension. Per the report, the patient had no neurological or muscle weakness of the extremities. Per the report, the patient was admitted with a diagnosis of acute exacerbation of chronic paranoid schizophrenia. Patient #7’s “BH Treatment Plans” for the 01/30/2026 admission, indicated the patient was at risk for falls as evidenced by a history of falls and being unsteady. A short-term goal was for the patient to experience no physical harm from any dizzy episodes (initiated 02/01/2026). Interventions directed staff to assist the patient in identifying fall risk prevention measures including use of a walker, cane, and wheelchair. The treatment plan did not include the use of a geriatric chair with attached tray table. Patient #7’s provider “Orders” revealed an order dated 01/30/2026 at 6:03 PM for ambulation, “assistance needed” three times per day and an order dated 01/30/2026 at 4:43 PM for an observation level of every 15 minutes. Patient #7’s “Assessments and Treatments” flowsheets dated 01/30/2026 at 9:22 PM at 9:29 PM, 01/31/2026 at 7:09 PM, and 02/01/2026 at 11:12 AM revealed the patient ambulated independently and had a steady gait. Patient #7’s Assessments and Treatments flowsheets also revealed that Patient #7 was in a geriatric chair on the following dates and times: - 01/30/2026 at 7:04 PM, 7:18 PM and 11:51 PM. - 01/31/2026 at 12:06 AM and 12:18 AM. - 01/31/2026 at 7:16 PM, 7:28 PM, 7:41 PM, 7:56 PM, 8:10 PM, 8:25 PM, 8:38 PM, 8:51 PM, 9:07 PM, 9:21 PM, 9:36 PM, 9:53 PM, 10:10 PM, 10:26 PM, 10:49 PM, 11:03 PM, 11:42 PM, and 11:55 PM. - 02/01/2026 at 12:08 AM, 12:20 AM, 12:43 AM, 12:57 AM, 1:11 AM 1:25 AM, 1:38 AM, 1:49 AM, 2:02 AM, 2:16 AM, 2:31 AM, 2:44 AM, 2:58 AM, 3:13 AM, 3:27 AM, 3:42 AM, 3:55 AM, 4:10 AM, 4:24 AM, 4:38 AM, 4:53 AM, 5:06 AM, 5:20 AM, 5:33 AM, 5:49 AM, 6:00 AM, 6:15 AM, 6:30 AM, 6:46 AM, 7:01 AM, 7:13 AM, and 7:21 AM. - 02/02/2026 at 2:04 AM, 2:16 AM, 5:06 AM, 5:20 AM, 5:26 AM, 5:42 AM, 6:10 AM, 6:19 AM, 6:35 AM, 6:50 AM, 6:59 AM, 7:13 AM, 7:37 AM, 7:48 AM, 7:59 AM, 8:12 AM, 8:23 AM, 8:36 AM, 8:48 AM, 9;01 AM, 9:14 AM, 9:27 AM, 9:39 AM, 9:50 AM, 10:03 AM, 10:15 AM, 10:26 AM, 10:38 AM, 10:50 AM, 11:02 AM, 1:17 PM, 1:26 PM, 1:37 PM, 1:47 PM, 1:58 PM, 2:11 PM, 2:35 PM, and 2:49 PM. On 02/02/2026 at 3:49 PM, Patient #7 was observed in a geriatric chair with the tray table on. The patient was asked and prompted to remove the tray table on the chair. The patient required staff assistance to remove the table. An observation on 02/02/2026 at 3:58 PM, revealed Patient #7 was in a chair with no table with their feet up. The observation revealed Patient #7 stood up from the chair on their own. Further review of the record revealed that Patient #7 did not have an order for the geriatric chair; did not reveal the patient demonstrated ability to remove the geriatric chair tray table on their own; and did not reveal any restraint documentation. A demographic record revealed the facility admitted Patient #8 on 01/29/2026 for suicidal ideation. A “History and Physical Reports” dated 01/29/2026, revealed Patient #8 had a past medical history of dementia, hypothyroidism, hyperlipidemia, gastroesophageal reflux disease, and Celiac disease (an autoimmune disorder triggered by gluten that causes inflammation in the small intestine). Per the report, the patient was ambulatory and had no muscle pain, joint pain, or stiffness. Per the report, the patient had full range of motion of joints in their upper and lower extremities with no evidence of impaired function or restriction in their range of motion. Patient #8’s “BH Treatment Plans” for the 01/29/2026 admission, indicated the patient was at risk for falls as evidenced by unsteady gait. A short-term goal was that the patient would wear appropriate footwear daily (initiated 02/01/2026). Interventions directed staff to monitor the patient’s vital signs for the side effects of medications that could cause falls and to assist the patient in identifying fall risk prevention measures including wearing non-skid socks, keeping their room uncluttered, wearing a color-coded wristband, and informing staff of increased agitation or sedation. The treatment plan did not include the use of a geriatric chair with attached tray table. Patient #8’s provider “Orders” revealed an order dated 01/29/2026 at 1:25 AM for ambulation, “assistance needed” three times per day and routine. Patient #8’s “Assessments and Treatments” flowsheets dated 01/29/2026 at 5:16 PM revealed the patient was agitated and pacing, 01/31/2026 at 4:34 PM revealed the patient ambulated with an unsteady gait, and 02/01/2026 at 12:43 AM revealed the patient ambulated without difficulty. Patient #8’s Assessments and Treatments flowsheets also revealed that Patient #8 was in a geriatric chair on the following dates and times: - 01/30/2026 at 1:47 AM, 1:57 AM, 2:28 AM, 2:46 AM, 3:12 AM, 4:01 AM, 4:08 AM, 4:19 AM, 4:29 AM, 4:43 AM, 4:59 AM, 5:11 AM, 5:22 AM, 5:46 AM, 7:56 AM, 8:05 AM, 8:17 AM, 8:28 AM, 8:38 AM, 8:50 AM, 8:59 AM, 9:12 AM, 9:25 AM, 9:37 AM, 9:48 AM, 10:01 AM, 10:13 AM, 10:25 AM, 10:36 AM, 10:45 AM, 10:55 AM, 11:05 AM, 11:15 AM, 11:25 AM, 11:36 AM, 11:47 AM, 11:59 AM, 12:12 PM, 12:24 PM, 1:02 PM, 1:31 PM, 1:40 PM, 1:52 PM, 2:04 PM, 2:17 PM, 3:16 PM, 3:29 PM, 3:40 PM, 3:52 PM, 4:03 PM, 6:56 PM, 10:14 PM, 10:27 PM, 10:43 PM, 10:59 PM, 11:13 PM, 11:24 PM, 11:38 PM, and 11:51 PM. - 01/31/2026 at 12:05 AM,12:19 AM, 2:19 AM, 2:34 AM, 2:49 AM, 3:04 AM, 3:19 AM, 3:32 AM, 3:45 AM, 3:59 AM, 4:12 AM, 4:27 AM, 4:39 AM, 4:53 AM, 5:07 AM, 5:21 AM, 5:33 AM, 5:43 AM, 5:57 AM, 6:07 AM, 6:18 AM, 6:32 AM, 6:46 AM, 6:57 AM, 7:10 AM, 7:35 AM, 7:45 AM, 7:56 AM, 8:09 AM, 8:22 AM, 8:34 AM, 8:47 AM, 9:00 AM, 9:14 AM, 9:27 AM, 9:39 AM, 9:51 AM, 10:04 AM, 10:17 AM, 10:30 AM, 10:42 AM, 10:54 AM, 11:06 AM, 11:20 AM, 12:00 PM, 3:57 PM, 4:07 PM, 5:46 PM, 6:14 PM, 7:15 PM, 7:28 PM, 7:41 PM, 7:56 PM, 8:10 PM, 8:25 PM, 8:39 PM, 8:55 PM, 9:10 PM, 9:24 PM, 9:39 PM, 9:54 PM, 10:15 PM, 10:31 PM, and 10:50 PM. - 02/01/2026 at 7:03 AM, 7:17 AM, 7:22 AM, 1:44 PM, 8:54 PM, 9:27 PM, 9:38 PM, 9:52 PM, 10:04 PM, 10:16 PM, and 10:24 PM. - 02/02/2026 at 6:34 AM, 6:48 AM, 6:59 AM, 7:12 AM, 7:24 AM, 7:36 AM, 7:48 AM, 7:59 AM, 8:12 AM, 8:23 AM, 8:36 AM, 8:48 AM, 9:01 AM, 9:14 AM, 9:26 AM, 9:38 AM, 9:50 AM, 10:03 AM, 10:15 AM, 10:26 AM, 10:38 AM, 10:52 AM, 11:04 AM, 12:33 PM, 12:44 PM, 12:55 PM, 1:06 PM, 1:18 PM, 1:27 PM, 1:36 PM, 1:38 PM, 1:48 PM, 1:59 PM, and 2:35 PM. On 02/02/2026 at 3:45 PM, Patient #8 was observed in a geriatric chair with the tray table on. The patient was asked and prompted to remove the tray table on the chair. The patient required staff assistance to remove the table. Further review of the record revealed that Patient #8 did not have an order for the geriatric chair; did not reveal the patient demonstrated ability to remove the geriatric chair tray table on their own; and did not reveal any restraint documentation. A demographic record revealed the facility admitted Patient #9 on 01/30/2026 for hallucinations. A “BH Admission History” dated 01/30/2026 revealed that prior to admission, Patient #9 was living at home with family, needed partial assistance with mobility, and minimal assistance with activities of daily living (ADL). The admission history indicated Patient #9 was at risk for falls. A “History and Physical Reports” dated 01/30/2026, revealed that Patient #9 had a past medical history of asthma, degenerative joint disease, and diverticulitis. Per the report, the patient had no joint pain or stiffness and no neurological or muscle weakness of the extremities. Per the report, the patient was ambulatory without assistance. Patient #9’s “BH Treatment Plans” for the 01/30/2026 admission, indicated Patient #9 did not have a care plan for falls. The treatment plan did not include the use of a geriatric chair with attached tray table. Patient #9’s provider “Orders” revealed an order dated 02/02/2026 at 8:46 AM for ambulation, “assistance needed” three times per day and routine. Patient #9’s “Assessments and Treatments” flowsheets dated 01/31/2026 at 5:43 PM revealed the patient ambulated with an unsteady gait and on 02/01/2026 at 10:29 AM ambulated with an unsteady gait. Patient #9’s Assessments and Treatments flowsheets also revealed that Patient #9 was in a geriatric chair on the following dates and times: - 01/30/2026 at 3:44 AM, 3:59 AM, 4:24 AM, 4:37 AM, 4:51 AM, 5:02 AM, 5:52 AM,8:07 AM, 8:19 AM, 8:31 AM. 8:43 AM, 8:54 AM, 9:04 AM, 9:29 AM, 9:51 AM, 10:03 AM, 10:14 AM, 10:25 AM, 10:56 AM, 11:05 AM, 11:15 AM, 11:47 AM, 12:01 PM, 12:13 PM, 12:24 PM, 12:50 PM, 12:59 PM, 1:31 PM, 1:40 PM, 1:52 PM, 2:04 PM, 2:17 PM, 2:27 PM, 3:03 PM, 3:16 PM, 3:28 PM, 3:39 PM, 3:54 PM, 4:03 PM, 4:26 PM, 4:36 PM, 4:48 PM, 5:15 PM, 5:28 PM, 7:04 PM, 7:29 PM, 7:39 PM, 7:50 PM, 7:59 PM, 8:09 PM, 8:18 PM, 8:30 PM, 8:44 PM, 8:56 PM, 9:05 PM, 9:20 PM, 9:32 PM, 9:49 PM, and 10:15 PM. - 01/31/2026 at 6:49 AM, 6:57 AM, 7:11 AM, 7:22 AM, 7:35 AM, 7:45 AM, 7:56 AM, 8:09 AM, 8:22 AM, 8:34 AM, 8:47 AM, 9:00 AM, 9:14 AM, 9:27 AM, 9:40 AM, 9:51 AM, 10:04 AM, 10:17 AM, 10:30 AM, 10:42 AM, 10:54 AM, 11:06 AM, 11:20 AM, 12:01 PM, 3:22 PM, 3:57 PM, 4:08 PM, 5:55 PM, 6:09 PM, 7:16 PM, 7:29 PM, 7:44 PM, 7:56 PM, 8:11 PM, 8:26 PM, 8:39 PM, 8:56 PM, 9:10 PM, 9:25 PM, 9:40 PM, 09:55 PM, 10:11 PM, 10:27 PM, 10:43 PM, 10:58 PM, 11:14 PM, 11:28 PM, 11:43 PM, and 11:57 PM. - 02/01/2026 at 12:12 AM, 12:25 AM, 12:39 AM, 12:53 AM, 1:04 AM, 1:33 AM, 1:46 AM, 2:01 AM, 2:15 AM, 2:29 AM, 2:43 AM, 2:55 AM, 3:10 AM, 3:24 AM, 3:38 AM, 3:52 AM, 4:17 AM, 4:28 AM, 4:53 AM, 5:06 AM, 5:08 AM, 5:23 AM, 5:36 AM, 5:50 AM. 6:02 AM, 6:18 AM, 6:31 AM, 6:46 AM, 7:02 AM, 7:13 AM, 7:22 AM, 9:06 PM, 9:16 PM, 9:39 PM, and 9:53 PM. - 02/02/2026 at 7:13 AM, 6:37 AM, 6:50 AM, 7:00 AM, 7:13 AM, 7:25 AM,7:36 AM, 7:48 AM, 8:00 AM, 8:12 AM, 8:23 AM, 8:36 AM, 8:48 AM, 9:01 AM, 9:14 AM, 09:27 AM, 9:39 AM, 9:50 AM, 10:03 AM, 10:15 AM, 10:27 AM, 10:39 AM, 10:21 AM, 11:03 AM, 12:21 PM, 12:32 PM, 12:44 PM, 12:54 PM, 1:37 PM, 1:47 PM, 1:58 PM, 2:11 PM, 2:31 PM, and 2:22 PM. Further review of the record revealed that Patient #9 did not have an order for the geriatric chair; did not reveal the patient demonstrated ability to remove the geriatric chair tray table on their own; and did not reveal any restraint documentation. During patient observations and a concurrent interview on 02/02/2026 at 4:08 PM, Registered Nurse (RN) #4 stated that Patient #9 was able to push the tray off after staff unclicked it. During patient observations on 02/02/2026 at 3:41 PM, RN #6 stated that not all the patients who were in geriatric chairs were able to remove their tray tables. She said they were dementia patients, so some could remove the tray tables, and some were unable to, but using them was for patient safety. She thought some did not know how to remove the table consistently because of dementia. She stated that the use of a geriatric chair was dependent on how the patient presented to the unit. Sometimes they were told a patient could not walk and were a high fall risk, but they observe the patient and see how they are to make the determination after seeing how they do on the unit. Nursing staff evaluated a patient’s need for a geriatric chair. Occasionally, the medical team was there when a patient arrived. She stated that there was a policy on the use of geriatric chairs that the CNO wrote, but it had not gone through the board yet for approval. She stated that they tried to get the patients up through the day, and they tried to elevate the patients’ legs throughout the day, but sometimes they had to put the patients’ trays back on. During an interview on 01/30/2026 at 9:22 AM, the COO stated that they did not use mechanical restraints; the only restraints they used were holds and chemical. During an interview on 02/02/2026 at 1:54 PM, RN #6 stated that patients who were at a high risk for falls, or even patients who would try to get up and walk without walkers or the staff would be patients that were considered for the geriatric chairs. They were not considered restraints because the trays were placed on and off during the day. Times when trays would be used would be during meal and hydration times. There was a policy, but it had not gone through board approval yet. Sometimes trays were taken off the chairs, so patients’ legs could be elevated. Geriatric chairs were used a lot for elevating patient legs; it can be difficult to elevate them well in a normal chair. Some patients who were safe to be in normal chairs preferred them because they were more comfortable like a recliner. She stated that geriatric chairs did not require an order because they were a lot like a recliner. During an interview on 02/02/2026 at 2:28 PM, RN #4 stated that on the geriatric unit they did not use restraints or seclusion. She said the last time they used seclusion was maybe 12 years ago. If they had to use a restraint, they would call the physician and get an order. Someone would stay with the patient, and the nurse would examine them. The patient’s family would also be notified. She stated that the geriatric chairs were used for patients whose legs needed to be elevated due to edema or to use the table for coloring, drawing, or other activities. She stated that the patients were able to take the tray tables off themselves, so it was not a restraint. She stated that there was no documented evaluation that the patient was able to remove the tray themselves, but you could watch them do it. She said it clicked into place, was not locked, and even if a patient were confused, they could remove it. The facility did not consider geriatric chairs as restraints. During an interview on 02/03/2026 at 10:57 AM, RN #6 stated that there was no formal documentation done of the evaluation nurses did to evaluate a patient’s need for a geriatric chair. She said the evaluation was fluid, and patients could change rapidly on the unit. The evaluation was based on mobility, cognition, and needs. Some patients improve and go from being in the chair to using their walker to walking on their own without assistance. They were always monitoring for safety and anyone at risk of falling. During an interview on 02/03/2026 at 12:01 PM, the CNO stated that the expectation was that patients were not in geriatric chairs constantly. There were utilized for high risk fall patients, patients that required a lot of assistance or who were total care, and patients that were “very” demented for the safety of the patient, but the patient could be moved out of the chair to offload to prevent skin breakdown. The patients in the chairs required the tray tables because without them, they could not reach a cup for hydration, participate in activities, or eat without them in place. Patients utilizing the chairs should be gotten up and walked with frequently. She stated that they did not have staffing capability to be one on one with each patient, so something needed to be done for their safety. The expectation was that the tray tables were taken off, so patients could get up and walk. Some patients were able to take the table off themselves. Usually, the facility did not have so many patients utilizing geriatric chairs, but recently they started receiving patients via a call center, and they had been receiving more complex patients. The need for the chair was evaluated by nursing staff based on a patient’s cognitive and physical abilities, and that could change throughout the day as well as throughout their stay. There was no formal documentation of the evaluation; it was just something that was done. There was no physician order for the geriatric chairs. There was no formal documentation of their use in a patient’s chart, but it may be documented in notes. She did not know if they evaluated whether the patient could remove the tray table or not. 2. The facility’s policy, titled, “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion,” dated 03/2023, indicated, “Physical Escort: Using a “light” grasp to escort a patient to a desired location. If the patient can easily remove or escape the grasp, it is not a physical restraint. If the patient cannot easily remove or escape the grasp this would be a physical restraint.” “Physical Restraints: The application of any manual method that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely (also named therapeutic hold, protective hold, or manual restraint).” The policy also indicated, “Restraint or seclusion shall be used in emergency situations only and requires an order from a physician.” A demographic record revealed the facility admitted Patient #5 on 12/30/2025 for psychosis. The facility’s material containing restraint and seclusion incidents, revealed that Patient #5 was placed in an escort physical restraint on 12/31/2025 from 9:30 PM to 9:35 PM. Review of Patient #5’s medical record for their admission from 12/30/2025 to 01/07/2026 did not reveal any notes or documentation including orders, assessment, or nursing notes, that the patient had been in any physical restraint, including being escorted on the unit. During an interview on 01/30/2026 at 12:11 PM, Registered Nurse (RN) #15 stated that she did not see an order for a physical hold or escort in Patient #5’s record from their 12/30/2025 admission. She also did not see documentation of the occurrence in the nursing documentation. She stated that the notes did not mention a physical hold. During an interview on 02/02/2026 at 10:30 AM, RN #1 stated that the only time a restraint was used was when the patient was an immediate danger to themselves or others. Per RN #1 everything used to be documented on paper, but now everything was documented in the computer system, which was a new process. A MIDAS [incident reporting system] was completed every time a physical hold was used, and that report was sent to the risk manager. Additional documentation included the restraint documentation in the medical record and a nurse’s note. He stated that it was still not clear to a lot of staff that they had to go back and do the restraint documentation in the computer system. He stated that with something such as restraints, as a house supervisor, he would help staff by entering the MIDAS report, but the patient’s nurse was responsible for documenting it in computer system. He did not remember Patient #5. During an interview on 02/03/2026 at 12:01 PM, the Chief Nursing Officer stated that she had not seen any restraint documentation in Patient #5’s record when she reviewed the record. During an interview on 02/03/2026 at 12:40 PM, the Director of Risk (DR) stated that the incident with Patient #5 qualified as a restraint because it was a physical hold by escort. He stated there was no follow up into the incident because there had not been a patient injury. Per the DR, he did not follow up on chart documentation because he did not handle documentation.”

“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: 45841 Based on interview, record review, and facility policy review, the facility failed to ensure twice daily nursing skin assessments were completed for 2 (Patient #1 and Patient #6) of 3 special care unit patients reviewed for skin care. Additionally, the facility failed to complete a Braden Scale on admission for 2 (Patient #2 and Patient #6) of 3 special care unit patients reviewed for skin care. Findings included: 1. A facility policy titled, “Skin and Wound Care Protocol Assessment,” revised in 05/2023, indicated, “3.0 Additionally, adult patients will be assessed upon admission by the staff RN [registered nurse] utilizing the “Braden Scale for Predicting Pressure Sore Risk” upon admission. 4.0 Nursing staff members of the patient’s treatment team shall specify a nursing plan of skin care on the treatment plan. 5.0 Specialty care unit patients will have twice daily skin assessments.” A facility policy titled, “Plan for the Provision of Care,” reviewed in 11/2023, indicated, “5.3 Assessment and Evaluation Procedures - Assessment of all patients begins on admission and is integral to the treatment process. Treatment planning is individualized according to individual needs identified through assessments.” A “[Corporate Abbreviation, Facility Name] Admission Orders for Specialty Care Unit,” record, dated 07/31/2024, revealed the facility admitted Patient #1 to the specialty care inpatient program for ages 65 years and older. A “History and Physical Report,” dated 08/01/2024, revealed the facility admitted Patient #1 for major depression. Patient #1’s “Skin” assessments revealed only one nursing skin assessment documented on 08/10/2024, 08/11/2024, 08/18/2024, 08/20/2024, and 08/24/2024 and no documented nursing skin assessments on 08/05/2024, 08/06/2024, 08/08/2024, 08/14/2024, 08/23/2024, 08/26/2024, and 08/27/2024. On 02/03/2026 at 10:13 AM, RN #6 revealed Patient #1’s medical records did not include two nursing skin assessments on the following dates: 08/05/2024, 08/06/2024, 08/08/2024, 08/10/2024, 08/11/2024, 08/14/2024, 08/18/2024, 08/20/2024, 08/23/2024, 08/24/2024, 08/26/2024, and 08/27/2024. 2. A demographic “Encounter Information,” dated 11/20/2025 at 11:26 PM, revealed the facility admitted Patient #2 to the inpatient adult psychiatric specialty care unit. A “History and Physical Report[s]” dated 11/21/2025, revealed the facility admitted Patient #2 for psychosis. Patient #2’s medical record did not reveal the patient had a Braden Scale for Predicting Pressure Sore Risk completed. On 02/03/2026 at 10:36 AM Nurse Leader (NL) #8 stated that Braden Scale assessments were to be completed upon admission, but she did not see one completed for Patient #2. 3. A demographic “Encounter Information,” dated 12/24/2025 at 2:51 PM, revealed the facility admitted Patient #6 for aggression. The Encounter Information document revealed the patient was admitted to the inpatient geriatric psychiatric specialty care unit. Patient #6’s “Integumentary [the body’s outermost layer consisting of skin, hair, nails, and glands] Basic Assessment” flowsheet revealed the patient only had one nursing skin assessment on 12/27/2025, 12/28/2025, 12/29/2025, and 12/30/2025, and there were no documented nursing skin assessments on 12/25/2025, 12/26/2025, or 12/31/2025. Patient #6’s medical record did not reveal the patient had a Braden Scale for Predicting Pressure Sore Risk completed. During a record review on 02/03/2026 at 10:44 AM, Nurse Leader (NL) #8 stated that Patient #6 did not have a Braden Scale for Predicting Pressure Sore Risk assessment completed. NL #8 confirmed Patient #6 had only one skin assessment documented on 12/24/2025, 12/27/2025, 12/28/2025, 12/29/2025, and 12/30/2025. NL #8 confirmed that there were no documented skin assessments for Patient #6 on 12/25/2205, 12/26/2025, or 12/31/2025. During an interview on 02/03/2026 at 12:01 PM, the Chief Nursing Officer (CNO) stated there probably was not as much documentation as there should have been because they did not think to document each time they applied an ointment or assessed the skin.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 47718 Based on review of medical records, observation, policies and procedures, and staff interviews, it was determined that the staff failed to document and secure the belongings of one patient (P) (P#1) of four patients (P#1, P#2, P#3, and P#4) reviewed, when P#1 was discharged without the personal belongings that they arrived with. Findings included: A review of medical records revealed that P#1 was admitted to the facility involuntarily on 8/9/25. Review of the valuables and belongings note within the discharge information dated 8/14/25 at 1:43 p.m., failed to reveal an inventory of P#1’s belongings. P#1 was sent home with no personal belongings. A video review took place in the facility ’ s office on 8/19/25 at 1:20 p.m. with Director of Risk Management (DRM) LL. During the video review, it was observed that on 8/9/25, at: 11:49 a.m. - P#1 was brought in on a stretcher by two Emergency Medical Service (EMS) personnel into the intake lobby. P#1 was observed to be in green scrubs. 11:50 a.m. - One of the EMS personnel handed over a plastic bag that appeared to contain some regular clothing to Mental Health Technician (MHT) JJ. 11:51 a.m. - P#1 was observed sitting on the chair. 11:52 a.m. - MHT JJ was seen exiting the door that led to the lobby with the two EMS personnel. MHT JJ was observed still holding onto the plastic bag. 11:54 a.m. - MHT JJ was observed still holding onto the plastic bag that contained P#1 ’ s belongings and was observed to be speaking to P#1 before going back to the intake office with the plastic bag. 11:58 a.m. - MHT JJ was observed coming back to the intake lobby without the plastic bag containing P#1 ’ s belongings. 12:52 p.m. - P#1 was observed going to an intake room with Assessment Counsellor (AC) KK. 1:16 p.m. - P#1 was observed coming out of the intake room. A tour to the facility ’ s Sub-Acute, Acute Unit, and Intake office/area took place on 8/20/25 at 12:15 p.m. with DRM LL. During the tour of the Acute unit, a couple of brown paper bags were observed lying on the floor at the nursing station with no labels on them. One of the brown bags had some clothing, which Nursing Supervisor (NS) OO stated belonged to a patient, but there was no patient ’ s name or room number on the brown paper bag, and another brown paper bag with no patient’s name or room number was stated to be trash by NS OO. A review of the facility ’ s policy titled “Patient Belongings and Valuables,” Policy #RI.038, last issued 12/24, stated that it was the policy of the facility to provide safe storage of valuable patient possessions during inpatient treatment. An interview took place in the facility ’ s conference room on 8/19/25 at 9:45 a.m. with Nurse Practitioner (NP) AA, who stated that the mental health technicians (MHTs) should check and document any patient ’ s belongings on admission and put the patient ’ s belongings in a locker with each locker having an identification number assigned to each patient. An interview took place in the facility ’ s conference room on 8/19/25 at 11:00 a.m. with Mental Health Technician (MHT) CC, who stated that when P#1 was discharged, he (MHT CC) could recall asking her (P#1) if she had any belongings, and P#1 had stated she had ’ clothes ’ , but there were no belongings documented or labelled with P#1 ’ s name. MHT CC stated that he could recall P#1 had on hospital clothing when she was discharged, and he (MHT CC) walked her (P#1) to the front with a family member present. An interview took place in the facility ’ s conference room on 8/19/25 at 12:00 p.m. with Registered Nurse (RN) EE, who stated that she could not recall P#1. RN EE stated that the MHTs should document patients ’ belongings on admission and keep them in a safe place as per protocol. An interview took place in the facility ’ s conference room on 8/19/25 at 12:30 p.m. with Director of Patient/Family Advocacy (DPFA) FF, who stated that he remembered going to P#1 and asking her if she had any clothing, and P#1 stated that she was waiting on the staff to give it to her. DPFA FF stated that he went to look for P#1 ’ s clothing and could not find anything. DPFA FF stated that he would continue to investigate and find out if P#1 came in with any personal clothing, and what may have happened to it. A telephone interview occurred in the facility ’ s conference room on 8/19/25 at 2:00 p.m. with Mental Health Technician (MHT) JJ, who stated that he could not really recall P#1, but it seemed P#1 had a bag containing clothing, amongst other things on arrival to the facility. MHT JJ stated that the intake staff would take the patient ’ s belongings alongside when taking the patient to the unit, and the intake staff would hand over the patient ’ s belongings to the staff on the unit; However, he (MHT JJ) could not recall if he was the one who accompanied P#1 to the unit on that day. An interview occurred in the facility ’ s conference room on 8/20/25 at 11:40 a.m. with Assessment Counsellor (AC) KK, who stated that the intake staff did not open patients ’ belongings but only kept them in a safe place in the intake room and transported the patients with their belongings to the unit. AC KK stated that the intake staff would give a report to the unit staff, and the patient ’ s belongings would be dropped on the floor in the designated area on the unit for the staff to document and out in the designated storage room on the unit. AC KK further stated that she could not recall who accompanied P#1 to the unit. An interview took place during the tour to the Intake room on 8/20/25 at 12:30 p.m. with Intake Director (ID) NN, who stated that whenever patients arrived at the facility, the MHTs and the Assessment Counsellors should take the patients ’ paperwork and all the patients ’ belongings into a storage room ensuring the belongings are adequately labelled pending the time the patients are taken to the unit with their belongings. A telephone interview took place on 8/21/25 at 8:30 a.m. with Registered Nurse (RN) MM, who stated that she could recall P#1 ’ s face, but she (RN MM) did not work directly with P#1 nor had any interaction with her (P#1).”

“DIETS CFR(s): 482.28(b)(2) All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals. This Standard is not met as evidenced by: 47718 Based on the review of medical records, observation, policies and procedures, and staff interviews, it was determined that the facility’s staff failed to perform a nutritional needs assessment and ensure dietary preferences were respected and accommodating for one patient (P) (P#1) of four patients (P#1, P#2, P#3, and P#4) reviewed. Findings included: Review of medical records revealed that P#1 was admitted to the facility involuntarily on 8/9/25 at 4:29 p.m. Documentation on 8/10/25 at 2:08 p.m. revealed that P#1 denied having any issues with appetite but reported she has changed her diet to deal with stomach issues. Documentation failed to reveal the specific type of diet/diet orders for P#1. A review of the initial nursing treatment plan documentation by Registered Nurse (RN) MM on 8/10/25 at 1:25 a.m., revealed the initiation of a dietitian consultation intervention with P#1 about/to determine appropriate weight. Further review of the medical record failed to reveal any assessment/consultation notes from the dietitian. A revi ew of the physician ’ s progress notes on 8/11/25 at 9:00 p.m. revealed that P#1 complained of headache and severe abdominal pain, noted constipation for two days, and also stated that the pain was worse with direct pressure. Documentation by the physician revealed that P#1 was sent to the emergency department for further evaluation due to the acuteness of P#1 ’ s abdominal pain; however, documentation failed to reveal the specific time P#1 went to the ED and returned to the facility. A continued review of the medical record failed to reveal any ED notes/documentation for 8/11/25. A review of the discharge summary documentation on 8/14/25 at 10:04 a.m. under the post-discharge care and the discharge orders/instructions revealed a regular diet. A review of the facility ’ s policy titled “Diet Orders,” Policy #TX.070, last revised 10/21, revealed that all patients must have a diet ordered by the physician upon admission. The diet order would be communicated to the Food Service Department through the use of the Census Form. The nursing staff was responsible for including the following information on the form: - Unit - Patient Name - Diet Order (as ordered by physician) - Allergies (to food). A review of the facility ’ s policy titled “Food Preferences,” Policy #TX.072, last revised 10/21, stated that patient food preferences would be honored for all patients admitted to the facility, within budgets for staffing time and cost. Personal food preferences/intolerance based upon cultural, religious, and ethnic background would be honored with consideration of time, cost, and staffing. A review of the facility ’ s policy titled “Plan for the Provision of Care,” Policy #CC.001, last revised 12/24, stated that Nutrition Assessment would be performed by a Registered Dietitian within 24 hours of a written order by the physician or notification by nursing that nutritional screening criteria established by the medical staff have been met, which included dietary needs, assessment of lab results, preferences, habits, and recommendations. Individual patient food preferences and nutritional needs should also take be into consideration. Consultation and education for patients on special diets should be provided by the dietitian. A review of the facility ’ s policy titled “Identification of Patients on Special Diets,” Policy #TX.071, last revised 10/21, stated that the nursing staff would complete a daily census list of all patients and their diet orders. Dietary staff would keep the list in a designated area behind the serving line for use when preparing trays. Nursing Staff would be responsible for ensuring that patients on special diets were identified using patient identification before receiving their food tray. An interview took place in the facility ’ s conference room on 8/19/25 at 9:45 a.m. with Nurse Practitioner (NP) AA, who stated that if a patient stated he/she was a vegan, the dietitian would be informed, who would let the cafeteria staff know about the patient ’ s diet. NP AA further stated that she could not recall P#1 because she only did the discharge paperwork, as she only filled in for a nurse who called out. An interview took place in the facility ’ s conference room on 8/19/25 at 10:30 a.m. with Mental Health Technician (MHT) BB, who stated that the only encounter she had with P#1 was when she (MHT BB) had to take her (P#1) alongside other patients from one unit to another unit, and then to the cafeteria. MHT BB stated that she had noticed P#1 was not really eating her food when they were at the cafeteria, and she (MHT BB) asked her (P#1) why, and P#1 had stated that it was because she was vegan. MHT BB stated she reported it to the nutritionist (dietitian) and a second nutritionist during one of the nutrition classes. MHT BB stated that she could not recall what day P#1 told her that she was vegan, and she (MHT BB) also could not recall if the two nutritionists she reported to did anything about it. An interview took place in the facility ’ s conference room on 8/19/25 at 12:00 p.m. with Registered Nurse (RN) EE, who stated that she could not recall P#1. RN EE stated that the intake staff and the admitting nurse should ask patients about diet preferences, and if the patient was on a special diet or had an allergy, the dietitian would be notified. An interview took place in the facility ’ s conference room on 8/20/25 at 9:20 a.m. with Dietitian (DT) II, who stated that she could not recall P#1. DT II stated that if a staff member had reported to her that P#1 was vegan, she (DT II) would have assessed P#1 to get more clarification, as sometimes patients used the word “ vegan “ misappropriately, and she (DT II) would also notify the kitchen regarding P#1 ’ s diet preference. DT II also stated that P#1 would have had access to something unless she (P#1) reported something specific, but she (DT II) never got any notification/report. An interview occurred in the facility ’ s conference room on 8/20/25 at 11:40 a.m. with Assessment Counsellor (AC) KK, who stated she could recall that when P#1 was in the intake lobby, she (AC KK) observed that P#1 did not eat the food (protein) the facility provided, and MHT JJ had to give her (P#1) a salad. AC KK also stated that the intake staff only asked patients about their food allergies during the intake assessment, and not their food preferences. A telephone interview took place on 8/21/25 at 8:30 a.m. with Registered Nurse (RN) MM, who stated that she could recall P#1 ’ s face, but she (RN MM) did not work directly with P#1. RN MM stated that P#1 was not among the patients she (RN MM) assessed, and she could not explain how her (RN MM) name was listed as the nurse who assessed P#1.”