Ridgeview Institute

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 46188 Based on staff interviews, record review, and review of policies and procedures, it was determined that the facility failed to ensure that one (P) (P2) of five sampled patients had an appropriate discharge plan and the family/representative of P2 were included in the discharge plan. This failure resulted in P2 discharging to a homeless shelter and wherabouts were unknown to his family. Findings included: A review of P2 ’ s medical record revealed that P2 was admitted to the facility on 01/18/2026 at 11:09 AM on a voluntary status. A review of a “ Medical History and Physical Examination (H&P) “ , dated 01/18/2026 at 11:44 AM by a Nurse Practitioner (NP), revealed that P2 was admitted for alcohol dependence with withdrawal and seeking assistance for detoxification. Continued review revealed that P2 had a past medical history of seizures (a sudden surge of abnormal electrical activity in the brain that causes temporary changes in movement, behavior, feelings, or awareness). P2 ’ s current living situation was with his niece and was able to return to that location upon discharge. A review of a “ Psychosocial Assessment “ , dated 01/20/2026 at 2:37 PM by a Program Therapist (PT) EE, revealed that PT EE listed P2 as a self conservator and guardian. P2 gave release of information for his niece. P2 reported current living arrangements with his niece and being homeless for a few months. PT EE noted that P2 was relying on family for discharge transport and was returning to an independent living home, home with family situation. PT EE attempted to contact P2 ’ s niece. P2 reported that he had guardianship court on 01/21/2026. A review of a “ Collateral Note “ , dated 01/21/2026 at 11:10 AM by PT EE, revealed that P2 ’ s niece reported having official guardianship paperwork. PT EE noted that P2 ’ s niece wanted to relinquish guardianship. A review of a “ Psychiatric Progress Note “ , dated 01/22/2026 at 1:38 PM by a psychiatrist, revealed that P2 endorsed anxiety related to discharge planning and asked the provider if P2 would be placed in an apartment. The provider did not have any contact with collaterals (a support person, family member, or patient representative). A review of a “ Release for Family Contact “ , dated 01/22/2026 at 3:12 PM, revealed an authorization for release of information to P2 ’ s niece signed by PT EE. A review of a “ Therapy Progress Note “ , dated 01/23/2026 at 1:00 PM by PT JJ, revealed a facilitated family session with P2 and his niece. P2 expressed about not wanting to go to the PHP program and wanted his own apartment. P2 ’ s niece stated that there was an order from a court that P2 would need to complete treatment and expressed concern for P2 ’ s wellbeing and poor decision making. PT JJ requested P2 ’ s niece to send over any paperwork related to the court request for treatment and guardianship. PT JJ noted that P2 ’ s niece was unsure if power of guardian applied in the state of Georgia since it was based in North Carolina. A review of a “ Therapist Discharge and Transition Record “ , dated 01/23/2026 at 1:38 PM by PT JJ, revealed that P2 had family involvement listed as his niece and that she was his guardian. P2 had a scheduled discharge status for the PHP recovery residence for 01/23/2026. A review of a “ Psychiatric Progress Note “ , dated 01/23/2026 at 1:53 PM by a psychiatrist, revealed that P2 was focused on discharge. The provider did not have any contact with collaterals. A review of a “ Psychiatric Progress Note “ , dated 01/26/2026 at 2:44 PM by a psychiatrist, revealed that the provider discussed the PHP program with P2 and P2 reported that he did not want to go to it. The provider did not have any contact with collaterals and noted that P2 has reached the maximum benefit in response to the physician treatment goal. A review of a “ Psychiatric Progress Note “ , dated 01/27/2026 at 1:48 PM by a psychiatrist, revealed that P2 was focused on discharge. The provider did not have any contact with collaterals and noted that P2 was being discharged. A review of a “ Therapist Discharge and Transition Record “ , dated 01/28/2026 at 12:19 PM by PT II, revealed that P2 had a discharge date of 01/28/2026 to a shelter. PT II noted that P2 was homeless and the mode of transportation was a taxi. A review of a “ Therapy Progress Note “ , dated 01/28/2026 at 3:09 PM by PT, revealed that P2 expressed interest in discharge placement to a shelter. A review of a “ Psychiatric Progress Note “ , dated 01/28/2026 at 4:33 PM by a psychiatrist, revealed that P2 was focused on discharge. The provider did not have any contact with collaterals and was being discharged. P2 was discharged from the facility on 01/28/2026 at 10:00 PM. A review of P2 ’ s medical record did not reveal guardianship paperwork. A review of the facility’s policy titled, “Discharge Planning,” policy #CL1015, last reviewed/revised 01/2026, revealed that the purpose of the policy was to provide an overview of the discharge planning process. Continued review revealed that the facility has in effect a discharge planning process that focuses on patient’s goals and treatment preferences and includes the patient and his/her caregivers/support person(s) in the discharge planning for post-discharge care. The facility’s discharge planning process identifies, on admission or at an early stage of hospitalization, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and provides a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. The discharge plan should: a. Screen all inpatients to determine which ones are at risk of adverse health consequences post-discharge if they lack discharge planning. b. Evaluate the post-discharge needs of inpatients identified in the early stage of hospitalization Continued review revealed that the facility’s discharge planning process requires regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. A telephone interview was conducted on 08/11/2026 at 10:40 AM with the complainant for P2. The complainant restated the original filed complaint and had no further questions for the surveyor. The complainant said that P2 was safe and has been with the complainant since the family received P2 from the shelter that P2 was discharged to by the facility. An interview was conducted on 08/12/2026, at 09:57 AM, with Program Therapist (PT) II. PT II revealed that the facility utilized PTs as therapists who run some activities but also were used in discharge planning. PT II said that during the initial discharge planning with the patient, the assigned PT will obtain all relevant background information for discharge planning such as where the patient lived prior to presenting to the facility, if the patient had a support or collateral person, where the patient may want to discharge to, and if the patient had any identified concerns or needs. PT II indicated that when a patient provided a PT with a support/collateral person or even family member, then the PT must still obtain a release of information (ROI) from the patient prior to contacting them. PT II said that if a family member reported that they had guardianship over a patient, then the PT should request paperwork for review and validation. PT II said that afterwards, the PT will proceed with including the guardian with the discharge planning process prior to discharging the patient. An interview was conducted on 08/12/2026, at 10:48 AM, with Program Therapist (PT) FF. PT FF revealed that discharging a patient to a homeless shelter was a last option and the PT should try to exhaust all other available options such as a family member. PT FF revealed that if a patient came from a family living situation, that should be the first option, and the PT should contact that family member to see if the patient could return there prior to going to a homeless shelter. An interview was conducted on 08/12/2026 at 3:25 PM with the Vice President of Performance Improvement (VPPI) LL. VPPI LL said that the medical record charting system does not carry over certain documents, such as guardianship paperwork, from one admission to another as a security measure to ensure that staff will continue checking the validity of the documents and order. VPPI LL said that for P2 ’ s admission of 01/18/2026, there was no guardianship paperwork uploaded into the patient ’ s chart. VPPI LL said that the facility did not receive any paperwork from P2 ’ s niece regarding guardianship for the admission of 01/18/2026.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 47718 Based on medical record review, observations, policy and procedures, and staff interviews, it was determined that the facility’s nursing staff failed to assess, document, and intervene for a change in the skin condition for one patient (P) (P1) of five patients reviewed (P1, P2, P3, P4, and P5). Specifically, the facility’s staff noticed a reddened area on P1’s forehead but failed conduct an assessment or intervention to rule out any potential injury before discharging P1. Findings include: A review of medical record revealed that P1 was admitted to the facility voluntarily on 04/06/2026 at 5:27 PM. A continued review of P1 ’ s medical record revealed documentation on 04/06/2026 at 6:44 PM that P1 had no history of falls, and skin was intact (undamaged or untouched by anything that harms or reduces it). A review of the daily nursing progress notes on 04/11/2026 at 2:14 AM revealed that P1 became aggressive toward a staff member, took a chair, and was ramming it into the window. Documentation revealed that P1 refused redirection and began threatening staff, and medication was administered to prevent P1 from causing serious and imminent physical harm to self and others. Documentation failed to reveal an incident report regarding the incident on 04/11/2026 at 2:14 AM and documentation failed to reveal that P1 ’ s family was notified of the incident. A review of the facility’s incident log from November 2025 to April 2026 failed to reveal any incidents regarding P1. A video review was conducted in the facility’s boardroom on 04/27/2026 at 1:43 PM with Director of Performance Improvement/Risk Management (DPI) FF. The video recording revealed that on 04/15/2026 at 12:35 PM P1 was seated quietly in the day room alongside other patients. However, the video quality was not sufficiently clear to definitively determine whether P1 sustained an injury or bruise to the forehead. Further review of the video recording on 04/14/2026 at 2:00 PM was also conducted, and no clear evidence of an injury was observed on P1 due to the video quality. Another video review of an incident involving P1 was conducted in the facility’s board room on 04/28/2026 at 1:00 PM. with DPI FF. According to the video review, it was observed that on 04/10/2026 at approximately 10:29 PM P1 was observed ambulating in the day room and sat down on the chair. At approximately 10:40 PM P1 was observed getting up from the chair and picking up another chair, and was swinging it, as staff members quickly tried to de-escalate the situation. At 10:42 PM P1 was observed to be lying on the floor as three staff members were seen holding onto her and helping her to get off the floor. The video footage did not clearly capture the exact mechanism of the fall due to the camera angle and the visibility limitations. A review of the facility’s policy titled “Assignment of Nursing Care,” Policy Number: NR13013, last reviewed 1/2026, revealed that assignments of nursing care would be based on identified needs of the patients as determined by the nursing process and per physician/ licensed practitioner/ provider order. The nurse in charge would be responsible for the pre-planning and assigning of patient care. The nursing care of each patient should be planned, supervised, and evaluated by the nurse in charge. A review of the facility’s policy titled “Nursing Assessment/Reassessment,” Policy Number: NR13076, last reviewed 1/2026, revealed that the facility would have a full nursing assessment completed on each patient within eight (8) hours of admission. Treatment planning would begin during this process and would be customized according to individual needs identified through the nursing assessment. Patients would have reassessments that occurred on a regular basis to ensure proper care and treatment planning were updated during their stay. The RN should reassess whenever the patient’s needs or status change. A review of the facility’s policy titled “Incident Reporting,” Policy Number: PI709, last reviewed 1/2026, revealed that the facility staff would complete an internal incident report for all patient incidents and untoward events, including but not limited to: accidents; injuries; medical emergencies; psychiatric emergencies; all restraint/seclusion events. The staff member who was involved or the staff member who witnessed the event must complete an incident report form prior to the end of the shift. The report is forwarded to the PI Director and CNO by the end of the shift. A review of the facility’s policy titled “Restraint and Seclusion,” Policy Number: NR13099, last reviewed 3/2026, revealed that the use of restraint and seclusion was limited to situations in which it was necessary to ensure the immediate physical safety of the individual served, staff members, or others. Restraint and seclusion were used only with the appropriate and adequate clinical justification when less restrictive interventions are ineffective, and the least restrictive means of restraint or seclusion to ensure safety was applied. It was not used as a means of coercion, discipline, convenience, or staff retaliation. An interview was conducted in the facility’s board room on 04/28/2026 at 10:30 AM with Registered Nurse (RN) BB, who stated that P1 never had a fall while on admission at the facility, as her gait was steady and strong. However, she (RN BB) noticed a small red dot, about the size of a quarter, on P1 ’ s’ forehead when she was assisting P1 to dress up at discharge, when her family arrived to pick her up. RN BB continued to state that the red dot did not look like a bruise, and it was nothing alarming, which was why she (RN BB) did not carry out any intervention. A telephone interview was conducted in the facility’s conference room on 04/28/2026 at 11:30 AM with Mental Health Technician (MHT) CC, who stated that there was no report of any falls involving P1, and she did not observe any injury on P1. An interview was conducted in the facility’s conference room on 04/28/2026 at 12:00 PM with RN EE, who stated that P1 was mostly in the dayroom and under constant observation. RN CC continued to state that P1 had no history of falls, was not aggressive, but could be troublesome at times, requiring staff attention and monitoring. RN EE further stated that she did not notice any injury on P1. A telephone interview was conducted on 04/29/2026 at 12:00 PM with Nursing House Supervisor (NHS) DD, who stated that she was not involved in direct patient care, but supervised and assisted nursing staff when required. NHS DD continued to state that she did the morning rounds on P1 the day she was discharged but did not notice any injury or bruise on P1. A telephone interview was conducted on 04/29/2026 at 12:30 PM with MHT II, who stated that he could not recall P1 or any incident involving P1. A telephone interview was conducted on 04/29/2026 at 1:30 PM with MHT HH, who stated that on the day of the incident, P1 had snatched a chair from underneath a staff member, and was trying to hit a window, but when P1 saw the staff members coming to intervene, she fell to the ground but was guided by one of the staff members. MHT HH continued to state that P1 did not hurt herself, so it was not necessary to report it as an incident.”

“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: 47718 Based on review of medical records, policies and procedures, incident logs, and staff interviews, it was determined that the facility’s Governing Body failed to provide oversight and effective systems for the delivery of safe, quality patient care, resulting in a failure to follow up on a physician-ordered diagnostic x-ray, failure to obtain medical consultation for ongoing symptoms, and failure to implement an appropriate treatment plan for one (P#1) of four sampled patients (P#1, P#2, P#3, and P#4) reviewed. This systemic failure resulted in P#1 being discharged on 11/21/25 with undiagnosed fractures of the left forearm and wrist. Cross refer to A-0063 related to the facility’s failure to ensure that the Governing Body maintained the systems, oversight, and processes necessary to deliver safe and effective patient care-including monitoring diagnostic results, completing ordered consults, reassessing patients with ongoing symptoms, and intervening appropriately.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47718 Based on review of medical records, policy and procedures, staff interviews, and the incident log, an Immediate Jeopardy (IJ) was identified on 12/2/25 at 1:42 p.m. when it was determined that the facility failed to protect and promote the rights of one (P#1) of four sampled patients (P#1, P#2, P#3, and P#4) reviewed. Specifically, the facility’s staff failed to provide care in a safe setting, resulting in harm to P#1, who was discharged with undiagnosed fractures after the facility failed to follow up on an ordered x-ray and failed to complete medical consultations for worsening arm pain and swelling. Cross refer to A-0144 related to the facility’s failute to provide care in a safe setting. Cross refer to A-1695 as it related to the facility’s failure to ensure that medical staff were available to assess and treat patient’s emergency and medical concerns.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 47718 Based on the review of medical records, policies and procedures, staff interviews, and the incident log, it was determined that the facility’s Governing Body failed to ensure that the medical staff as a group was accountable to the governing body for the quality of care provided to one (P#1) of four sampled patients (P#1, P#2, P#3, and P#4) reviewed. Specifically, facility’s staff failed to follow up on a provider-ordered x-ray for P#1 ’ s left arm pain and swelling and failed to ensure medical consultations were completed, which resulted in P#1 being discharged with undiagnosed fractures of the left forearm and wrists. This noncompliance resulted in P#1 seeking emergency treatment at another facility’s emergency department following discharge. Findings include: A review of Patient (P) #1’s medical record revealed that P#1 was admitted to the facility involuntarily (1013) on 10/31/25 at 1:20 a.m. with the chief complaint of psychosis (a condition where a person loses contact with reality marked by symptoms like hallucinations, delusions, and disorganized thinking or speech). Documentation under the Post Injury/Fall Nursing Progress Notes on 11/3/25 at 9:23 p.m. revealed that P#1 was found on the floor in a sitting position with pants ripped off. Documentation also revealed that P#1 stated that she did not fall, that she was just sitting on the floor. Documentation revealed no observed injury. Documentation of the Fall Risk Follow-up on 11/3/25 at 9:23 p.m. revealed that the physician was notified and non-skid footwear, environmental hazards identified/modified, adequate night lighting, assistive devices, and the treatment plan was updated. A review of the Post Injury/Fall Nursing Progress Notes on 11/10/25 at 4:13 a.m. revealed that P#1 was found sitting on the floor. Documentation of the Post Injury/Fall Nursing Progress Notes on 11/10/25 at 1:28 p.m. revealed that P#1 stated she did not fall but just wanted to sit on the floor. A review of the “ MobileX “ documentation under the Discharge Record on 11/10/25 at 5:38 p.m. revealed an order from a provider to obtain an x-ray of the left forearm and wrist to rule out fractures of the left arm and wrist, as the nursing assessment revealed swelling. Documentation failed to reveal a follow-up on the x-ray order or updates to P#1 ’ s treatment plan. A review of documentation under the Consults revealed an order of a medical consultation for P#1 on 11/13/25 at 12:52 a.m. due to P#1 having a left-hand swelling, and documentation that P#1 reported she broke her arm, and nobody was listening to her, and it was painful. Documentation failed to reveal that a medical consultation was completed. P#1 was discharged on 11/21/25 at 5:12 p.m. Facility 2 A review of P#1 ’ s medical record from Facility #2 (F#2) revealed that P#1 arrived at F#2’s emergency department on 11/21//25 at 9:10 p.m. P#1 ’ s transfer source was from an assisted living facility with the chief complaint of arm swelling. A review of documentation under the ‘Physical Exam’ revealed that there was a limited range of motion of P#1 ’ s wrist due to discomfort, swelling, tenderness, and deformity was present. A review of documentation under the results of the x-ray of the left wrist revealed a fracture and generalized soft tissue swelling. A review of the left elbow x-ray results revealed a soft tissue swelling. However, the lateral view was limited due to partial extension. P#1 was diagnosed with left forearm fractures. A review of the facility ’ s document titled “ Governing Board Bylaws and Constitution, “ last amended/reviewed 12/2024, revealed that the facility was managed by the Governing Board, and the Board was ultimately accountable for the quality of patient care, treatment, and services. The Governing Board ensured the safety of patients, staff, and others. The Governing Board had oversight to ensure an ongoing program for performance improvement and risk management at the facility. A review of the facility ’ s document, titled “ 2025 Performance Improvement Plan, “ revealed that the Performance Improvement (PI) Plan was an integrated, coordinated, and systematic program to identify opportunities to improve care, detect potential problems, prevent or resolve problems, and monitor the effectiveness of actions taken. The PI Program was the ultimate responsibility of the Board of Directors of the facility. The Board delegated the responsibility of oversight to the hospital administration and medical staff. The Board received and acted on quarterly reports that provided pertinent quality and performance information. The Board remained ultimately accountable for the program. A review of the facility ’ s policy titled “Medical Emergency” , Policy #RNP083, last reviewed 1/2025, revealed that all hospital employees would be instructed on emergency care procedures: The nursing staff of the unit would notify the patient ’ s physician/ licensed practitioner/ provider. The person involved would be transferred to a medical care facility if the emergency warrants action. Document the event on an Incident Report and in the patient ’ s medical record, if applicable. A review of the facility’s incident log from June 2025 to December 2025 revealed that on 11/10/25, P#1 reported she fell in her bathroom the evening of 11/9/25, and reported left forearm and wrist pain. Documentation revealed that the medical team was informed, and an x-ray was ordered. A telephone interview was conducted in the facility ’ s conference room on 12/2/25 at 9:45 a.m. with Mental Health Technician (MHT) AA, who stated that P#1 reported to her that she had fallen the night prior. MHT AA continued to explain that P#1 complained of pain in the left arm; and her arm appeared swollen. MHT AA stated that she reported her observations to the nurse, and the nurse stated that she would talk to P#1 to confirm what happened. An interview was conducted in the facility ’ s conference room on 12/2/25 at 10:15 a.m. with Mental Health Technician (MHT) BB, who stated that she could not recall P#1. However, if a patient had a fall on the unit, either witnessed or unwitnessed, she would inform the nurse, do a set of vitals on the patient, and the nurse would do a thorough assessment to determine if the patient needs to be sent out to the hospital or not. An interview was conducted in the facility ’ s conference room on 12/2/25 at 10:30 a.m. with Registered Nurse (RN) CC, who stated that she could not recall P#1. However, if a patient had a fall, and there are signs of fracture, such as the patient complaining of pain or guarding the limb, she would report it to the nursing supervisor, the provider, and call the emergency services if the patient had a change in neurological status or vital signs. RN CC also stated that she would notify the family. An interview was conducted in the facility ’ s conference room on 12/2/25 at 11:30 a.m. with Registered Nurse (RN) DD, who stated that if a patient had a fall and there was a bump on the head, that would be an automatic send-out to the hospital for further evaluation. RN DD stated that the provider and the house supervisor would be notified, as well as the patient ’ s family. An interview was conducted in the facility ’ s conference room on 12/2/25 at 12:00 p.m. with Physician (MD) EE, who stated that P#1 was in a wheelchair and would sometimes put herself on the floor; however, P#1 was able to communicate her needs. MD EE continued to explain that he put in an order for an x-ray of the left arm for P#1 due to pain and swelling of the arm. MD EE stated that he did not follow up with the x-ray results because a medical consultation was put in, and the nurse practitioner was supposed to follow up. MD EE confirmed that he never saw the x-ray results. An interview occurred in the facility ’ s conference room on 12/2/25 at 1:00 p.m. with Registered Nurse (RN) FF, who stated that a staff member had reported that P#1 complained of left arm pain, but there was nothing on the treatment plan suggestive that P#1 had a fracture. RN FF stated that x-ray results were usually faxed to the unit, but he was not aware of any x-ray results for P#1. An interview was conducted in the facility ’ s conference room on 12/2/25 at 1:30 p.m. with Director of Risk Management (DRM) GG, who stated that when P#1 had a fall, an x-ray was done, but they never got the x-ray results. DRM GG stated a third-party company conducts mobile x-ray for patients at the facility. DRM GG expressed that the third-party company had explained to her that they had been faxing x-ray results to the facility ’ s Access Center, which is also the Intake Unit. She continued to explain that the staff at the intake unit stated that they did not receive any results. DRM GG stated that she was uncertain how long this issue has been ongoing. An interview occurred in the facility ’ s conference room on 12/2/25 at 1:45 p.m. with Chief Nursing Officer (CNO) HH, who stated that x-ray results were usually faxed from the third-party company directly to the unit, and the medical records team would pick up the results and scan them to the system, but she was unsure what went wrong. A telephone interview occurred in the facility ’ s conference room on 12/3/25 at 12:40 p.m. with Medical Services Supervisor and a Medical Doctor (MD) II, who stated that, to his knowledge, P#1 did not have any medical consultation for the left arm, and he was unsure why. MD II stated that an x-ray was ordered for P#1 to rule out potential fractures, but no follow-up was completed on the x-ray results due to a system failure. A telephone interview occurred in the facility ’ s conference room on 12/3/25 at 1:15 p.m. with Nurse Practitioner (NP) JJ, who stated that he could not recall P#1. However, when there is an order for a medical consultation, it should flag green on the system. NP JJ confirmed that he could not recall seeing a medical consultation for pain and swelling in P#1’s left arm.”

“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: 47718 Based on review of medical records, policy and procedures, the incident logs, and staff interviews, the facility failed to ensure that care was provided in a safe setting for one (P#1) of four sampled patients (P#1, P#2, P#3, and P#4) reviewed. Specifically, the facility’s staff failed to follow up on an ordered diagnostic (x-ray) test, and failed to complete specific ordered medical consultations and update the treatment plan. These failures resulted in P#1 being discharged with undiagnosed fractures, which resulted in P#1 seeking emergency treatment at another facility’s emergency department following discharge. Findings include: A review of Patient (P) #1’s medical record revealed that P#1 was admitted to the facility involuntarily (1013) on 10/31/25 at 1:20 a.m. with the chief complaint of psychosis (a condition where a person loses contact with reality marked by symptoms like hallucinations, delusions, and disorganized thinking or speech). Documentation under the Post Injury/Fall Nursing Progress Notes on 11/3/25 at 9:23 p.m. revealed that P#1 was found on the floor in a sitting position with pants ripped off. Documentation also revealed that P#1 stated that she did not fall, that she was just sitting on the floor. Documentation revealed no observed injury. Documentation of the Fall Risk Follow-up on 11/3/25 at 9:23 p.m. revealed that the physician was notified and non-skid footwear, environmental hazards identified/modified, adequate night lighting, assistive devices, and the treatment plan was updated. A review of the Post Injury/Fall Nursing Progress Notes on 11/10/25 at 4:13 a.m. revealed that P#1 was found sitting on the floor. Documentation of the Post Injury/Fall Nursing Progress Notes on 11/10/25 at 1:28 p.m. revealed that P#1 stated she did not fall but just wanted to sit on the floor. A review of the “ MobileX “ documentation under the Discharge Record on 11/10/25 at 5:38 p.m. revealed an order from a provider to obtain an x-ray of the left forearm and wrist to rule out fractures of the left arm and wrist, as the nursing assessment revealed swelling. Documentation failed to reveal a follow-up on the x-ray order or updates to P#1 ’ s treatment plan. A review of documentation under the Consults revealed an order of a medical consultation for P#1 on 11/13/25 at 12:52 a.m. due to P#1 having a left-hand swelling, and documentation that P#1 reported she broke her arm, and nobody was listening to her, and it was painful. Documentation failed to reveal that a medical consultation was completed. P#1 was discharged on 11/21/25 at 5:12 p.m. Facility 2 A review of P#1 ’ s medical record from Facility #2 (F#2) revealed that P#1 arrived at F#2’s emergency department on 11/21//25 at 9:10 p.m. P#1 ’ s transfer source was from an assisted living facility with the chief complaint of arm swelling. A review of documentation under the ‘Physical Exam’ revealed that there was a limited range of motion of P#1 ’ s wrist due to discomfort, swelling, tenderness, and deformity was present. A review of documentation under the results of the x-ray of the left wrist revealed a fracture and generalized soft tissue swelling. A review of the left elbow x-ray results revealed a soft tissue swelling. However, the lateral view was limited due to partial extension. P#1 was diagnosed with left forearm fractures. A review of the facility ’ s policy titled “Assessments” , Policy #RNP016, last reviewed 1/2025, revealed that patients should be reassessed when a significant change occured in their condition and in an ongoing manner to determine their response to treatment A review of the facility ’ s policy titled “Patient Assessment and Nursing Flow Sheet” , Policy #RNP097, last reviewed 1/2025, revealed that the Patient Assessment/Nursing Flow Sheets should be completed on all patients as a method of documentation of assessment/reassessment and to provide a baseline for treatment. The nurse should complete the nursing flow sheet every shift and document progress notes. Documentation in the progress notes should be carried out by the nursing staff. The nurse must document if the following situations occurred during the nurse’s shift: a. Abnormal findings indicated on the form. b. Transfer to another hospital or unit. c. Medical Emergency. d. Seclusion/Restraint. e. Significant interactions with patient/family/guardian. A review of the facility ’ s policy titled “Patient Rights “ , Policy #A&R#17, last reviewed 1/2025 revealed that patients had the right to be free of abuse and neglect and receive care in a setting. A review of the facility ’ s policy titled “Incident Reporting” , Policy #NR#73, last reviewed 1/2025, revealed that once an incident has been observed or reported, the patient’s attending physician, the Clinical Services Coordinator, and the patient’s parent or legal guardian (if a minor or under guardianship) should be notified. A review of the facility ’ s policy titled “Medical Emergency” , Policy #RNP083, last reviewed 1/2025, revealed that immediate actions to be taken by all staff in the event of a medical emergency. If the incident involved a patient: Notify the unit staff, Initiate emergency code overhead, Begin emergency first aid care. The nursing staff of the unit would notify the patient ’ s physician/ licensed practitioner/ provider. The person involved would be transferred to a medical care facility if the emergency warrants action. Document the event on an Incident Report and in the patient ’ s medical record, if applicable. A review of the facility’s incident log from June 2025 to December 2025 revealed that on 11/10/25, P#1 reported she fell in her bathroom the evening of 11/9/25, and reported left forearm and wrist pain. Documentation revealed that the medical team was informed, and an x-ray was ordered. A telephone interview was conducted in the facility ’ s conference room on 12/2/25 at 9:45 a.m. with Mental Health Technician (MHT) AA, who stated that P#1 reported to her that she had fallen the night prior. MHT AA continued to explain that P#1 complained of pain in the left arm; and her arm appeared swollen. MHT AA stated that she reported her observations to the nurse, and the nurse stated that she would talk to P#1 to confirm what happened. An interview was conducted in the facility ’ s conference room on 12/2/25 at 10:15 a.m. with Mental Health Technician (MHT) BB, who stated that she could not recall P#1. However, if a patient had a fall on the unit, either witnessed or unwitnessed, she would inform the nurse, do a set of vitals on the patient, and the nurse would do a thorough assessment to determine if the patient needs to be sent out to the hospital or not. An interview was conducted in the facility ’ s conference room on 12/2/25 at 10:30 a.m. with Registered Nurse (RN) CC, who stated that she could not recall P#1. However, if a patient had a fall, and there are signs of fracture, such as the patient complaining of pain or guarding the limb, she would report it to the nursing supervisor, the provider, and call the emergency services if the patient had a change in neurological status or vital signs. RN CC also stated that she would notify the family. An interview was conducted in the facility ’ s conference room on 12/2/25 at 11:30 a.m. with Registered Nurse (RN) DD, who stated that if a patient had a fall and there was a bump on the head, that would be an automatic send-out to the hospital for further evaluation. RN DD stated that the provider and the house supervisor would be notified, as well as the patient ’ s family. An interview was conducted in the facility ’ s conference room on 12/2/25 at 12:00 p.m. with Physician (MD) EE, who stated that P#1 was in a wheelchair and would sometimes put herself on the floor; however, P#1 was able to communicate her needs. MD EE continued to explain that he put in an order for an x-ray of the left arm for P#1 due to pain and swelling of the arm. MD EE stated that he did not follow up with the x-ray results because a medical consultation was put in, and the nurse practitioner was supposed to follow up. MD EE confirmed that he never saw the x-ray results. An interview occurred in the facility ’ s conference room on 12/2/25 at 1:00 p.m. with Registered Nurse (RN) FF, who stated that a staff member had reported that P#1 complained of left arm pain, but there was nothing on the treatment plan suggestive that P#1 had a fracture. RN FF stated that x-ray results were usually faxed to the unit, but he was not aware of any x-ray results for P#1. An interview was conducted in the facility ’ s conference room on 12/2/25 at 1:30 p.m. with Director of Risk Management (DRM) GG, who stated that when P#1 had a fall, an x-ray was done, but they never got the x-ray results. DRM GG stated a third-party company conducts mobile x-ray for patients at the facility. DRM GG expressed that the third-party company had explained to her that they had been faxing x-ray results to the facility ’ s Access Center, which is also the Intake Unit. She continued to explain that the staff at the intake unit stated that they did not receive any results. DRM GG stated that she was uncertain how long this issue has been ongoing. An interview occurred in the facility ’ s conference room on 12/2/25 at 1:45 p.m. with Chief Nursing Officer (CNO) HH, who stated that x-ray results were usually faxed from the third-party company directly to the unit, and the medical records team would pick up the results and scan them to the system, but she was unsure what went wrong. A telephone interview occurred in the facility ’ s conference room on 12/3/25 at 12:40 p.m. with Medical Services Supervisor and a Medical Doctor (MD) II, who stated that, to his knowledge, P#1 did not have any medical consultation for the left arm, and he was unsure why. MD II stated that an x-ray was ordered for P#1 to rule out potential fractures, but no follow-up was completed on the x-ray results due to a system failure. A telephone interview occurred in the facility ’ s conference room on 12/3/25 at 1:15 p.m. with Nurse Practitioner (NP) JJ, who stated that he could not recall P#1. However, when there is an order for a medical consultation, it should flag green on the system. NP JJ confirmed that he could not recall seeing a medical consultation for pain and swelling in P#1’s left arm.”

“Availability of Professional Personnel CFR(s): Doctors of medicine or osteopathy and other appropriate professional personnel must be available to provide necessary medical and surgical diagnostic and treatment services. If medical and surgical diagnostic services and treatment are not available within the institution, the institution must have an agreement with an outside source of these services to ensure that they are immediately available or a satisfactory agreement must be established for transferring patients to a general hospital that participates in the Medicare program. This Standard is not met as evidenced by: 47718 Based on review of medical records, policies and procedures, the incident logs, and staff interviews, it was determined that the facility failed to ensure the availability and coordination of professional medical personnel services for one (P#1) of four sampled patients (P#1, P#2, P#3, and P#4) reviewed.. This failure resulted in the lack of follow-up on a physician-ordered diagnostic test and the absence of required medical consultation services, contributing to the patient being discharged with undiagnosed left arm fractures. Findings Include: Documentation under the ‘Post Injury/Fall Nursing Progress Notes’ on 11/3/25 at 9:23 p.m. revealed that P#1 was found on the floor in a sitting position with pants ripped off. Documentation also revealed that P#1 stated that she did not fall, that she was just sitting on the floor. the way it was supposed to be. Documentation also revealed no observed injury. Documentation of the ‘Fall Risk Follow-up’ on 11/3/25 at 9:23 p.m. revealed that the physician was notified and non-skid footwear, environmental hazards identified/modified, adequate night lighting, assistive devices, and the treatment plan was updated. A review of the Post Injury/Fall Nursing Progress Notes on 11/10/25 at 4:13 a.m. revealed that P#1 was found sitting on the floor. Documentation of the Post Injury/Fall Nursing Progress Notes on 11/10/25 at 1:28 p.m. revealed that P#1 stated she did not fall but just wanted to sit on the floor. A review of the “ MobileX “ documentation under the Discharge Record on 11/10/25 at 5:38 p.m. revealed an order from a provider to obtain an x-ray of the left forearm and wrist to rule out fractures of the left arm and wrist, as the nursing assessment revealed swelling. Documentation failed to reveal a follow-up on the x-ray order or updates to P#1 ’ s treatment plan. A review of documentation under the Consults revealed an order of a medical consultation for P#1 on 11/13/25 at 12:52 a.m. due to P#1 having a left-hand swelling, and documentation that P#1 reported she broke her arm, and nobody was listening to her, and it was painful. Documentation failed to reveal that a medical consultation was completed. P#1 was discharged on 11/21/25 at 5:12 p.m. Facility 2 A review of P#1 ’ s medical record from Facility #2 (F#2) revealed that P#1 arrived at F#2’s emergency department on 11/21//25 at 9:10 p.m. P#1 ’ s transfer source was from an assisted living facility with the chief complaint of arm swelling. A review of documentation under the ‘Physical Exam’ revealed that there was a limited range of motion of P#1 ’ s wrist due to discomfort, swelling, tenderness, and deformity was present. A review of documentation under the results of the x-ray of the left wrist revealed a fracture and generalized soft tissue swelling. A review of the left elbow x-ray results revealed a soft tissue swelling. However, the lateral view was limited due to partial extension. P#1 was diagnosed with left forearm fractures. A review of the facility ’ s document titled “ Governing Board Bylaws and Constitution, “ last amended/reviewed 12/2024, revealed that the facility was managed by the Governing Board, and the Board was ultimately accountable for the quality of patient care, treatment, and services. The Governing Board ensured the safety of patients, staff, and others. The Governing Board had oversight to ensure an ongoing program for performance improvement and risk management at the facility. A review of the facility ’ s document, titled “ 2025 Performance Improvement Plan, “ revealed that the Performance Improvement (PI) Plan was an integrated, coordinated, and systematic program to identify opportunities to improve care, detect potential problems, prevent or resolve problems, and monitor the effectiveness of actions taken. The PI Program was the ultimate responsibility of the Board of Directors of the facility. The Board delegated the responsibility of oversight to the hospital administration and medical staff. The Board received and acted on quarterly reports that provided pertinent quality and performance information. The Board remained ultimately accountable for the program. A review of the facility’s “Medical Staff Bylaws”, revised 1/2025, revealed that one of the purposes of the medical staff was to provide oversight of care, treatment, and services provided by practitioners with privileges, provide for a uniform quality of patient care, treatment and services, and report to and be accountable to the Governing Board. A review of the facility ’ s policy titled “Medical Emergency” , Policy #RNP083, last reviewed 1/2025, revealed that all hospital employees would be instructed on emergency care procedures: The nursing staff of the unit would notify the patient ’ s physician/ licensed practitioner/ provider. The person involved would be transferred to a medical care facility if the emergency warrants action. Document the event on an Incident Report and in the patient ’ s medical record, if applicable. A review of the facility’s incident log from June 2025 to December 2025 revealed that on 11/10/25, P#1 reported she fell in her bathroom the evening of 11/9/25, and reported left forearm and wrist pain. Documentation revealed that the medical team was informed, and an x-ray was ordered. A telephone interview was conducted in the facility ’ s conference room on 12/2/25 at 9:45 a.m. with Mental Health Technician (MHT) AA, who stated that P#1 reported to her that she had fallen the night prior. MHT AA continued to explain that P#1 complained of pain in the left arm; and her arm appeared swollen. MHT AA stated that she reported her observations to the nurse, and the nurse stated that she would talk to P#1 to confirm what happened. An interview was conducted in the facility ’ s conference room on 12/2/25 at 10:15 a.m. with Mental Health Technician (MHT) BB, who stated that she could not recall P#1. However, if a patient had a fall on the unit, either witnessed or unwitnessed, she would inform the nurse, do a set of vitals on the patient, and the nurse would do a thorough assessment to determine if the patient needs to be sent out to the hospital or not. An interview was conducted in the facility ’ s conference room on 12/2/25 at 10:30 a.m. with Registered Nurse (RN) CC, who stated that she could not recall P#1. However, if a patient had a fall, and there were signs of fracture, such as the patient complaining of pain or guarding the limb, she would report it to the nursing supervisor, the provider, and call the emergency services if the patient had a change in neurological status or vital signs. RN CC also stated that she would notify the patient’s family. An interview was conducted in the facility ’ s conference room on 12/2/25 at 12:00 p.m. with Physician (MD) EE, who stated that P#1 was in a wheelchair and would sometimes put herself on the floor; however, P#1 was able to communicate her needs. MD EE continued to explain that he put in an order for an x-ray of the left arm for P#1 due to pain and swelling of the arm. MD EE stated that he did not follow up with the x-ray results because a medical consultation was put in, and the nurse practitioner was supposed to follow up. MD EE confirmed that he never saw the x-ray results. An interview occurred in the facility ’ s conference room on 12/2/25 at 1:00 p.m. with Registered Nurse (RN) FF, who stated that a staff member had reported that P#1 complained of left arm pain, but there was nothing on the treatment plan suggestive that P#1 had a fracture. RN FF stated that x-ray results were usually faxed to the unit, but he was not aware of any x-ray results for P#1. An interview was conducted in the facility ’ s conference room on 12/2/25 at 1:30 p.m. with Director of Risk Management (DRM) GG, who stated that when P#1 had a fall, an x-ray was done, but they never got the x-ray results. DRM GG stated a third-party company conducted mobile x-ray for patients at the facility. DRM GG expressed that the third-party company had explained to her that they had been faxing x-ray results to the facility ’ s Access Center, which is also the Intake Unit. She continued to explain that the staff at the intake unit stated that they did not receive any results. DRM GG stated that she was uncertain how long this issue has been ongoing. An interview occurred in the facility ’ s conference room on 12/2/25 at 1:45 p.m. with Chief Nursing Officer (CNO) HH, who stated that x-ray results were usually faxed from the third-party company directly to the unit, and the medical records team would pick up the results and scan them to the system, but she was unsure what went wrong. A telephone interview occurred in the facility ’ s conference room on 12/3/25 at 12:40 p.m. with Medical Services Supervisor and a Medical Doctor (MD) II, who stated that, to his knowledge, P#1 did not have any medical consultation for the left arm, and he was unsure why. MD II stated that an x-ray was ordered for P#1 to rule out potential fractures, but no follow-up was completed on the x-ray results due to a system failure. A telephone interview occurred in the facility ’ s conference room on 12/3/25 at 1:15 p.m. with Nurse Practitioner (NP) JJ, who stated that he could not recall P#1. However, when there is an order for a medical consultation, it should flag green on the system. NP JJ confirmed that he could not recall seeing a medical consultation for pain and swelling in P#1’s left arm.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 40979 Based on review of facility policies and procedures, medical records, and staff interviews, it was determined that the facility failed to ensure that the discharge planning evaluation was discussed with the patient’s representative and power of attorney (POA) when one patient (P) (P#5) of four (P#5, P#6, P#7 and P#8) sampled patents was discharged to a personal care home by way of taxi without notification to the family representative. Findings included: A review of the facility’s policy titled “Patient Bill of Rights,” Policy # A&R #17, last reviewed 1/2025 revealed the following: I. Policy. It is the policy of this hospital to ensure that all patients receive a copy of the Patient’s Bill of Rights form, as well as an oral explanation of those rights and responsibilities, both in their primary language and in simple non-technical terms. II. Procedure. 1. At the time of admission, each individual shall be provided with a copy of the Patient’s Bill of Rights form and a verbal explanation of those rights in their primary language in simple nontechnical language. 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. A review of the facility’s policy titled “Discharge Planning,” Policy #RNP046, last reviewed 1/2025, revealed the following: I. Policy. 1. The development of a Discharge Plan begins on admission. II. Procedure. 1. As a component of the assessment process, treatment recommendations are formulated. These recommendations include the various levels of care indicated to assure the patients are treated at the appropriate level of care. 2. The Discharge Plan Should: (a) Prepare the patient and family for the transition to the next level of care. (b) Address the patient’s and family’s need for instructions about continued treatment. (c) Delineate how progress made in the current level of care will continue after discharge. 4. In developing discharge aftercare plans, the following is considered as appropriate: a. Family relationships. D. housing needs and/or placement issues. A review of P#5’s medical record revealed that he was admitted to the facility on 10/26/25. A review of transition record dated 11/4/25 at 10:19 a.m. revealed the discharge disposition was to a group home; Family involvement: yes; Mode of Transportation: Taxi An interview was conducted with Social Worker (SW) HH on 11/18/25 at 2:10 p.m. in the administration conference room. SW HH stated after reviewing P#5 medical record that he vaguely recalls the patient. He stated that he did not speak with P#5’s family representative during his inpatient stay at the facility. SW HH stated that it is the facility’s policy to keep the patient’s representative, if known, up to date on the process of their family member. SW HH confirmed that P#5’s family representative was not notified prior to his discharge back to his personal care home. SW HH confirmed that P#5’s family was not given the opportunity to transport him back to his personal care home to avoid P#5 being placed in a taxi. He stated that Discharge Planner (DP) II is new in her position at the facility and failed to contact P#5’s family during his admission at the facility. A telephone interview was conducted with Discharge Planner (DP) II on 11/18/25 at 5:45 p.m. DP II stated that she started at the facility the end of October 2025. She stated that she did recall P#5 during his inpatient admission at the facility. DP II stated that she could not recall reaching out to P#5’s family regarding his discharge. An interview was conducted with the Director of Clinical Services (DCS) KK on 11/19/25 at 12:30 p.m. in the administration conference room. DCS KK stated that she became aware of the situation concerning P#5 when this surveyor entered the facility to investigate this complaint. She continue to explain that after reviewing P#5’s medical record she confirmed that communication with his family was not documented. DCS KK continued to explain that the responsibility for continuous communication with the patient’s family collectively falls on the interdisciplinary team as a whole. She continued to say that in this case Program Therapist (PT) LL was assigned to P#5 and was responsible for communicating with his family as it relates to his progress in the program as well as plans for his discharge. DCS KK stated that the role of Discharge Planner (DP) also maintains communication with the patient and their representatives when necessary. She continued to explain that the DP is also responsible for communicating with the facilities that refer the patient and/or for patient placement. DCS KK stated that P#5 was accepted back to his personal care home, and this may be the reason communication with his family was not completed. DCS KK confirmed that P#5, who has been diagnosed with dementia, should not have been transported back to his personal care home in a Taxi. She continued to say that PT LL should have reached out to P#5’s family and documented the interaction regarding his discharge plan. An interview was conducted with Program Therapist (PT) LL on 11/19/25 at 1:30 p.m. in the administration conference room. PT LL stated that she vaguely recalled P#5. She continued to explain that as a PT she is responsible for facilitating individual therapy and group therapy with patients and their families. She continued to say that it is important that the PTs and interdisciplinary team to ensure that all patients are stabilized before discharge. PT LL confirmed that she did not communicate with P#5’s family during his admission to the facility. She continued to explain that although she did not speak to P#5’s family someone had to know his family could not pick him up and that is why a taxi was called to transport him back to his personal care home. PT LL confirmed that there was no documentation in P#5’s medical record indicating a call was made to P#5’s family or representative regarding his discharge and transportation back to personal care home. She continued to say that she accepts responsibility for not ensuring communication was completed with P#5’s representative.”

“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: 47718 Based on review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to notify POA (power of attorney) of a fall while at the facility for one patient (P) (P#1) of five patients reviewed when P#1 sustained a fall on 7/9/25. Findings Included: A review of medical records revealed that P#1 was admitted to the facility involuntarily (1013) on 7/4/25 at 4:25 p.m. A review of the Intake Assessment: Conservator under the AR Assessment on 7/5/25 at 9:05 a.m. revealed documentation of a Power of Attorney (POA) with a note indicating the name of P#1 ’ s family member. A review of the Intake Assessment: Summary of Clinic under the AR Assessment on 7/5/25 at 9:05 a.m. revealed that P#1 ’ s family member, who held his (P#1) power of attorney, reported his (P#1) medical history of dementia, and also noted that P#1 did not like being assisted by female staff for any aspect of his care. Documentation under the emergency contact name on 7/5/25 at 9:09 a.m. revealed that P#1 ’ s family member, who was also the POA was listed as P#1 ’ s emergency contact. Further review of P#1 ’ s medical record revealed under the Post Injury/Fall Nursing Progress Notes, documentation by RN EE on 7/8/25 at 10:22 p.m., that P#1 was found yelling “ HELP “ and was found on the bathroom floor lying on the right side with the head up and shoulder down. During an electronic medical record review at the facility on 9/8/25 at 1:30 p.m. with Chief Nursing Officer (CNO) LL, documentation revealed that the medical providers (NP CC and PSY DD) and the director of PI/Risk were informed of P#1 ’ s fall. Documentation failed to reveal that P#1 ’ s POA was informed about the incident. A review of the facility ’ s Incident log from 3/2/25 to 9/2/25 revealed an incident reported on 7/9/25 regarding P#1. Documentation by RN EE revealed that P#1 was found on the floor after he (P#1) yelled for help. Documentation revealed that P#1 was found lying on the right side with his head up and his shoulder down. Further review of the incident report log revealed that P#1 was assisted to a sitting position, and he was able to answer questions and give a full spelling of his name. Documentation also revealed that the doctor was notified. Documentation failed to reveal that P#1 ’ s POA was notified. A review of the facility ’ s policy titled “Patient Rights ,” last reviewed 1/2025 revealed that patients had the right to be free of abuse and neglect and receive care in a setting. A review of the facility ’ s policy titled “Incident Reporting,” Policy #NR#73, last reviewed 1/2025, stated that only the employee who is directly involved in the occurrence or incident, either through witnessing the event or being told by a visitor that an event has occurred, should initiate and document on the Incident Report form. This should be done immediately after the incident occurred (if witnessed) or as soon as one becomes aware of such an occurrence (receiving information from another person). Once an incident has been observed or reported, the patient’s attending physician, the Clinical Services Coordinator, and the patient’s parent or legal guardian (if a minor or under guardianship) should be notified. The legal guardian must be notified of all unusual incidents. The information should be shared by the charge nurse unless a decision was made that it would be more appropriate by the therapist or physician. The report should be made as soon as possible, and requested for any necessary follow-up (i.e., tests, medical treatment, etc). The nurse completed the nursing flow sheet every shift and documented progress notes. An interview took place in the facility ’ s conference room on 9/8/25 at 3:30 p.m. with Program Nurse Manager (PNM) BB, who stated that she could not recall P#1, nor the incident. PNM BB stated that if a patient sustained a fall, a full assessment would be done by the nurse, and the MD (medical doctor) would be notified. PNM BB stated that if the patient had obvious injuries or bleeding, then the patient would be sent out to the ED (emergency department) for further evaluation, and she (PNM BB) would expect that the patient ’ s POA or legal guardian on file would be notified. An interview took place in the facility ’ s conference room on 9/9/25 at 10:00 a.m. with Nurse Practitioner (NP) CC, who stated that he could not recall P#1, but he usually received a lot of calls from the nurses regarding patients ’ falls. NP CC stated that based on the nursing assessment and nursing judgement coupled with the questions he (NP CC) would ask via the phone (if the call was outside hours), the patient may be sent out to the ED for further evaluation. NP CC also stated that he would only see the patient post-fall if there was a consultation that the patient needed to be seen by the medical team, or if the patient sustained an injury, or had any acute issues, as the psychiatrist always did a daily round on all patients. An interview took place in the facility ’ s conference room on 9/9/25 at 10:30 a.m. with Psychiatrist (PSY) DD, who stated that he could not recall P#1. However, if there was a fall on the unit, based on the assessment parameters by the nursing team and evaluation by the medical providers, the medical team could decide to send the patient out for further evaluation, and he (PSY DD) would expect the nursing team to notify the patient ’ s POA, as that was the nurses ’ responsibility. An interview took place in the facility ’ s conference room on 9/9/25 at 1:45 p.m. with Mental Health Technician (MHT) JJ, who stated that he could not recall P#1. However, if a patient sustained a fall, either witnessed or unwitnessed, the protocol would be to inform the nurse and obtain vital signs from the patient. MHT JJ stated that the nurse would then notify the doctor and take it from there. A telephone interview took place on 9/10/25 at 9:00 a.m. with Registered Nurse (RN) GG, who stated that she could not recall P#1or the incident. RN GG stated that if a patient had a fall on the unit, the protocol would be to take a set of vital signs and inform the provider to obtain the next set of orders. The provider would decide whether to send the patient out or not based on the parameters of the vital signs and nursing assessment. A telephone interview took place on 9/10/25 at 9:30 a.m. with Nursing Supervisor (NS) FF, who stated that if a patient had a POA, and it had been determined at the patient ’ s initial assessment that the POA could be given updates about the patient ’ s care, then she (NS FF) would expect that the patient ’ s POA would also be informed if the patient had an incident.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 49398 Based on a review of the EMTALA Log, medical records, Medical Staff Rules and Regulations, facility policy and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) within the facility’s capability and capacity , including ancillary services routinely available to the dedicated emergency department, in order to determine whether or not an emergency medical condition (EMC) exists for six (P#1,P#4, P#7, P#9, P#11, and P#17) of 20 sampled patients. Specifically: 1. Medical screening exams (MSE) were not conducted by qualified medical personnel (QMP) as defined in the facility’s Medical Staff Rules and Regulations and policies for six (P#1, P#4, P#7, P#9, P#11, and P#17) of 20 sampled patients, who entered the facility seeking medical assistance for psychiatric complaints. Refer to findings in Tag A- 2406 2. Based on review of facility policy and procedures, EMTALA Log, Hospital-Wide On-call Calendar, patient census report and interviews with staff, it was determined that the facility failed to provide further medical examination and treatment as required for one (P#7) of 20 sampled patients. P#7 was denied inpatient admission for chemical dependency due to their lack of financial resources. Specifically, P#7 arrived at the facility on 12/3/24 with a complaint of alcohol withdrawal. P#7 reported symptoms of nausea, vomiting, and ‘shakes’. It was recommended that P#7 be admitted for inpatient detoxification treatment; however, after speaking to the facility’s financial counselor, P#7 expressed an inability to afford the hospitalization. P#7 was then discharged with an outpatient referral without further medical assessment. Refer to findings in Tag A- 2408. 3. Based on review of the EMTALA Log, medical records, policies and procedures, and staff interviews it was determined that the facility failed to provide an appropriate transfer for four (P#1, P#11, P#13 and P#15) of 20 sampled patients reviewed. Specifically: a. The facility failed to complete a memo of transfer that included documentation of risks and benefits, confirmation of an accepting physician, nurse to nurse report, mode of transport and confirmation of medical records accompanied the patient for P#1 and P#11. b. The facility failed to effect an appropriate transfer utilizing qualified personnel and transportation equipment for P#13 when the patient was instructed to go to an acute care ED for evaluation of his elevated blood pressure and for P#15 when he was instructed to go to an acute care ED after a suicide attempt by overdose. Refer to findings in Tag A-2409.”

“HOSPITAL MUST MAINTAIN RECORDS CFR(s): 489.20(r)(1) [The provider agrees,] in the case of a hospital as defined in §489.24(b), (including both the transferring and receiving hospitals), to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer. This Standard is not met as evidenced by: 49398 Based on review of the EMTALA Log, and staff interviews, it was determined that the facility failed to maintain/initiate medical and other records for nine (P#2, P#3, P#5, P#8, P#12, P#16, P#18, P#19, and P#20) of 20 sampled patients that presented to the facility’s intake department seeking medical assistance for psychiatric complaints. Findings Included: During a review of the facility’s EMTALA Log for 7/1/24 through 3/25/25, the facility failed to produce medical records for nine (P#2, P#3, P#5, P#8, P#12, P#16, P#18, P#19, and P#20) of 20 sampled medical records requested. During an interview on 3/26/25 at 9:45 a.m. with the Vice President of Clinical Services (VPCS) EE in a conference room, VPCS EE acknowledged that the facility was unable to produce several of the requested medical records. He said he was not aware that medical records were not being created on all patients. During an interview on 3/27/25, at 9:54 a.m. with the Medical Director (MD) II in an office, he explained that he expects staff to create a medical record for every patient being treated and he expects staff to follow documentation requirements. The facility failed to implement an effective system as it relates on maintaining medical records for individuals who present to the intake department seeking medical assistance for P#2, P#3, P#5, P#8, P#12, P#16, P#18, P#19, and P#20.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 49398 Based on a review of the EMTALA Log, medical records, Medical Staff Rules and Regulations, facility policy and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the facility’s dedicated emergency department, including ancillary services routinely available to the dedicated emergency department, to determine whether or not an emergency medical condition (EMC) exists for six (P#1,P#4, P#7, P#9, P#11, and P#17) of 20 sampled patients. Specifically: Medical screening exams (MSE) were not conducted by qualified medical personnel (QMP) as defined in the facility’s Medical Staff Rules and Regulations and policies for six (P#1, P#4, P#7, P#9, P#11, and P#17) of 20 sampled patients who presented to the facility seeking medical assistance for psychiatric complaints. Findings Included: A review of Medical Staff Rules and Regulations reviewed 10/2024 revealed in Chapter VI g). Medical Screening Exam (MSE) 1) The process required to determine within reasonable clinical confidence where an Emergency Medical Condition (EMC) does or does not exist. The MSE is an ongoing process and must be done within the facilities capability. The Qualified Medical Personal (QMP) designated to provide an MSE is a physician, advanced practice registered nurse or registered nurse, whose scope of responsibilities are approved by the hospital’s governing board through the medical staff rules and regulations. A review of the facility’s policy number 21, titled “Emergency Medical Treatment and Active Labor Act (EMTALA)” last revised on 1/2025 reveled the following: POLICY: Ridgeview Institute will assure that (1) all patients who come to the hospital requesting emergency services receive an appropriate Medical Screening Examination. DEFINITIONS: “Qualified Medical Personnel” means a licensed registered nurse, advanced practice nurse (APN) or licensed physician whose scope of responsibilities are approved by the hospital’s governing board and the Medical Staff Rules & Regulations. PROCEDURE: Medical Screening Exam (MSE): The Medical Screening Examination is to be provided by Qualified Medical Personnel (QMP). Procedure for Completion of the MEDICAL SCREENING EXAMINATION 1: Receptionist will notify the Assessment & Referral Department that a person has been presented seeking medical/psychiatric services. 2: Upon completion of the initial screening by the Assessment & Referral staff, assignment of care will be based on the identified acuity. A qualified medical professional will evaluate all patients by performing a medical screening examination. Psychiatric Emergency The law requires that a person must be, because of a mental disorder, a danger to self, a danger to others, or gravely disabled. The physician and/or on call physician is responsible for supervision, evaluation, and stabilization of the patient. In the absence of the physician, a designated Qualified Medical Professional (QMP) who has demonstrated competency may be conducted in a medical screening examination. A review of the EMTALA Log revealed that P#1 arrived at the facility via walk-in on 3/16/25 at 10:15 a.m. A review of the medical record revealed that a master’s Level Clinician (MLC) initiated the EMTALA Medical Screening at 8:09 p.m. P#1’s chief complaints were depression and alcohol dependence. P#1 reported suicidal ideation with a plan to overdose on medication. Patient #1 had an emergency medical condition of suicidal ideation and at risk for self-harm. Review of the medical record revealed the medical screening examination was conducted by a MLC, who was not designated qualified medical personnel. A review of the EMTALA Log revealed that P#4 arrived at the facility via walk-in on 11/8/24 at 6:30 a.m. A review of the Intake Assessment revealed the patient’s Chief Complaint was listed as “Cause my mom knows I want to kill myself because I hate myself.” P#4’s presenting problems were suicide with self-injurious behavior (cutting), body dysmorphia (a mental health condition where a person spends a lot of time worrying about flaws in their appearance), and homicidal ideations (thoughts). The medical record revealed the patient was assessed/evaluated by a Licensed Master Social Work (LMSW), who was not designated as qualified to perform Medical Screening examinations. A review of the EMTALA Log revealed that P#7 arrived at the facility via walk-in on 12/3/24 at 3:21 p.m. A review of the medical record revealed that P#7’s chief complaint was listed as “I have a big drinking problem.” Patient #7’s presenting problem was alcohol (ETOH) detoxification. He reported drinking a fifth of vodka daily and experiencing withdrawal symptoms including nausea, vomiting, and tremors (shaking). The patient denied suicidal and homicidal ideation, and hallucinations. The medical record revealed the patient was evaluated by a Marriage and Family Therapist. The review failed to reveal documentation that an EMTALA Medical Screening examination was performed by qualified medical personnel. A review of the EMTALA Log revealed that P#9 arrived at the facility via walk-in on 1/5/25 at 3:12 p.m. A review of the medical record revealed that P#9’s chief complaint and presenting problem was listed as” Pt. (patient) presents due to Detox.” alcohol (ETOH) detoxification. The patient reported he was going through withdrawal symptoms, including auditory and visual hallucinations, paranoia daily due to lack of sleep, confusion, irritability daily due to urges of cravings, and panic attacks. He reported his last use of alcohol was four days ago. P#9 denied any medical conditions and denied suicidal or homicidal ideations. The medical record revealed the assessment by a Master of Social Work. The review failed to reveal documentation that an EMTALA Medical Screening was conducted by qualified medical personnel. A review of the EMTALA Log revealed that P#11 arrived at the facility via walk-in on 1/3/25 at 3:00 p.m. A review of the medical record revealed that P#11’s Chief Complaint was “Pt. stated “I don’t have the will power to live.” The presenting Problem was listed as, “Pt. presented seeking an assessment to help with SI (suicidal ideation), depression and substance abuse use.” The patient’s Psychiatric symptoms stated in part, Poor eye contact, Affect Flat, Dysphoria (very unhappy, or dissatisfied), Thought Process Confused, Judgment and Insight, was poor. The patient’s medical history included bipolar disorder (psychiatric illness characterized by both manic and depressive episodes) and schizoaffective disorder (Delusions-fixed beliefs, Hallucinations such as hearing or seeing things that are not there), and Diabetes. Further review revealed the patient reported paranoid ideation, and a history of psychosis (Mental health condition characterized by a disconnection from reality). Review also revealed substance abuse, the patient reported the use of “Amphetamine/Stimulants/ (meth) and last use was “yesterday”, and last alcohol intake was “Last night.” Review of the summary revealed in part Patient #11, “Precautions: Suicidal and Self-Harm. Level of Suicide ...Moderate/Low ... Pt. reported suicidal ideations with no specific method stating “I’m just tired, I want to try to end it” unable to elaborate. Pt (patient). has history if attempts, cutting on her legs, arm, and torso; last episode 3-4 weeks ago ...Pt. denied HI (homicidal ideation) and AVH (Audio/Visual hallucinations) although pt stated that she was unsure if what if what she is experiencing is some level of paranoia. Pt. reported impaired sleep ...Pt was observed to be confused, nodding out during the assessment, and unable to focus. Further review revealed that an EMTALA Medical Screening Examination was conducted by a Licensed Master Social Worker. The medical record failed to documentation that an EMTALA Medical Screening Examination was conducted by a qualified medical personnel member. A review of the EMTALA Log revealed that P#17 arrived at the facility on 11/12/24 at 8:21 a.m. A review of the Intake Assessment Report revealed P#17 had a complaint of bizarre behavior and possible hallucinations. The patient was accompanied by his mother. The patient’s presenting problems revealed, in part, “Patient is a 14-year-old ... presents voluntarily for walk in assessment due to possible psychosis with delusions. Further review revealed the patient’s eye contact was poor, Judgment and insight was poor. The patient denied suicidal and homicidal ideation, or self-harming behaviors. He had a past medical history of asthma and concussion. Further review revealed the MSE was inappropriate because a non-designated person performed the MSE. The medical record failed to reveal evidence that an EMTALA Medical Screening was conducted by a qualified medical personnel member. During an interview on 3/25/25, at 10:15 a.m. with the Director of Assessments and Referrals (DAR) AA in a conference room, DAR AA stated that her duties as Director include oversight of the facility clinicians and the call center. DAR AA explained that when a patient arrives at the facility by walk-in or by ambulance, they are triaged and placed in an intake room based on their acuity until they can be assessed. She stated that a master-level clinician (MLC), who is a master’s prepared mental health counselor or social worker, conducts an initial medical screening examination (MSE) on the patient. During an interview on 3/25/25 at 11:31 a.m. with Registered Nurse (RN) CC in a conference room, RN CC explained that every patient who presents to the facility requesting treatment should have a medical screening exam (MSE). She added that there are parameters for the MLC to follow, as they do not have medical training and are therefore unable to determine what constitutes an appropriate interpretation of the medical information. RN CC explained that if she is not notified by an MLC that a patient’s condition is acute or deteriorating, she would not be aware of it otherwise. RN CC stated that MLCs conduct the MSE. Still, it should be done by an RN because they have clinical experience to determine if a patient requires reassessment, emergency intervention, or transfer based on their vital signs and presentation. During an interview on 3/26/25 at 9:45 a.m. with the Vice President of Clinical Services (VPCS) EE in a conference room, VPCS EE stated that many medical records failed to reveal that a medical screening examination (MSE) was conducted. He said that the facility staff have not been following the facility’s process of documenting or conducting MSEs on patients. He said he was not aware that MSEs were not being conducted prior to the survey. During a follow-up interview on 3/26/25 at 10:35 a.m. with VPCS EE, VPCS EE said that MLCs are not qualified to conduct MSEs and that MSEs should be conducted by an RN or a licensed physician. He added that MLCs do conduct assessments, but to triage and assign acuity levels. When this surveyor asked VPS EE if MLCs are trained to triage and assign acuity levels, he replied that they have not been trained to do so, as they are not medical personnel. A follow-up interview was conducted on 3/26/25 at 1:46 p.m. with RN EE. RN EE stated that master-level clinicians conduct MSEs, and the MSE is then forwarded to her or a house supervisor for review and signature. She added that there are times when it is not reviewed right away, which defeats the purpose of reviewing the values. During an interview on 3/26/25 at 2:18 p.m. with Master Level Clinician (MLC) DD in a conference room, MSW DD explained that when patients arrive in the waiting room, she assesses and prioritizes them based on their mental status. She added that one of her responsibilities as a master social worker in intake is to conduct MSEs and initial assessments. She explained that once she completes an MSE, she is supposed to send it to an RN, who will review the assessment and sign it. A telephone interview was conducted on 3/26/25 at 8:30 p.m. with House Supervisor (HS) KK. She stated that one of her duties as a house supervisor is to respond to medical emergencies and to review and sign medical screening examinations (MSE) sent over by the intake department. HS KK noted that every patient who enters the access/intake department should receive a medical screening exam (MSE). She added that the intake department staff conduct the MSE and forward it to the RN for review and signature. HS KK explained that personnel qualified to conduct medical screening exams include RNs, advanced practitioners, and physicians, and that MLCs are not qualified and lack medical experience. During an interview on 3/27/25, at 9:54 a.m. with the Medical Director (MD) II in an office, MD II stated that his responsibilities as medical director include overseeing the medical staff, attending medical staff meetings, conducting chart audits to ensure compliance, creating provider schedules, managing outpatient clinics, and seeing approximately 60 patients. He explained that the MSE must be conducted by a qualified medical practitioner (QMP). He added that the facility bylaws stipulate that a QMP must be a registered nurse (RN), advanced practitioner, or physician, and that master-level clinicians are not qualified to conduct an MSE. MD II explained that elements of an MSE include a review of symptoms, pain assessment, physical exam, past and current medical history, medication review, psychological assessment, and vital signs. MD II stated that he was unaware of the MSEs being conducted by MLCs. During an interview on 4/15/25 at 2:11 p.m. with the Regional Director of Quality (RDQ) MM, in a conference room, RDQ MM stated that she had worked as the Director of Quality at the facility’s sister location for four years, was recently promoted to RDQ, and floats between all the facilities. She explained that patient MSEs have been hit or miss in terms of ensuring every patient who enters the facility gets one. She acknowledged that most of the sample patients had not received an MSE. She stated the staff did not recall the specifics of what caused the sample patients not to have an MSE. RDQ MM explained that MSE’s are documented on the form titled ‘EMTALA Medical Screening’ and if that form was not in the record, an MSE was not conducted. The facility failed to ensure that their own Medical Staff Rules and Regulations and EMTALA policy were followed as evidenced by failing to ensure that all patients who come to the hospital requesting emergency services received an appropriate medical screening examination by a QMP whose scope of responsibilities are approved by the hospital’s governing board Medical Staff Rules and Regulations. This failure resulted in inappropriate Medical Screening examinations being conducted by individuals not approved by the hospital’s governing board for six (P#1, P#4, P#&, P#9, P#11, and P#17) of 20 sampled patients who presented to the hospital seeking medical assistance for psychiatric complaints.”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 49398 Based on review of facility policy and procedures, EMTALA Log, Hospital-Wide On-call Calendar, patient census report and interviews with staff, it was determined that the facility failed to provide further medical examination and treatment as required, after inquiring about the individual’s method of payment for one (P#7) of 20 sampled patients. P#7 was denied inpatient admission for chemical dependency due to their lack of financial resources. Specifically, P#7 arrived at the facility on 12/3/24 with a complaint of alcohol withdrawal. P#7 reported symptoms of nausea, vomiting, and ‘shakes’. It was recommended that P#7 be admitted for inpatient detoxification treatment; however, after speaking to the facility’s financial counselor, P#7 expressed an inability to afford the hospitalization. P#7 was discharged with an outpatient referral without further medical assessment. Findings included: A review of facilities policy number 21, titled “Emergency Medical Treatment and Active Labor Act (EMTALA) “, last revised on 1/2025, revealed in part the following: “c. The MSE will not be delayed inquiring about a person’s ability to pay or perform any insurance verification .... ... if the patient has no insurance, no further questions regarding payment should be asked of the patient until after the medical screening examination has taken place. The Assessment and Referral personnel should not under no circumstances (1) Discuss cost of the service; (2) Ask how the patient will pay for the service; or (3) Make an attempt to collect payment.” A review of the patient census for 12/3/24 revealed a total facility census of 134 patients. Of the 134 patients, 16 patients were on the detoxification/substance abuse unit. A review of the ‘Hospital-Wide On-Call Calendar for December 2024 revealed that on 12/3/24, a nurse practitioner was on call beginning at 5:00 p.m. A review of the EMTALA Log revealed that P#7 arrived at the facility on 12/3/24 at 3:21 p.m. The ED revealed the patient’s complaint was listed as “Psychiatric”. The section of the ED Log titled, “Emergency Medical/Psychiatric Condition” documentation revealed “Yes” P#7 had an emergency condition. The patient’s disposition was listed as “Referred Out.” The Intake Assessment dated 12/3/2024 at 6:29 p.m. was reviewed. The patient’s chief complaint was,” I have a drinking problem.” The section of the medical record titled “Psychiatric Symptoms” revealed the patient’s presenting problem was seeking alcohol detox (detoxification-process of removing toxic substances particularly drugs, alcohol from the body), and that his insight was listed as “fair.” Psychosocial Assessment: Financial Problems: Yes ...” I’ve got a lot of bills ...I’m broke most of the time.” Further review of medical record revealed that P#7 reported drinking a fifth of vodka daily and was experiencing withdrawal symptoms, including nausea, vomiting, and shakes. He had a past medical history of depression, anxiety, alcohol abuse, and a suicide attempt in 2021. P#7 had six previous hospital admissions, with the latest one being a year ago for alcohol detox. P#7 denied any current suicidal or homicidal ideations. The section of the medical record titled “LEVEL OF CARE DETERMINATION” revealed, “Symptoms Meet: Criteria for Acute Psychiatric/Chemical dependency Inpatient admission. Acute Inpatient Psychiatric/Chemical Dependency Care: Condition requires a medical monitored detoxification process.” Review of the “Summary of Clinical Information” revealed that P#7 was recommended for inpatient detox treatment. After receiving a financial consultation, he expressed an inability to afford services and was referred to an outpatient program. The medical record failed to reveal evidence of outpatient referral information. The facility failed to ensure that their own policy and procedure was followed as evidence by having the financial consult inquire and ask questions about how P#7 would pay for further medical evaluation and treatment. This resulted in P#7, on 12/3/24, not being admitted to the facility’s inpatient unit for his Acute Psychiatric/Chemical Dependency, as his condition required medical monitoring for the detoxification process. During a virtual interview on 8/5/25 at 1:00 p.m., CEO LL explained that financial counseling was conducted on all patients that present to the intake department to be in compliance with the ‘no surprise billing act’. Financial counseling was done after an assessment but prior to admission. .”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 49398 Based on review of the EMTALA Log, medical records, policies and procedures, and staff interviews it was determined that the facility failed to provide an appropriate transfer for four (P#1, P#11, P#13 and P#15) of 20 sampled patients reviewed. Specifically: 1. The facility failed to complete a memo of transfer that included documentation of risks and benefits, confirmation of an accepting physician, nurse to nurse report, mode of transport and confirmation of medical records accompanied the patient for P#1 and P#11. 2. The facility failed to effect an appropriate transfer utilizing qualified personnel and transportation equipment for P#13 when the patient was instructed to go to an acute care ED for evaluation of his elevated blood pressure and for P#15 when he was instructed to go to an acute care ED after a suicide attempt by overdose. Findings Included: A review of the EMTALA Log revealed that P#1 arrived at the facility via walk-in on 3/16/25 at 10:15 a.m. A medical record revealed that a master’s Level Clinician (MLC) initiated EMTALA Medical Screening (MSE) at 8:09 p.m. P#1’s chief complaints were depression and alcohol dependence. P#1 reported suicidal ideation with a plan to overdose on medication. P#1 had a past medical history of cirrhosis (irreversible condition where scar tissue replaces healthy liver tissue, hindering the liver’s ability to function correctly, and can lead to liver failure), diabetes (a chronic condition where the body either doesn’t produce enough insulin or can’t effectively use the insulin it produces, leading to high blood sugar levels), hypertension (a condition where the force of blood against artery walls is consistently too high), daily diarrhea, incontinence of urine and feces, and a past suicide attempt by overdose of medication. Continued review revealed P#1 was placed on high-risk suicide precautions. A consultation with the Medical Director was initiated, and a decision was made to transfer P#1 to an area hospital for medical clearance due to her past medical history. The medical record failed to include an order to transfer, a completed memorandum of transfer, and documentation that copies of medical records were provided to EMS. There was no documented evidence that Patient #1 medical records were forwarded to the receiving physician and receiving hospital. There was no documentation in the medical record to indicate that the receiving hospital had the required specialized capability that P#1 required. Additionally, there was no documented evidence that the receiving hospital agreed to accept the transfer of P#1 to provide the additional necessary medical intervention for the patient’s identified EMC. A review of the EMTALA Log revealed that P#11 arrived at the facility on 1/13/25 at 3:00 p.m. An Intake Assessment was started by MLC DD on 1/13/25 at 3:48 p.m. A continued review revealed that the EMTALA Medical Screening was started on 1/13/25 at 11:06 p.m. Psychiatrist FF was consulted on 1/14/25 at 12:00 a.m. and determined that P#11 would be admitted as an inpatient for “Acute Psychiatric/Chemical Dependency” but would require a medical clearance at an acute care facility due to emergent medical/physical/psychiatric conditions. The ‘Signature of Qualified Medical Personnel Completing MSE’ was signed by Registered Nurse (RN) GG on 1/14/25 at 8:40 a.m. The medical record failed to include a memorandum of transfer form or documentation that copies of the medical record were provided to EMS. There was no documented evidence that Patient #11’s medical records were forwarded to the receiving physician and receiving hospital. There was no documentation in the medical record to indicate that the receiving hospital had the required specialized capability that Patient #11 required. There was no documented evidence that the receiving hospital agreed to accept the transfer of P#11 to provide the additional necessary medical intervention for the patient’s identified EMC. Continued review of the ‘A&R Clinical Note’ dated 1/14/25 at 10:05 a.m. revealed that P#11 was returned to the facility on 1/14/25 from the acute care facility. A review of the EMTALA Log revealed that P#13 arrived at the facility on 1/5/25 at 12:05 p.m. An Intake Assessment was initiated 1/5/25 at 3:35 p.m. by MLC KK with a chief complaint of medication needs related to psychosis and blood pressure. P#13 stated that he ran out of his medication, and his psychosis was getting worse. The EMTALA Medical Screening was initiated on 1/5/25 at 6:11 p.m. and the patient’s blood pressure was 183/108 mmHg. Continued review revealed that P#13’s blood pressure was re-checked after 45 minutes for 166/111. The nursing supervisor was informed, and P#13 was asked by the nursing supervisor to go to the emergency room (ER) for medical clearance related to his blood pressure. Further review revealed that the MSE was signed by Registered Nurse (RN) GG on 1/6/25 at 7:30 a.m. The record failed to reveal a discharge time. The medical failed to reveal how P#13 was transferred to another hospital. There was no documentation that a memorandum of transfer form was completed. There was no documented evidence in the medical record that the receiving hospital had the required specialized capabilities that this patient required. There was no documented evidence that the receiving hospital agreed to accept the transfer of P#13 to provide the additional necessary medical interventions to evaluate the patient’s elevated blood pressure. A review of the EMTALA Log revealed that P#15 arrived at the facility on 2/17/25 at 11:05 a.m. A review of the ‘Triage Information’ revealed that P#15 had a previous suicide attempt on 2/16/24 and a history of ‘abuse’ from 2008 through 2025 and stopped 2/13/25. The document failed to specify the substance. An Intake Assessment revealed that the patient exhibited paranoid ideations. Continued review revealed that at the time of the assessment, P#15 was alert and mood appropriate. He reported no current suicidal or homicidal ideations and no previous suicide attempts. The final disposition revealed that P#15 was sent out for medical clearance. EMTALA Medical Screening was initiated at 2:17 p.m. that revealed the chief complaint of ‘Attempted suicide by overdose’. P#15 reported taking 10-15 Abilify (medicine used for depression) pills. The ‘Signature of Qualified Medical Personnel Completing MSE’ was signed at 3:26 p.m. by a registered nurse. Further review of the ‘Disposition’ revealed that P#15 was sent out for medical clearance. A review of the ‘Memorandum to Transfer (Hospital to Hospital) revealed that P#15 was transported by his mother and partner. No documented evidence in the medical records indicated that portions of the medical record that were available and relevant to transfer were sent with the patient as stated in the facility’s transfer policy and procedure. The record failed to reveal a discharge time. A review of the facility policy titled ‘Transfer from Intake Department to another Facility’, Policy A&R #19, and last reviewed 1/25 revealed I part: “I. PROCEDURE A. Transfer shall be done with the knowledge and consent of the patient/legal guardian following evaluation by a qualified psychiatric/medical examiner or physician. B. A Psychiatric/Medical Screening Exam, Medical Screening Exam Certification and Consent for Transfer shall accompany the patient being transferred. C. The transfer shall be completed with knowledge of and arrangements made for acceptance by the receiving facility/physician. D. A petition shall accompany the patient when transfer is to another facility for acute psychiatric care. E. All efforts shall be made to complete a certificate to accompany the patient when transfer is to another facility for acute psychiatric care F. Transportation shall be by ambulance A review of facility’s policy number A&R 15, titled “MEMORANDUM OF TRANSFER” last reviewed on 1/2025 revealed following: This policy applies to all individuals who are present at RIS for emergency care and/or treatment. POLICY: A Memorandum of Transfer will be completed on all patients transferred outside the Hospital’s facilities ... Procedure: Responsibilities of Hospital Administration: ...Administration is responsible for the implementation and adherence to the hospital’s Transfer Policy & Procedure and Memorandum of Transfer form ... Transportation for Patient Transfers: Patients transferred to and from another hospital will be transferred by ambulance. Transfer of Patients with Emergency Medical Conditions: (A) If a patient at RIS has an emergency medical condition which has not been stabilized or when stabilization of the patient’s condition is not possible because RIS does not have the appropriate equipment or staff to correct the underlying condition, transfer shall be carried out as quickly as possible. Medical Record Requirements: (A) A Memorandum of Transfer must be completed for every patient transferred and must contain the following information: the patient’s full name if known; the patient’s ...physical handicap if known; the patient’s address and telephone number, if known; the names, addresses and telephone numbers of the transferring and receiving physicians; the time and date on which the patient first presented pr was presented to the transferring physicians; the time and date on which the transferring physician secured a receiving physician; signature, time, and title of the transferring hospital administration who contacted the receiving hospital; a Certification signed by the physician who includes a summary of the risks and medical benefits reasonably expected as a result of the transfer. (B) (Documentation on the Memorandum of the transfer form). The time and date on which the receiving physician assumed responsibility for the patient; ...type of vehicle and company used for transfer; type of equipment and personnel needed in transfers; name and city to which patient was transported; diagnosis by transferring physician; and attachments ( as noted on the Memorandum of Transfer form) by transferring hospital ...(C) A copy of the Memorandum of Transfer shall be retained by the transferring ...hospitals.” During an interview on 3/25/25, at 11:31 a.m. with Registered Nurse (RN) CC in a conference room, RN CC explained that MLC’s can transfer patients out but are required to consult with an RN or shift supervisor first. She said there are occasions when an MLC has transferred a patient out without consulting the RN. She added that the procedure for properly transferring a patient involves initiating a consultation with the RN and a provider to ensure a medical transfer is necessary, then completing a memorandum of transfer and an incident report. She stated that a copy of the patient’s medical record should be created, along with all the transfer forms, and sent with the patient. She added that when EMS arrives, whoever is transferring the patient should determine the facility to which the patient is being transferred, contact the command center, and provide a report on the patient to the ED charge nurse. An interview was conducted with Interim Assistant Chief Nursing Officer (ACNO) GG on 3/27/25 at 9:00 a.m. in the facility’s conference room. ACNO GG was not sure why a “Memorandum to transfer” and incident report not done on P#1 or P#11. ACNO GG acknowledged that there was no discharge information in the record for P#13 and P#15 and staff did not recall the reason a transfer was not done for these two patients. A telephone interview was conducted on 3/27/25 at 11:03 a.m. with Master Level Clinician (MLC) HH. MLC HH stated that if a patient needs to be transferred for medical clearance, she will consult with an RN to ensure the transfer is appropriate. Her responsibility in the transfer process is to make a copy of any relevant documents to send with the patient. The RN’s responsibility is to complete the Memorandum of Transfer (MOT) and call to give a report to the receiving hospital’s ED charge nurse. The facility failed to ensure that their policies and procedures were followed as evidenced by failing to ensure that appropriate transfer protocols were followed as stated in the facility’s policy and procedure for P#1, P#11, P#13, and P#15.”

“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: 40979 Based on a review of medical records, Governing Body Bylaws, governing body meeting minutes, incident log, incident reports, staff interviews, and facility policies, it was determined that the facility failed to have an effective Governing Body that provided oversight and was responsible for the quality assessment and performance improvement plan and safety of patients for 13 (P) (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#22, P#23) of 23 sampled patients involved in allegations of inappropriate sexual behavior or sexual assault. The facility’s Governing Body failed to ensure that policies on incident reporting were adhered to when allegations of inappropriate sexual behavior or sexual assault were not included on the facility’s incident log, were not investigated, and results were not reported through the facility’s established quality assessment and performance improvment processes. In addition, incident reporting policies were not adhered to when staff failed to document allegations in patient medical records. Findings included: A review of the Governing Body Bylaws, last approved 1/15/25, revealed Article III, Governing Board, Section 3.1: General Powers. The affairs of the facility are managed by the Governing Board. The Board is ultimately accountable for the quality of patient care, treatment and services. The Governing Board ensures the safety of patients, staff and others. The Governing Board upholds the Medical Staff By Laws, Rules and Regulations, the Credentialing Process and the policies that have been approved by the Governing Board. The Governing Board has oversight to ensure an ongoing program for performance improvement and risk management at the facility. A review of the Governing Body meeting minutes dated January 2024 through January 2025 failed to reveal a review or discussion of incidents/allegations of sexual assault. An interview was conducted with Chief Executive Officer (CEO) BB on 2/25/25 at 9:30 a.m. in the administration conference room. CEO BB stated that he came on board with the facility on September 1, 2024. He continued to explain that he was made aware of the alleged sexual assaults soon after coming aboard as the CEO. He continued to say that he did review reports that were documented in 2024 through 2025 thus far. CEO BB stated that he is a part of the Governing Body and attends the meeting every other month. He continued to explain that all serious assaults result in a thorough investigation including police reports and are reported through the Performance Improvement (PI) manager, then reported through the Medical Executive (MED Exec) Committee and then up to the Governing Body. CEO BB stated that he agrees with the current process for documenting and investigating each allegation that is reviewed by the Risk Management Director and her team. Cross refer to A-0043 as it relates to the facility’s failure to develop, implement, and maintain an effective quality assessment and performance improvement program.”

“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: 40979 Based on review of the facility’s incident log, policy and procedures and staff interviews it was determined that the facility failed to develop, implement and maintain an effective quality assessment and performance improvement program when it was determined that allegations of inappropriate sexual behavior and sexual assault were not tracked, were not investigated, and were not reported to the Governing Board. Seven incidents that involved 10 (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10) of 23 sampled patients were identified that were not included on the facility’s incident log and was not investigated by the facility. One incident that involved one (P#11) of 23 sampled patients was not investigated. Findings included: Cross -refer to A-0286 as it relates to the facility’s failure to track, trend, investigate and report to the Governing Body, allegations of inappropriate sexual behavior and sexual assault.”

“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: 40979 Based on review of the facility’s incident log, policy and procedures and staff interviews it was determined that the facility failed to ensure that adverse patient events were tracked and/or investigated for 11 (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11) of 23 sampled patients. Specifically, On 4/22/24, P#1 and P#2 were alleged to have a sexual encounter that was not included on the facility’s incident log and an investigation was not conducted. On 7/28/24, P#4 allegedly raped P#3 that was not included on the facility’s incident log and an investigation was not conducted. On 11/18/24, P#6 allegedly groped P#5 that was not included on the facility’s incident log and an investigation was not conducted. On 12/25/24, P#8 allegedly sexually assaulted P#7 that was not included on the facility’s incident log and an investigation was not conducted. On 12/27/24, P#8 allegedly sexually assaulted P#9 that was not included on the facility’s incident log and an investigation was not conducted. On 7/21/24, P#10 observed having inappropriate sexual activity with an unknown peer that was not included on the facility’s incident log and an investigation was not conducted. In December 2024, P#11 reported being raped by an unnamed person. The allegation was not investigated by the facility. Findings included: A review of the facility’s incident log for 1/1/24 through 2/28/25 failed to reveal the following: An entry involving P#1 and P#2 on 4/22/24. An entry involving P#3 and P#4 on 7/28/24. An entry involving P#5 and P#6 on 11/18/24. An entry involving P#7 and P#8 on 12/25/24. An entry involving P#8 and P#9 on 12/27/24. An entry involving P#10 on 7/21/24. A review of an incident report that involved P#11 failed to reveal that an investigation including witness statements was conducted. A review of the facility’s “Incident Reporting” policy, no policy number, last reviewed 1/2025 revealed I. Policy. The Incident Report is a mechanism for informing Administration of the occurrences of circumstances surrounding untoward events. An “Incident” is defined as any happening that is not consistent with the normal or usual operation of the hospital and/or department. Injury does not have to have occurred. The potential for injury and/or property damage is sufficient for an event to be considered an incident. III. Procedure. 1. Only the employee who is directly involved in the occurrence or incident, either through witnessing the event or being told by a visitor that an event has occurred, should initiate and document on the Incident Report form. This should be done immediately after the incident occurs (if witnessed) or as soon as one becomes aware of such an occurrence (receiving information from another person). 4. Instructions for completing the Incident Report form: E. The fully completed form should be signed, dated, timed, and forwarded immediately to the staff member’s supervisor for review and signature. 5. All occurrences involving patients should be charted in the patient’s medical records; no mention of the occurrence report should be made in the medical record. 6. The legal guardian must be notified of all unusual incidents. The information should be shared by the charge nurse unless a decision is made that it would be more appropriate by the therapist or physician. The report should be made ASAP and consent requested for any necessary follow-up. A review of the facility’s policy titled “Protection of Evidence from Assault,” Policy #RNP101, last reviewed/revised 1/2025, revealed the following: I. Policy. It is the policy of Ridgeview Institute-Smyrna (RIS) to ensure that evidence from assault is protected from destruction or tampering. II. Procedure. C. If a patient reports sexual assault, the unit RN will arrange to transfer patient to the ER as per physician orders. G. The patient’s legal guardian is to be notified of the allegation (if applicable) and the patient being sent to the ER. H. Documentation of the allegation, intervention to ensure the safety of the patient, and all notifications need to be placed in the medical record and a separate incident report is to be completed. A review of the facility’s policy titled “Grievances and the Patient Advocate,” Policy #RNP069, last revised 1/2025 revealed the following: It is the policy of the facility to encourage responsive and open communication with patients at all levels in the facility with the objective of resolving complaints and grievances through appropriate problem-solving actions. II. Procedure. 2. It is the responsibility of each staff member to respond promptly to any concern or grievance voiced by patients and others no matter how trivial the complaint may appear to be. The staff member receiving the complaint should notify his/her supervisor when the issue cannot be immediately resolved, or if there is an allegation of abuse or neglect, or patient right violation allegation. The Supervisor must respond immediately to ensure that the patient and /or patients are safe. 5. The patient has a right to the following: H. Be free from all forms of abuse and harassment. An interview was conducted with Risk Manager (RM) AA on 2/24/25 at 12:30 p.m. in the administration conference room. RM AA stated that she has been in her role for approximately three months and her responsibilities include managing the Patient Advocate role which reports up to her. She continued to explain that she is responsible for receiving and reviewing all incident reports. RM AA stated that the Patient Advocate will review and log all complaint and grievances reported and she will review and investigate all incidents that are serious in nature, such as sexual assault. RM AA stated that apart of her investigation includes pulling video footage from all the common areas as well as the hallways. She continued to explain that there are no cameras in the bedrooms or bathrooms however she will develop a timeline from video footage and interview staff as well as some residents, if the resident feels comfortable in speaking with her. She continued to explain that many of the assault cases are peer-to-peer and in these instances the peers have been able to be separated from one another to different units. She continued to explain that if a resident displays sexual aggression or sexually acting out (SAO) than the resident will be placed on SAO precautions with no roommate. An interview was conducted with Chief Executive Officer (CEO) BB on 2/25/25 at 9:30 a.m. in the administration conference room. CEO BB stated that he came on board at the facility on September 1, 2024. He continued to explain that he was made aware of the alleged sexual assaults soon after coming aboard as the CEO. He continued to say that he did review reports that were documented in 2024 through 2025 thus far. CEO BB stated that he is a part of the Governing Body and attends the meeting every other month. He continued to explain that all serious assaults resulting in a thorough investigation including police reports are reported through the Performance Improvement (PI) manager, then reported through the Medical Executive (MED Exec) Committee and then up to the Governing Body. CEO BB stated that he agrees with the current process for documenting and investigating each allegation that is reviewed by the Risk Management Director and her team. An interview was conducted with Regional Director (RD) CC on 2/25/25 at 9:45 a.m. in the administration conference room. RD CC stated that she was involved in the allegations of assault from August of 2024 through the present. She continued to explain that prior to August 2024 when a new process and procedure was implemented the previous Chief Operating Officer (COO) was expected to document and investigated each allegation and the expectations were not being met and therefore he was relieved of his duty at the facility as of August 2024. RD CC stated that when the recent news story was reported she was personally involved in the investigation and communication with the local police department for the seven allegations reported of sexual assault. RD CC confirmed that there was one male patient who was named in an alleged sexual assault arrested on site and his case is still open and under investigation. RD CC confirmed that all serious allegations of assault requiring a thorough investigation and police involvement is reported to the Medical Executive Committee and the Governing Body. RD CC stated that she is in the process of attempting to find any investigative documentation left by COO prior to his termination.”