Neuropsychiatric Hospital of Indianapolis, LLC

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to complete initial discharge assessment and discharge planning in 1 of 10 (patient 2) medical records reviewed. Findings include: 1. Facility policy titled Therapist’s Responsibilities, PolicyStat ID 12197157, last approved 08/2022, indicated under Policy, 1. Complete the initial evaluation of all patients assigned within 72 hours, within normal business hours. In circumstances when the therapist is not available, the Department Director will designate another primary therapist to do so. 2. Facility policy titled, Discharge Planning, last approved 03/2024, indicated under Documentation: The Social Worker documents discharge information on social service notes and the Master Treatment Plan utilized by the multidisciplinary team. 3. Review of patient 2’s medical record indicated the following: a. The patient was admitted on 04/27/2026. b. Medical record lacked documentation of the initial evaluation, initial data collection, biophysical assessment, and discharge planning. c. The patient was discharged on 05/03/2026. 4. Interview with A1 on 06/23/2026 at approximately 4:06 p.m. confirmed patient 2’s medical record lacked documentation of the initial biophysical assessment, evaluation, and discharge planning.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing failed to note and transcribe provider orders for 1 of 10 (patient 2) medical records reviewed and failed to notify provider of change in patient’s condition in 1 of 10 (patient 2) medical records reviewed. Findings include: 1. Facility policy titled, Physician Orders/Receipt and Notation, last approved on 09/2022, indicated under Procedure, 5. Provider orders are to be noted and transcribed by RNs, LPNs, or Pharmacists., 6. Noting includes transcriptions of medications and notification of other departments (i.e. laboratory; medical imaging; etc.). 2. Facility policy titled, Provider Communication, Policy ID: 92275841, last approved 01/2025, indicated under Process: 1. Indications for Provider Notification: Providers must be notified promptly for: Changes in Condition, Abnormal vital signs, Refusal of medication, and Refusal of nutrition. 3. Review of patient 2’s MR indicated the following: a. The patient was admitted on 02/12/2026. Admission orders indicated the following laboratory tests: complete blood count, thyroid stimulating hormone (TSH), complete metabolic panel (CMP), Hemoglobin A1C, Lipid Panel, Depakote level. Medical record lacked documentation laboratory tests were drawn. Medical record indicated the patient’s admission weight was 137.8 pounds. b. On 02/15/2026, daily nursing assessment indicated patient’s weight was 129.6 pounds, an 8 pound loss in 4 days. Medical record lacked documentation of provider notification of patient weight loss. c. On 02/26/2026, medical record indicated the provider ordered the following laboratory tests: complete blood count, complete metabolic panel, Lipid Panel, and Urinalysis. Medical record lacked documentation laboratory tests were drawn. d. On 02/27/2026, psychiatric provider note indicated notified medical provider labs that were ordered yesterday were not collected. 3. Interview with A3 on 05/15/2026 at approximately 9:40 a.m. confirmed patient 2’s MR lacked documentation that patient admission laboratory tests and laboratory tests ordered on 02/24/2026 were drawn.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48704 Based on document review and interview, nursing failed to notify the provider for medications held or not administered in 4 of 11 patients (Patient 3, 4, 10, and 11) medical records reviewed, failed to administer scheduled medications per order in 4 of 11 patients (Patient 3, 4, 10, and 11) medical records reviewed, and failed to document and obtain order for home medication use in 1 of 11 (Patient 3) medical records reviewed. The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing failed to document patient belongings were returned to patients upon discharge in 9 of 11 patient (Patients 1, 2, 3, 4, 5, 6, 7, 9, and 10) medical records reviewed, failed to document shower/hygiene care in 5 of 11 patients (Patient 1, 2, 3, 4, and 5) medical records reviewed, failed to notify the provider for medications held or not administered in 4 of 11 patients (Patient 3, 4, 10, and 11) medical records reviewed, failed to administer scheduled medications per order in 4 of 11 patients (Patient 3, 4, 10, and 11) medical records reviewed, and failed to document and obtain order for home medication use in 1 of 11 (Patient 3) medical records reviewed. Findings include: 1. Facility policy titled, Patient Care Management, PolicyStat ID 12197166, last approved 08/2022, indicated under Medication Administration, 3. Scheduled doses will be administered as ordered. and under 4. Medications refused or withheld will be documented on the MAR with reason identified. 2. Facility policy titled, Provider Communication, PolicyStat ID 92275841, last approved 01/2025, indicated under Process, 1. Indications of Provider Notification: Providers must be notified promptly for: Refusal of medication. Under 3. Documentation Requirements: Record all attempts to notify providers, including: Date and time of each attempt. Provider (s) contacted. Outcome of each notification attempt. Instructions or orders received, if applicable. 3. Facility policy titled, Medications Brought In With Patients, Annual Review 02/2025, indicated under Procedures, 3. Admission procedures: the admission nurse receives the patient own medications brought into the hospital. A physical inventory and count will be completed for controlled substances (and signed off by a witness). Non-controlled substances will be documented but a count is not needed. The nurse will follow hospital policy regarding recording keeping documentation. POMs will be placed in a sealed bag with a security tag. The security tag is stored in the patient’s medical chart. It is recommended that a picture of medications brought into the hospital is downloaded into the electronic medical record. 4. Storage of Patient Own Medications: All medications are stored in the nursing medication room where the patient is located. Two security measures must be used, a. In use and with a provider order: 4. Facility policy titled, Physician Orders/Receipt and Notation, last approved 08/2022 indicated under Procedure, 1. Provider orders will be received in a written or telephone format from a credentialed provider. Provider orders are to be dated, timed, and signed. 2. Provider telephone orders may be accepted by an RN, LPN or Pharmacist. Telephone orders are to be verified by a “read back and verified” system. The orders are to be read back to the provider who verbalized the orders, by the individual receiving the orders. Documentation of the “read back” verification process will be indicating utilizing Telephone Order Read Back “TORB” as part of the written order. Provider telephone orders are to be dated, timed and signed. 5. Facility policy titled, Patient Personal Care, PolicyStat ID 12197137, last approved 08/2022, indicated under General Care, All patients shall be encouraged or assisted in grooming daily or more often as needed. Grooming articles such as soap, shampoo, shaving equipment, etc., are available per patient need. 6. Review of patient 10’s medical record indicated the following: a. The patient was admitted on 02/20/2026. Medication reconciliation indicated the patient was to continue Insulin Lispro, indication Type 2 Diabetes Mellitus, 2 units SubQ before each meal daily and Insulin Glargine, indication Type 2 Diabetes Mellitus, 18 units SubQ twice a day (BID). Provider ordered and signed Facility #1’s sliding scale hyperglycemia and hypoglycemia protocol. b. On 02/21/2026, patient’s blood glucose (BG) was 70 at 7:30 a.m., 180 at 11:30 a.m., and 126 at 4:30 p.m. medication administration record indicated patient was not administered scheduled doses of Lispro 2 units before meals and was marked as held at the 7:30 a.m. dose, the 11:30 a.m. dose, and the 4:30 p.m. dose. MR lacked documentation provider was notified. c. On 02/22/2026, patient’s BG was 106 at 7:30 a.m., 100 at 11:30 a.m., and 306 at 4:30 p.m. Medication administration record indicated that patient was not administered scheduled doses of Lispro 2 units before meals and was marked as held at the 7:30 a.m. dose, the 11:30 a.m. dose, and the 4:30 p.m. dose and was not administered scheduled doses of Glargine 18 units and marked held at 9:00 a.m. and 9:00 p.m. MR lacked documentation provider was notified. d. On 02/23/2026 patient’s BG was 169 at 7:30 a.m., 531 at 11:30 a.m., 463 at 4:30 p.m. 405 at 9:00 p.m. Medication administration indicated patient was not administered scheduled doses of Lispro 2 units before meals and marked as held at the 7:30 a.m. dose, the 11:30 a.m. dose, and the 4:30 p.m. dose and not administered scheduled doses of Glargine 18 units and marked held at 9:00 a.m. and 9:00 p.m. MR lacked documentation provider was notified. e. On 02/24/2026 patient’s BG was 176 at 7:30 a.m., 332 at 11:30 a.m., and 364 at 2:30 p.m. The patient was transferred to the emergency department for further evaluation for elevated blood glucose. f. MR indicated the Patient Personal Effects Inventory form lacked documentation of the staff and witness signature, date, and time indicating the patient received their personal belongings at discharge. g. The patient did not return to facility and was admitted for hyperglycemia. 7. Review of Patient 4’s medical record indicated the following: a. The patient was admitted on 01/23/2026. Medication reconciliation indicated patient was to continue Insulin Aspart, indication Type 2 Diabetes Mellitus, 7 units subcutaneously (SubQ) with meals daily and Lantus, indication Diabetes Mellitus, 15 units SubQ at bedtime (QHS) daily. Provider ordered and signed the sliding scale hyperglycemia and hypoglycemia protocol. b. On 01/24/2026, provider order indicated to change Insulin Lispro to Insulin Lispro 7 units SubQ with meals. MAR lacked documentation of administration of Insulin Lispro 7 units at 7:30 a.m. and 11:30 a.m. and provider notification of missed medication administration. Provider orders at 2:50 p.m. indicated the following medication substitution: Insulin Lispro 7 units SubQ with each meal daily substituted with Lispro 7 units SubQ with each meal daily. Provider orders at 3:06 p.m. indicated Insulin sliding scale for extra units to be administered with meals with scheduled dose of Lispro as follows: blood sugar (BG) greater than 200 to 300, administer 2 units of Lispro SubQ, BG of 301 to 400, administer 4 units of Lispro SubQ, BG of 401 to 500, administer 6 units of Lispro SubQ. MAR lacked documentation of Lispro 7 units at 4:30 p.m.; medical record lacked documentation provider notification of missed medication administration. The patient’s BG ranged from 76 to 116; no critical values and no indication for sliding scale coverage. c. On 01/28/2026, MAR indicated Lispro 7 units SubQ was refused at the 12:00 p.m. dose and the 5:00 p.m. dose; medical record lacked documentation of provider notification medication was refused. The patient’s BG ranged from 91 to 141; no critical values and no indication for sliding scale coverage. d. The MAR indicated Lispro 7 units SubQ was not administered and was marked held at the 7:00 a.m. dose, 12:00 p.m. dose, and 5:00 p.m. dose on each of the following days: 01/25/2026, 01/26/2026, 01/27/2026, 01/28/2026, 01/29/2026, 01/30/2026, 01/31/2026, 02/01/2026, and 02/02/2026. The patient’s BG ranged from 79 to 164; no critical values and no indication for sliding scale coverage. Medical record lacked documentation of provider notification of held medications and lacked provider order to hold medications. b. Medical record lacked documentation of a complete shower/care sheet on 01/24/2026, 01/25/2026, 01/27/2026, 01/28/2026, 01/29/2026, 01/30/2026, 01/31/2026, and 02/03/2026. c. Medical record indicated the Patient Personal Effects Inventory form lacked documentation of the staff and witness signature, date, and time indicating the patient received their personal belongings at discharge. d. The patient was discharged on 02/03/2026. 8. Review of patient 11’s medical record indicated the following: a. The patient was admitted on 04/03/2026. b. On 04/04/2025, medication reconciliation indicated patient was to continue Jardiance, indication Type 2 Diabetes Mellitus, 10 mg PO three times day (TID). The MAR indicated Jardiance 10 mg TID was not administered and was marked not available for the 2:00 p.m. dose and 9:00 p.m. dose on 04/04/2026. The patient’s BG ranged from 94 to 151; no critical values and no indication for sliding scale coverage. Medical record lacked documentation of provider notification of lack of medication availability. c. The MAR indicated Jardiance 10 mg PO was not administered and was marked not available for the 9:00 a.m. dose, the 2:00 p.m. dose, and the 9 p.m. dose on 04/05/2026 and 04/06/2026, and the 9:00 a.m. dose on 04/07/2026. The patient’s BG ranged from 69 to 115; no critical values and no indication for sliding scale coverage. Medical record lacked documentation of provider notification of lack of medication availability. 9. Review of Patient 3’s medical record indicated the following: a. The patient was admitted on 01/22/2026. b. On 01/23/2026, medication reconciliation indicated to continue Guanfacine HCl (hydrochloride), indication: Attention-Deficit Hyperactivity Disorder, 4 milligrams (mg) by mouth (PO) at bedtime and Ciclopirox topical, indication: Onychomycosis, apply every day. Provider orders indicated to start Atomoxetine, indication: Attention-Deficit hyperactivity Disorder, 60 mg PO every morning. c. On 01/24/2026, the medication administration record (MAR) indicated Ciclopirox was not available; Medical record lacked documentation of provider notification. d. On 01/25/2026, MAR indicated the patient was not administered Atomoxetine 60 mg and indicated Ciclopirox was not available; MR lacked documentation of provider notification. On 01/26/2026, MAR indicated Ciclopirox was not available; Medical record lacked documentation of provider notification. e. On 01/27/2026, MAR indicated the patient was not administered Atomoxetine 60 mg and indicated Ciclopirox was not available; Medical record lacked documentation of provider notification. f. On 01/29/2026, provider orders indicated to start Lexapro, indication depression, 20 mg PO daily. MAR indicated the patient was not administered the scheduled doses of Lexapro 20 mg and Guanfacine HCl 4 mg; Medical record lacked documentation of provider notification. f. On 01/30/2026, MAR indicated the patient was not administered the scheduled doses of Lexapro 20 mg and Guanfacine HCl 4 mg; Medical record lacked documentation of provider notification. g. MAR indicated Atomoxetine HCl was located in patient’s home medication bin; MR lacked documentation of medication received by Facility #1 and the provider order to take patient’s own medication. h. Medical record lacked documentation of a complete shower/care sheet on 01/24/2026, 01/25/2026, 01/26/2026, 01/27/2026, 01/28/2026, 01/29/2026, 01/31/2026, 02/01/2026, 02/02/2026, 02/03/2026, and 02/04/2026. i. Medical record indicated the Patient Personal Effects Inventory form lacked documentation of the staff and witness signature, date, and time indicating the patient received their personal belongings at discharge. j. The patient was discharged on 02/05/2026. 10. Review of patient 1’s medical record indicated the following: a. The patient was admitted on 01/03/2026.. b. Medical record lacked documentation of a complete shower/care sheet on 01/05/2026, 01/06/2026, 01/10/2026, 01/11/2026, 01/12/2026, 01/15/2026, 01/18/2026, 01/19/2026, 01/20/2026, 01/21/2026, 01/25/2026, and 01/27/2026. c. Medical record indicated the Patient Personal Effects Inventory form lacked documentation of the staff and witness signature, date, and time indicating the patient received their personal belongings at discharge. d. The patient was discharged on 01/29/2026. 11. Review of patient 2’s medical record indicated the following: a. The patient was admitted on 01/20/2026. b. Medical record lacked documentation of a complete shower/care sheet on 01/24/2026, 01/25/2026, 01/26/2026, 01/27/2026, 01/28/2026, 01/29/2026, 01/30/2026, 01/31/2026, 02/02/2026, 02/03/2026, and 02/04/2026. c. Medical record indicated the Patient Personal Effects Inventory form lacked documentation of the staff and witness signature, date, and time indicating the patient received their personal belongings at discharge. d. The patient was discharged on 02/04/2026. 12. Review of Patient 5’s medical record indicated the following: a. The patient was admitted on 01/26/2026. b. Medical record lacked documentation of a complete shower/care sheet on 01/27/2026, 01/28/2026, 01/29/2026, 01/30/2026, and 01/31/2026. c. Medical record indicated the Patient Personal Effects Inventory form lacked documentation of the staff and witness signature, date, and time indicating the patient received their personal belongings at discharge. d. The patient was discharged on 02/03/2026. 13. Review of Patient 6’s medical record indicated the following: a. The patient was admitted on 02/03/2026. b. On 02/04/2026, nursing note at 8:00 p.m. indicated the patient’s blood pressure was 162/107 and provider was notified; provider ordered one time dose of Clonidine 0.1 milligrams (mg) by mouth (PO) which was administered at 9:00 p.m. Patient’s blood pressure at 11:50 p.m. was 168/116 and the patient indicated they had pain in their chest. Provider notified and patient was transferred to the emergency room for further evaluation. MR lacked documentation of a provider order to transfer the patient to the emergency room and lacked documentation of Facility #1’s (Acute Psychiatric Facility) transfer form. c. Medical record indicated the Patient Personal Effects Inventory form lacked documentation of the staff and witness signature, date, and time indicating the patient received their personal belongings at discharge. d. The patient was discharged on 02/04/2026. 14. Review of Patient 7’s medical record indicated the following: a. The patient was admitted on 02/05/2026. b. Medical record lacked documentation of a Patient Personal Effects Inventory form. c. The patient was discharged on 02/06/2026. 15. Review of patient 9’s medical record indicated the following: a. The patient was admitted on 02/08/2026. b. Medical record indicated the Patient Personal Effects Inventory form lacked documentation of the staff and witness signature, date, and time indicating the patient received their personal belongings at discharge. c. The patient was discharged on 02/16/2026. 16. Interview with P1 (Nurse Practitioner) on 04/06/2026 at approximately 12:30 p.m. confirmed nursing staff cannot hold medications without notifying the provider and would need to obtain a provider order to hold medication. 17. Phone interview with N2 (Licensed Practical Nurse) on 04/07/2026 at approximately 12:40 p.m. indicated they recalled the patient 10; N2 indicated they were unable to answer why they did not give the patient their scheduled insulin. N2 indicated they should have called the provider. 18. Interview with A1 (Director of Quality and Risk) on 04/07/2026 at approximately 12:40 p.m. confirmed the lack of signature on the Patient Personal Effects Inventory Form for patients 1, 2, 3, 4, 5, 6, 7, 9, and 10 indicating patient received their belongings at time of discharge; confirmed incomplete documentation on the Facility #1’s shower/care sheet in patient 1, 2, 3, 4, and 5; confirmed held and missed medication administrations, lack of provider notification, and lack of provider orders to hold medications for patients 3, 4 and 10; confirmed lack of provider order for patient to take home medications for patient 3; confirmed lack of transfer order or transfer form for patient 6; confirmed there was not an incident form for completed for patient 10’s transfer on 02/24/2026. Interview with A1 at approximately 3:30 p.m. confirmed lack of documentation in medical record of provider notification of unavailability of medication, provider orders to hold or discontinue medication for patient 11.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing failed to complete an incident report for a emergent transfer of a patient in 1 of 2 (Patient 10) transferred patients reviewed. Findings include: 1. Facility policy titled, Incident Reports, PolicyStat ID 13033981, last approved 01/2023, indicated under Purpose: It is the policy of the hospital to support a culture of shared accountability for the identification, reporting and management of patient events that may impact the quality of care provided. An Incident is defined as: any event which is not consistent with the routine operation of the hospital and that adversely affects or threatens to affect the well-being of the patients, employees, medical staff, visitors, consultants, or property of, regardless of whether an actual injury is involved or not. Any hospital staff member who witnesses, discovers or has direct involvement in and/or knowledge of an event must complete an incident report, or give a detailed report to the person completing the incident report. 2. Review of Incident Reports lacked documentation of an incident report for patient 10’s transfer on 02/24/2026. 3. Review of patient 10’s MR indicated the following: a. The patient was admitted on 02/20/2026. b. On 02/24/2026, patient’s blood sugar was 176 at 7:30 a.m. and nursing note indicated patient was administered scheduled dose of Lispro 2 units. Nursing note indicated patient’s blood sugar at 11:30 was 332, patient had not eaten lunch, and patient was slightly lethargic. Nurse notified provider and administered 6 units of Lispro per sliding scale. At 3:00 p.m. patient’s blood sugar was 364, provider notified and ordered to send patient to emergency department (ED) for evaluation. Emergency medical services arrived at 3:15 and patient was transferred to ED for further evaluation. 4. Interview with A1 (Director of Quality and Risk) on 04/07/2026 at approximately 12:40 p.m. confirmed there was not an incident form for completed for patient 10’s transfer on 02/24/2026.”

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to ensure that a transfer order was written in 1 of 11 (Patient 6) medical records reviewed. Findings include: 1. Facility policy titled Physician Orders/Receipt and Notation, last approved 08/2022, indicated under Procedure, 1. Provider orders will be received in a written or telephone format from a credentialed provider. Provider orders are to be dated, timed, and signed. 2. Provider telephone orders may be accepted by an RN, LPN or Pharmacist. Telephone orders are to be verified by a “read back and verified” system. The orders are to be read back to the provider who verbalized the orders, by the individual receiving the orders. Documentation of the “read back” verification process will be indicating utilizing Telephone Order Read Back “TORB” as part of the written order. Provider telephone orders are to be dated, timed and signed. 2. Review of Patient 6’s medical record indicated the following: a. The patient was admitted on 02/03/2026. b. On 02/04/2026, nursing note at 11:50 p.m. indicated patient’s blood pressure was elevated and patient reported chest pain, provider notified and indicated orders received to send patient out for further evaluation. Medical record lacked documentation of a provider order to transfer the patient to the emergency room. 3. Interview with A1 (Director of Quality and Risk) on 04/07/2026 at approximately 12:40 p.m. confirmed patient 6’s medical record lacked documention of transfer order.”

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 48704 Based on document review and interview, pharmacy failed to provide prescribed medications for 2 of 11 patient (patients 3 and 11) medical records reviewed. Findings include: 1. Facility policy titled, Therapeutic Interchange and Substitution, Origination Date 03/2024, indicated under 4.0 Procedure: 4.3 A physician may ask for an item only when such a product is best for an individual patient-specific disorder. The physician must put “medically necessary” on the order and complete a medication exception request form. These non-formulary items may require up to forty eight (48) hours in order to obtain the product. 2. Facility policy titled, Medications Brought In With Patients, Annual Review 02/2025, indicated under Procedures, 3. Admission procedures: the admission nurse receives the patient own medications brought into the hospital. A physical inventory and count will be completed for controlled substances (and signed off by a witness). Non-controlled substances will be documented but a count is not needed. The nurse will follow hospital policy regarding recording keeping documentation. POMs will be placed in a sealed bag with a security tag. The security tag is stored in the patient’s medical chart. It is recommended that a picture of medications brought into the hospital is downloaded into the electronic medical record. 4. Storage of Patient Own Medications: All medications are stored in the nursing medication room where the patient is located. Two security measures must be used, a. In use and with a provider order: 3. Review of patient 11’s medical record indicated the following: a. The patient was admitted on 04/03/2026. b. On 04/04/2025, medication reconciliation indicated patient was to continue Jardiance, indication Type 2 Diabetes Mellitus, 10 mg PO three times day (TID). The MAR (medication administration record) indicated Jardiance 10 mg TID was not administered and was marked not available for the 2:00 p.m. dose and 9:00 p.m. dose on 04/04/2026. Medical record lacked documentation of provider notification of lack of medication availability. c. The MAR indicated Jardiance 10 mg PO was not administered and was marked not available for the 9:00 a.m. dose, the 2:00 p.m. dose, and the 9 p.m. dose on 04/05/2026 and 04/06/2026, and the 9:00 a.m. dose on 04/07/2026. Medical record lacked documentation of provider notification of lack of medication availability. 4. Review of Patient 3’s medical record indicated the following: a. The patient was admitted on 01/22/2026. b. On 01/23/2026, medication reconciliation indicated to continue Ciclopirox topical, indication: Onychomycosis, apply every day. Provider orders indicated to start Atomoxetine, indication: Attention-Deficit hyperactivity Disorder, 60 mg PO every morning. c. On 01/25/2026, MAR indicated the patient was not administered Atomoxetine 60 mg and indicated Ciclopirox was not available; MR lacked documentation of provider notification. d. On 01/26/2026, MAR indicated Ciclopirox was not available; Medical record lacked documentation of provider notification. e. On 01/27/2026, MAR indicated the patient was not administered Atomoxetine 60 mg and indicated Ciclopirox was not available; Medical record lacked documentation of provider notification. f. MAR indicated Atomoxetine HCL (hydrochloride) was located in patient’s home medication bin; MR lacked documentation of medication received by Facility #1 and the provider order to take patient’s own medication. g. The patient was discharged on 02/05/2026. 5. Interview with A5 (Pharmacist) on 04/06/2026 at approximately 2:20 p.m. confirmed that scheduled insulin is a time critical medication per policy. A5 indicated they could not recall if patient 3 had medications from home but would be indicated on the medication administration record. A5 indicated if a home medication is brought in, pharmacy verifies the order, creates a new label, inputs it into the system to print on the MAR which indicates that the medication is in the patient’s designated drawer in medication room on patient’s respective unit and MAR would indicate medication was in the medication drawer. 6. Interview with A5 on 04/07/2026 at approximately 3:00 p.m. indicated that the medication was reconciled by pharmacy and a form was in the nurse’s station to inform the provider the medication was unavailable. A5 confirmed the form lacked documentation the provider had acknowledged the form. 7. Phone interview with P1 (Nurse Practitioner) on 04/07/2026 at approximately 3:14 p.m. indicated that staff reported on 04/06/2026 Jardiance was not in stock. P1 indicated they recalled providing an order to discontinue Jardiance for patient 11; unable to recall if it was written or verbal order. P1 indicated they were not aware of the process of pharmacy form notification. 8. Interview with A1 (Director of Quality and Risk) on 04/07/2026 at approximately 12:40 p.m. confirmed held and missed medication administrations, lack of provider notification, and lack of provider orders to hold medications for patients 3 and confirmed lack of provider order for patient to take home medications for patient 3. Interview with A1 at approximately 3:30 p.m. confirmed lack of documentation in medical record of provider notification of unavailability of medication, provider orders to hold or discontinue medication for patient 11.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing services failed to notify the provider of medications held, failed to document intravenous medications administered, failed to ensure a nutritional consultation was completed, failed to notate 6 of 9 provider orders, and failed to ensure patient medication reconciliation was completed in 1 of 10 patients (Patient 6) medical records reviewed. Findings include: 1. Facility policy titled, Standardized Medication Administration, PolicyStat ID: 12197198, last approved 08/2022, indicated under General Knowledge, B. All medications administered will be recorded in the patient’s Medication Administration Record (MAR) including the initials of the person administering the medication. 2, Facility policy titled Medication Reconciliation (Admission and Discharge Medications), PolicyStat ID 12197197, last approved 01/2025, indicated under Medication Reconciliation Procedure: B. The provider must order each drug, dosage, etc. by written or verbal order. Those medications, which match these orders, are considered to be reconciled and a check should be placed in the “(admit) Continue” box. 3. Facility policy titled Hypertensive Medication and Hold Parameters, PolicyStat ID 65480035, last approved 01/2025, indicated under Procedure: 2. Hold parameters for Hypertensive Medications: Medication is to be held if: SBP equal to or less than 100 mmHg and/or HR less than 60 bpm. Medication must be withheld if one or both conditions apply. Provider Notification: Notify the provider immediately of any abnormal findings. Documentation must include: Provider notification, Orders received (e.g. “Give medication”, “Hold medication”, “Recheck vitals”), any follow-up actions taken. 4. Review of Patient 6’s medical record indicated the following: a. The patient was admitted on 09/23/2025 for agitation, confusion, refusing to take medications and recent cognitive changes in the past 48 hours. b. On 09/25/2025, provider ordered a nutritional consultation; medical record lacked documentation of a nutritional consultation; provider orders lacked date and time of nursing notation. c. On 09/27/2025, the medical record indicated the provider ordered intravenous (IV) fluids for dehydration; Nursing note at 12:30 p.m. indicated IV placed, patient tolerated well. Medication administration record lacked documentation of the IV fluids that were administered, start time of IV fluid administration, and end time when administration infusion was complete. Nursing note at 6:30 p.m. indicated patient refused to dinner, patient weak but alert, provider notified, and order received to transfer patient for further evaluation and treatment. Patient transferred at 6:50 p.m. to Facility #2 (Acute Care Facility). Three provider orders lacked date and time of nursing notation, one provider order lacked documentation of date, time, and signature of nursing notation. d. On 09/28/2025, the medical record indicated patient returned from Facility #2 and the patient was treated for dehydration. The medication administration record indicated on 09/28/2025, ordered Norvasc 10 mg and Toprol-XL 50 mg were held; did not meet facility’s policy parameters to hold for a systolic blood pressure equal to or less than 100 and/or heart rate less than 60. Medical record indicated patient’s blood pressure was 118/74 and pulse was 87. Medical record lacked documentation of provider notification. e. On 09/29/2025. the medication administration record indicated on 09/29/2025, ordered Norvasc 10 mg and Toprol-XL 50 mg were held and did not meet facility’s policy parameters of systolic blood pressure equal to or less than 100 and/or heart rate less than 60. Medical record indicated patient’s blood pressure was 109/73 and pulse was 107. Medical record lacked documentation of provider notification. Medical record indicated the provider ordered intravenous fluids for lethargy; nursing note at 8:50 a.m. indicated IV started successfully and running patent. Medication administration record lacked documentation of the IV fluids that were administered, start time of IV fluid administration, and end time when administration infusion was complete. Provider order lacked documentation of date, time, and signature of nursing notation. Nursing note at 10:55 a.m. indicated patient became more lethargic, order received to transfer patient for further evaluation and treatment. Patient was transferred at 11:07 a.m. to Facility #2. Nursing note at 2:00 p.m. Facility #2 indicated patient was admitted with a diagnosis of stroke. Patient did not return to Facility #1 (Psychiatric Care Facility). 5. Interview with A3 (Director of Quality and Compliance) and A4 (Director of Nursing) 11/03/2025 at approximately 3:10 p.m. confirmed the following: a. Patient 6’s medication administration record indicated on 09/28/2025 and 09/29/2025 that the patient’s ordered Norvasc 10 mg PO and Toprol-XL 50 mg PO were held; and patient’s vital signs did not meet the parameters to hold medication and medical record lacked documentation of provider notification. b. Patient was administered intravenous fluids on 09/27/2025 and 09/29/2025. Medication administration record lacked documentation of intravenous fluid administration. c. Medication Reconciliation Form lacked documentation of which home medications were ordered and provider signature. d. The following dates for provider orders lacked documentation of complete nursing notation: 09/25/2025, all provider orders on 09/27/2025, and 09/29/2025.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing services failed to document patient belongings upon admission and discharge in 6 of 10 (Patients 1, 2, 4, 5, 6, and 7) medical records reviewed; failed to notify the provider for medications not administered for 5 of 10 (Patient 1, 2, 5, 7, and 10) medical records reviewed ; and failed to accurately complete the daily fall risk assessment in 1 of 10 (Patient 6) medical records reviewed. Findings include: 1. Facility policy titled, Management of Patient Belongings, PolicyStat ID 13950524, last approved 07/2023, indicated under Procedure: Admission, 4. Upon admission, staff will inventory all patient belongings, and sign the Personal Belongings Inventory Form. Patient will then sign the form. 2. Facility policy titled, Standardized Medication Administration, PolicyStat ID 12197198, last approved 08/2022, indicated under General Knowledge, E. All medications will be administered within one hour (before or after) of administration time or physician will be notified with reason medication not administered and an incident report will be completed if needed. 3. Review of Patient 1’s medical record indicated the following: a. The patient was admitted on 03/21/2025. b. On 03/13/2025, the MR indicated medication reconciliation was completed and the provider ordered for home medications to be continued which included the following medications: Toprol XI 100 mg (milligram) PO (by mouth) daily, Protonix 40 mg PO daily, Miralax 17 grams PO daily, Seroquel 50 mg PO BID (twice a day). c. On 04/01/2025, the medication administration record (MAR) indicated the patient was not administered their 9:00 a.m. scheduled medications which included the following: Toprol XI 100 mg PO, Protonix 40 mg PO, Miralax 17 grams PO, and Seroquel 50 mg PO; the nursing note lacked documentation the provider was notified the above medications were not administered. d. MR indicated the Patient Personal Effects Inventory form lacked documentation of the patient’s or witness signature, date, and time upon admission and documentation indicating the patient received their personal belongings upon discharge. e. The patient was discharged on 04/08/2025. 4. Review of Patient 2’s medical record indicated the following: a. The patient was admitted on 12/02/2024. b. On 12/02/2024, the medical record indicated medication reconciliation was completed and the provider ordered for Vraylar 3 mg PO daily to be continued during patient’s hospitalization. c. The medication administration record indicated Vraylar 3 mg PO was not available on the following dates and were not administered to the patient: 12/18/2024 through 12/25/2024, 01/01/2025, 01/06/2025, 01/08/2025, 01/10/2025, 01/13/2025, 01/15/2025 through 01/25/2025, 01/27/2025, 01/28/2025, 02/03/2025, 02/05/2025, 02/11/2025, 02/19/2025, 02/24/2025, 02/26/2025 through 03/03/2025, and 03/05/2025 through 03/11/2025. The medication administration record lacked documentation of administration, refusal, or medication not available on the following dates: 01/29/2025 through 02/02/2025, 02/04/2025, and 03/12/2025. Medical record lacked documentation in the nursing notes of provider notifications that the medication was not available nor that the medication was not administered to the patient. d. MR lacked documentation of the Patient Personal Effects Inventory form. e. The patient was discharged on 03/13/2025. 5. Review of Patient 4’s medical record indicated the following: a. The patient was admitted on 02/25/2025. b. MR lacked documentation of the Patient Personal Effects Inventory form. c. The patient was discharged on 03/03/2025. 6. Review of Patient 5’s medical record indicated the following: a. The patient was admitted on 03/13/2025. b. On 03/13/2025, the MR indicated medication reconciliation was completed and the provider ordered for home medications to be continued which included the following medications: Toprol XI 100 mg PO daily, Protonix 40 mg PO daily, Miralax 17 grams PO daily, Seroquel 50 mg PO BID. c. On 03/24/2025, the medication administration record (MAR) indicated the patient was not administered their 9:00 a.m. scheduled medications which included the following: Toprol XI 100 mg PO, Protonix 40 mg PO, Miralax 17 grams PO, and Seroquel 50 mg PO; the nursing note lacked documentation the provider was notified the above medications were not administered. d. MR lacked documentation of the Patient Personal Effects Inventory form. e. The patient was discharged on 03/26/2025. 7. Review of Patient 6’s medical record indicated the following: a. Patient was admitted on 03/28/2024. The medical record indicated the patient’s admission assessment fall risk assessment was marked low to moderate risk with a score of 75 using the Morse Fall Scale. The Morse Fall Scale indicates a score greater than 45 is high risk. b. Medical record indicated the patient’s day shift fall risk assessment was marked low to moderate risk on 03/18/2025, 03/22/2025, and 03/25/2025 with a score of 90 for all dates using the Morse Fall Scale. The Morse Fall Scale indicates a score greater than 45 is high risk. c. Medical record indicated the patient’s day shift fall assessment was marked no risk on 03/28/2025 with a score of 65 using the Morse Fall Scale. The Morse Fall Scale indicates a score greater than 45 is high risk. d. Medical record indicated the Patient Personal Effects Inventory form lacked documentation of the patient’s or witness signature, date, and time upon admission and documentation indicating the patient received their personal belongings upon discharge. e. Patient was discharged against medical advice (AMA) on 03/28/2025. 8. Review of Patient 7’s medical record indicated the following: a. Patient was admitted on 03/30/2025. b. On 03/30/2025, the medical record indicated medication reconciliation was completed and the provider ordered Pimavanserin Tartrate (Nuplazid) 25 mg PO daily to be continued during patient’s hospitalization. c. On 03/31/2025 through 04/10/2025, the medication administration record indicated Pimavanserin Tartrate (Nuplazid) 25 mg PO was not available and was not administered to the patient. The medical record lacked documentation of provider notification the medication was not administered and not available. d. MR indicated the Patient Personal Effects Inventory form lacked documentation of the patient’s or witness signature, date, and time upon admission and documentation indicating the patient received their personal belongings upon discharge. e. The patient was discharged on 04/10/2025. 9. Review of Patient 10’s medical record indicated the following: a. Patient was admitted on 04/08/2025. b. On 04/09/2025, the medical record indicated the ordered Zinc Gluconate 25 mg, 1 tablet, PO daily was to be substituted to Zinc Sulfate 220 mg PO daily. c. On 04/10/2025 through 04/15/2025, the medication administration record indicated that Zinc Sulfate 220 mg PO was not available. The medical record lacked documentation of provider notification that the medication was not administered and not available. e. Patient was a current inpatient. 10. Interview with A1 (Director of Quality and Risk) on 04/17/2025 at approximately 5:30 p.m. confirmed the above findings.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing services failed to administer ordered and scheduled medications for 5 of 10 patient (Patient 1, 2, 5, 7, and 10) medical records reviewed. Findings include: 1. Facility policy titled, Standardized Medication Administration, PolicyStat ID 12197198, last approved 08/2022, indicated under General Knowledge, E. All medications will be administered within one hour (before or after) of administration time or physician will be notified with reason medication not administered and an incident report will be completed if needed. 2. Facility policy titled, Generic Substitution, Policy Number - PHR-106, Origination Date: 03/2024, indicated under 4.0 Procedure: 4.2 The Pharmacy Department will attempt to locate the drug from a local Pharmacy or hospital if the medication is not stocked at the facility. 3. Review of Patient 1’s medical record indicated the following: a. The patient was admitted on 03/21/2025. a. On 03/21/2025, provider orders indicated Aricept 5 milligrams (mg) by mouth (PO) daily, Namenda 5 mg PO twice a day (BID) and Tagamet 400 mg BID were ordered and Norvasc 5 mg daily and Protonix 40 mg PO daily were to be continued from patient’s home medication list. c. On 04/01/2025, the medication administration record (MAR) indicated the patient was not administered their 9:00 a.m. scheduled medications which included the following: Toprol XI 100 mg PO, Protonix 40 mg PO, Miralax 17 grams PO, and Seroquel 50 mg PO. 4. Review of Patient 2’s medical record indicated the following: a. The patient was admitted on 12/02/2024. b. On 12/02/2024, the medical record indicated medication reconciliation was completed and the provider ordered for Vraylar 3 mg PO daily to be continued during patient’s hospitalization. c. The medication administration record indicated Vraylar 3 mg PO was not available, was not administered, or lacked documentation on the following dates: 12/18/2024 through 12/25/2024, 01/01/2025, 01/06/2025, 01/08/2025, 01/10/2025, 01/13/2025, 01/15/2025 through 01/25/2025, 01/27/2025 through 02/05/2025, 02/11/2025, 02/19/2025, 02/24/2025, 02/26/2025 through 03/03/2025, and 03/05/2025 through 03/12/2025. 5. Review of Patient 5’s medical record indicated the following: a. The patient was admitted on 03/13/2025. b. On 03/13/2025, the MR indicated medication reconciliation was completed and the provider ordered for home medications to be continued which included the following medications: Toprol XI 100 mg PO daily, Protonix 40 mg PO daily, Miralax 17 grams PO daily, Seroquel 50 mg PO BID. c. On 03/24/2025, the medication administration record (MAR) indicated on 04/01/2025, the patient was not administered their 9:00 a.m. scheduled medications which included the following: Toprol XI 100 mg PO, Protonix 40 mg PO, Miralax 17 grams PO, and Seroquel 50 mg PO. 6. Review of Patient 7’s medical record indicated the following: a. Patient was admitted on 03/30/2024. b. On 03/30/2025, the medical record indicated medication reconciliation was completed and the provider ordered Pimavanserin Tartrate (Nuplazid) 25 mg PO daily to be continued during patient’s hospitalization. c. On 03/31/2025 through 04/10/2025, the medication administration record indicated Pimavanserin Tartrate (Nuplazid) 25 mg PO was not available and was not administered to the patient. 7. Review of Patient 10’s medical record indicated the following: a. Patient was admitted on 04/08/2025. b. On 04/09/2025, the medical record indicated the ordered Zinc Gluconate 25 mg, 1 tablet, PO daily was to be substituted to Zinc Sulfate 220 mg PO daily. c. On 04/10/2025 through 04/15/2025, the medication administration record indicated Zinc Sulfate 220 mg PO was not available and was not administered to the patient. 8. Interview with A1 (Director of Quality and Risk) on 04/17/2025 at approximately 3:05 p.m. confirmed that patients 1, 2, 5, 7 and 10’s MR lacked documentation of ordered medication administration as indicated above.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing services failed to document admission and/or weekly skin assessments in 8 of 10 patient (Patients 1, 2, 3, 4, 5, 6, 7, and 8) medical records reviewed; failed to document a complete wound admission assessment in 1 of 10 patient (Patient 3) medical records reviewed; failed to notify the provider of medications not administered for 2 of 10 patient (Patient 4 and 7) medical records reviewed; and failed to accurately complete the daily fall risk assessment in 6 of 10 patient (Patients 1, 2, 5, 6, 7, and 8) medical records reviewed. Findings include: 1. Facility policy titled, Skin Assessment, PolicyStat ID 12385990, last approved on 09/2022 indicated under Procedure: Assessment, 1. A head-to-toe assessment should be done prior to or upon admission to the unit. Additional skin assessments should be completed one time per week or as ordered by provider; under f. Identification additional risk factors for developing pressure ulcers; and under I. If a skin condition, wound, pressure ulcer is noted, the wound should be assessed by the nurse and documented on the skin/wound form. 2. Facility policy titled, Standardized Medication Administration, PolicyStat ID 12197198, last approved 08/2022, indicated under General Knowledge, E. All medications will be administered within one hour (before or after) of administration time or physician will be notified with reason medication not administered and an incident report will be completed if needed. 3. Review of Patient 1’s medical record indicated the following: a. The patient was admitted on 03/07/2025. b. Medical record lacked documentation of the weekly skin assessment on 03/08/2025 and 03/15/2025. c. Medical record lacked documentation of the daily fall risk assessment for day shift on 03/08/2025. d. The patient was discharged on 03/18/2025. 4. Review of Patient 2’s medical record indicated the following: a. The patient was admitted on 03/10/2025. b. Medical record lacked documentation of the weekly skin assessment on 03/15/2025. c. Medical record lacked completed documentation of daily fall risk assessment on 03/13/2025 day shift and 03/14/2025 day shift. d. The patient was discharged on 03/21/2025. 5. Review of Patient 3’s medical record indicated the following: a. The patient was admitted on 03/13/2025. b. The medical record indicated on the admission skin assessment the patient had a scabbed sacral pressure ulcer that measured 4 by 4 by 1; lacked documentation of metrics used for measuring, documentation on the skin/wound form, and wound care during hospitalization. c. Medical record lacked documentation of the weekly skin assessment on 03/15/2025. d. The patient was discharged on 03/20/2025. 6. Review of Patient 4’s medical record indicated the following: a. The patient was admitted on 03/13/2025. b. Medical record lacked documentation of the weekly skin assessment on 03/15/2025 and 03/22/2025. c. On 03/13/2025, the provider ordered to continue Ivermectin 3 milligrams by mouth every two weeks. d. Medication administration record lacked documentation that Ivermectin was administered to the patient on 03/28/2025 and lacked documentation that the provider was notified the reason the medication was not administered. e. The patient was discharged on 03/28/2025. 7. Review of Patient 5’s medical record indicated the following: a. The patient was admitted on 03/20/2025. b. Medical record lacked documentation of the admission skin assessment on 03/20/2025. c. Medical record lacked documentation of the weekly skin assessment on 03/22/2025. d. Medical record lacked documentation of the daily fall risk assessment on 03/25/2025 on day shift. e. The patient was discharged on 03/28/2025. 8. Review of Patient 6’s medical record indicated the following: a. The patient was admitted on 03/21/2025. b. Medical record lacked documentation of the weekly skin assessment on 03/22/2025 and 03/29/2025. c. Medical record indicated the patient’s day shift fall risk assessment was marked low to moderate risk on 03/22/2025, 03/29/2025, 03/30/2025, and 04/01/2025 with a score of 90 on all dates using the Morse Fall Scale. The Morse Fall Scale indicates a score greater than 45 is high risk. d. The patient was a current inpatient. 9. Review of Patient 7’s medical record indicated the following: a. The patient was admitted on 03/23/2025. b. Medical record lacked documentation of the weekly skin assessment on 03/29/2025. c. Medical record lacked complete documentation of the admission fall risk assessment on on day and night shift on 03/27/2025. d. On 03/24/2025, the provider ordered to continue Sunosi 150 milligrams by mouth daily and the facility should obtain the medication. e. Medication administration record indicated the medication was scheduled to be administered daily and lacked documentation that the patient received the medication for the duration of their hospitalization from 03/24/2025 through 03/31/2025 and lacked documentation that the provider was notifed the reason the medication was not administered. f. The patient was discharged on 03/31/2025. 10. Review of Patient 8’s medical record indicated the following: a. The patient was admitted on 03/25/2025. b. Medical record lacked documentation of the weekly skin assessment on 03/29/2025. c. Medical record lacked complete documentation of the admission fall risk assessment on 03/25/2025 and daily fall risk assessment on day and night shift on 03/27/2025. d. The patient was a current inpatient. 11. Interview with A2 (Director of Risk and Quality) and A3 (Director of Nursing) on 04/02/2025 at approximately 2:15 p.m. confirmed the above findings.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing services failed to report allegations of patient abuse in one (1) instance (Patient 7). Findings include: 1. Facility policy titled, Patient Abuse and Neglect, last approved on 04/2024, indicated under Purpose: To provide procedures for reporting, investigating, and following up when an allegation of patient abuse or neglect is made, or when other information is received indicating that patient abuse or neglect may have occurred; under Responsibilities: Employee Responsibilities and Initial Notification Procedures, Employees who witness or have knowledge of patient abuse shall immediately report the incident to the CEO and Director of Nursing, or designee. 2. Review of Patient 7’s medical record indicated the following: a. The patient was admitted on 03/23/2025 and the admission skin assessment indicated the patient had a bruise on the back right shoulder, back of right arm, bruise on the upper left arm, and a skin tear on the right finger. b. On 03/24/2025, the medical record indicated in a nursing note the patient accused staff of old bruises on arm. c. On 03/26/2025, the nursing note indicated patient 7 requested to talk to a nurse about filing a grievance. The patient indicated that they had been physically assaulted and berated by staff. Patient 7 indicated that they had an accident in bed and called for S1 (Behavioral Health Associate) to help; S1 asked S2 (Behavioral Health Associate) to help. Patient 7 indicated that S1 and S2 were rough, threw them around the bed, and S2 held their upper body. d. On 03/28/2025, the skin monitoring form indicated the patient had bruising on their back left shoulder, bruising down the upper and lower left arm indicated by 9 circles versus the initial assessment upon admission which indicated a bruise on the right shoulder, back of right arm, bruise on the upper left arm and a skin tear on the right finger. 3. Interview with S1 on 04/02/2025 at approximately 3:55 p.m. confirmed that they cared for patient 7 on 03/24/2024 day shift. S1 indicated S1 and S2 changed patient 7. S1 indicated that patient 7 indicated they could not move due to a neurological condition. S1 indicated patient 7 informed S1 that S2 bruised patient 7. S1 indicated they told a staff nurse about patient 7’s allegations. 4. Interview with A2 (Director of Risk and Quality) and A3 (Director of Nursing) on 04/02/2025 at approximately 2:15 p.m. confirmed the above findings.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing services failed to administer ordered and scheduled medications for 2 of 10 patient (Patient 4 and 7) medical records reviewed. Findings include: 1. Facility policy titled, Standardized Medication Administration, PolicyStat ID 12197198, last approved 08/2022, indicated under General Knowledge, E. All medications will be administered within one hour (before or after) of administration time or physician will be notified with reason medication not administered and an incident report will be completed if needed. 2. Review of Patient 4’s medical record indicated the following: a. On 03/13/2025, the provider ordered to continue Ivermectin 3 milligrams by mouth every two weeks. b. On 03/28/2025, the medication administration record indicated that the medication was scheduled to be administered. c. Medication administration record lacked documentation that Ivermectin was administered to the patient on 03/28/2025. 3. Review of Patient 7’s medical record indicated the following: a. On 03/24/2025, the provider ordered to continue Sunosi 150 milligrams by mouth daily and the facility should obtain the medication. b. Medication administration record indicated the medication was scheduled to be administered daily and lacked documentation that the patient received the medication for the duration of their hospitalization from 03/24/2025 through 03/31/2025. 4. Interview with A2 (Director of Risk and Quality) and A3 (Director of Nursing) on 04/02/2025 at approximately 2:15 p.m. confirmed the above findings.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48061 Based on document review and interview, the facility failed to notify a provider of abnormal laboratory values, failed to notify a provider of patient weight loss per policy, failed to notify a provider of a patient’s refusal of meals, liquids, and/or medications, failed to obtain and document an admission weight, failed to document weekly weights in a patient’s medical record, failed to complete and/or document activities of daily living including but not limited to showering, bathing, and grooming, and failed to review and update a care plan for 1 of 10 patient medical records reviewed. (P1) The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48061 Based on document review and interview, nursing staff failed to notify a provider of abnormal laboratory values, failed to notify a provider of patient weight loss per policy, failed to notify a provider of a patient’s refusal of meals, liquids, and/or medications, failed to obtain and document an admission weight, failed to document weekly weights in a patient’s medical record, and failed to complete and/or document activities of daily living including but not limited to showering, bathing, and grooming for 1 of 10 patient medical records reviewed. (P1) Findings Include: 1. Facility policy titled,”Laboratory Process”, PolicyStat ID 12197196, last revised 05/2021, indicated under PROCEDURE: 8. Nurses/Unit Clerks obtain laboratory results from lab website and print results. 1. Nurse updates provider of abnormal results as needed, including obtaining new orders. 2. Facility policy titled,”Provider Communication”, PolicyStat ID 92275841, last revised 01/2025, indicated under POLICY: Licensed nursing staff are responsible for notifying providers of any changes in patient conditions that many negatively impact treatment or medical well-being. Communication ensures timely interventions to support patient safety and care. PROCESS: 1. Indications for Provider Notification: Providers must be notified promptly for: Changes in condition. Abnormal vital signs. Refusal of medication. Refusal of nutrition. 3. Facility policy titled,”Change of Condition”, PolicyStat ID 12197218, last revised 05/2021, indicated under PROCEDURE: 1. All nursing staff members will communicate any noted changes of condition that a patient has to the assigned nurse of the patient. 2. The nurse will evaluate the patient and notify the provider with findings. 3. Findings, provider notification, and any interventions and/or orders received will be documented. The change of conditionally continued to be monitored and provider updated as needed. 4. Facility policy titled,”Patient Personal Care”, PolicyStat ID 12197137, last revised 01/2020, indicated under PROCEDURE: General Care: All patients shall be encouraged or assisted in grooming daily or more often as needed. Grooming articles such as soap, shampoo, shaving equipment, etc., are available per patient need. A wash cloth to bath will be provided with staff supervision and/or assistance. Patients who are incontinent shall be assisted with cleaning or bathing and in a manner that respects privacy. Oral care is to be encouraged. Toothbrush and toothpaste will be provided as needed. 5. Facility policy titled.”Vital Signs and Weight”, PolicyStat ID 12386461, last revised 09/2022, indicated under POLICY: All patients will have their vital signs, weight and height taken on admission. PROCEDURE: Vital signs will be taken a minimum of once per shift, unless the provider orders a more frequent schedule. Weights will be taken a minimum of once per week, unless diagnosis deems need for increased frequency. The bed scale will be used for bedfast patients. Staff is to report any significant changes or abnormal findings to the nurse. Nurses will notify the provider of findings outside patient’s normal range. Record vital signs and weekly weights in the patient’s medical record. 6. Review of P1’s MR (Medical Record) indicated the following: a. On 12/18/24 at 6:40 pm physician placed orders for an admission weight and weekly weights, laboratory orders for CBC (Complete Blood Count) with differential, CMP (Complete Metabolic Panel), TSH (Thyroid Simulating Hormone), Lipid Panel, Hemoglobin A1C, urinalysis with C&S (Culture and Sensitivity). b. MR lacked physician/provider notification of abnormal laboratory values resulted on 12/27/24 at 4:02 pm. Chloride 108.22 mmol/L (normal range 96 - 106), White blood cell count 12.72 x10^3/ul (normal range 3.70-10.30 x10^3/ul),Glucose 68.6 (normal range 70-99), Platelet 389 x10^3/mcl (normal range 155-369 x10^3/mcl), Neutrophil 8.36 x10^3/mcl (normal range 1.60-6.10 x10^3/mcl), Monocyte,.92 x10^3/mcl (normal range 0.30-0.90 x10^3/mcl), BUN/ Creatinine Ratio 23.93 (normal range 9.00-20.00). c. MR lacked documentation of patient admission weight. d. MR lacked documentation of weekly weight values, e. MR lacked provider notification of change in patient weight for dates 12/21/24-1/25/25. P1 weekly weight documentation found in facility weekly weight log book as follows: 12/21/24 189.3 lbs.(pounds). 12/28/24 183.0 lbs. 1/11/25 175.2 lbs. 1/18/25 166.0 lbs. 1/25/25 157.3 lbs. f. MR lacked provider notification of documented refusal of medications for dates included but not limited to 1/27/25,1/19/25, 1/16/25, 1/13/25, 1/11,25, 1/1/25, and 12/21/24. g. MR lacked provider notification of documented decrease of oral intake including meals and/or liquids for dates included but not limited to 1/27/24, 1/23/25, 1/22/25, 1/18/25, 1/16/25, 1/10/25, 12/27/24,12/25/24,12/23/24, 12/22/24, 12/21/24. h. MR lacked ADL (Activities of Daily Living) documentation indicating P1 refusal and/or was showered, bathed, and/or groomed for the following days 12/19/24, 12/21/24, 12/22/24,12/23/24, 12/25/24, 12/25/24, 12/26/24, 12/28/24,12/30/24, 12/31/24, 1/2/25, 1/4/25, 1/7/25, 1/9/25, 1/10/25, 1/11/25, 1/14/25, 1/15/25, 1/16/ 25, 1/18/25, 1/19/25, 1/20/25, 1/22/25, 1/23/25, 1/25/24, 1/27/25. 6. In interview on 2/17/25 at approximately 12:12 pm NP1 (Nurse Practitioner) confirmed he/she was not notified by nursing of P1’s decreased appetite, oral intake, and/or weight loss. 7. In interview on 2/17/25 at approximately 12:46 pm with NP2 (Nurse Practitioner) confirmed nursing notified him/her of the P1’s refusal to take medications. Was not notified of the pt’s weight loss nor refusal to eat or drink. Confirmed he/she has not received any on-call notifications of P1 concerns by nursing. 8. In interview on 2/17/25 at approximately 12:54 pm NP3 (Nurse Practitioner) confirmed he/she was not notified of P1’s refusal to eat, drink, take medications, weight loss, abnormal laboratory values. 9. In Interview on 2/17/2025 at approximately 3:11 pm with NP4 (Nurse Practitioner) confirmed he/she was not notified of P1’s weight loss or weekly weight trends, P1’s refusal of fluids and food, abnormal laboratory values. 10. In interview on 2/17/25 at approximately 5:00 pm with A3 (Director of Nursing) confirmed nursing staff did not notify provider(s) with weekly weights, decreased appetite, refusal of meals and/or fluids, refusal of vital signs and or change in condition related to the above-mentioned issues, but should have.”

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility dietician failed to complete a nutritional evaluation within 72-hours of request for 1 of 10 medical records reviewed. Findings include: 1. Facility policy titled, “ Standards of Nutrition Care”, PolicyStat ID 12511831, last revised 10/2022, indicated under PROCEDURE: B. Nurtitional Assessment. All patients who are referred to the diettician will have a comprehensive nutrition assessment completed within 72 hours of the referral. 2. MR review for P1 indicated on 12/30/24 at 10:30 am a nutritional consultation was placed by facility nursing staff. MR for P1 lacked a nutritional consult completed by a registered dietician within 72 hours as policy dictates. 3. In the interview on 2/17/25 at approximately 10:00 am with D1 (Clinical Dietician) confirmed he/she did not have knowledge of a dietician referral related to P1’s poor intake ordered on 12/30/24. The comprehensive nutrition assessment for P1 was not completed within 72 hours but should have been.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 49709 Based on document review, observation, and interview nursing services failed to review medications with patient at discharge for 1 of 1 patient observed (P11), and failed to ensure that patient received a daily shower in 1 of 10 MR reviewed (P1). Findings include: 1. Review of policy/procedure “Medication Reconciliation (Admission and Discharge Medications)” PolicyStatID: 12197197, last approved 08/2022, indicates under Medication Reconciliation Procedure: D. Discharge Reconciliation: At the time of discharge the Medical Doctor or Registered Nurse will review the discharge medications with the Medication Reconciliation List that was completed at the time of admission. 3. The Medication Reconciliation List will be reviewed with the patient and/or significant other at the time of discharge. During this education process, the nurse will review any changes to previous home medication dose or schedule, when the next dose is due, and all new medications that will be added to the patient’s home medication regimen. Food and Drug interaction will also be discussed with the patient. 5. Provide the patient (or family as needed) with written information on the medication the patient should be taking when he or she is discharged from the hospital or at the end of an outpatient encounter. This will include name, dose, route, frequency, and purpose. 2. Review of policy/procedure titled, “Patient Personal Care,” PolicyStatID: 12197137, last approved 08/2022, indicates under Policy: All patients admitted to the hospital will be supported and educated in activities of daily living (ADLs), focusing on personal hygiene and grooming. Under Procedure: Definition: CMS defines ADLs as activities related to personal care, which includes the following: Bathing/showering Under Education: All patients will be provided education upon admission regarding the process for ADLs, including but not limited to: Bathing/showers will be offered daily Under General Care: All patients shall be encouraged or assisted in grooming daily or more often as needed. 3. Review of P1 MR lacked documentation of completed shower on 10/21/24. MR lacked documentation of refusal to shower on 10/21/24. 4. On 01/07/25 at approximately 2:30 p.m. this surveyor, accompanied by A1 (Project Chief Executive Officer, Interim Director), was escorted to the unit to observe the nurse, A5 (Director of Nursing [DON]), conduct the discharge of a current patient (P11). During this observation A5 failed to review the patient’s discharge medications with the patient. 5. In interview with A8 (BHA) on 01/08/25 at approximately 1:10 p.m., indicated patients are asked every day in the a.m. and p.m. if they want to take a shower. A8 indicated the patient has the right to refuse. If the patient does refuse, A8 encourages the patient to wash up at the sink. Showering is documented on the 15-minute check sheet. If the patient refuses, A8 informs the nurse and documents it on the 15-minute check sheet.”

“PATIENT VISITATION RIGHTS CFR(s): 482.13(h)(3), (h)(4) [A hospital must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation. A hospital must meet the following requirements]: (3) Not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. (4) Ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility staff failed to allow a patient to receive a visitor for 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled, “Patient Rights and Responsibilities”, PolicyStat ID 13517670, last revised 09/2021, indicated under PROCEDURE: You have the right to: 23. Designate visitors of your choice, if you have decision-making capacity, whether or not the visitor is related by blood or marriage, unless: a. No visitors are allowed. b. The facility reasonably determines that they presence of a particular visitor would endanger the health or the safety of a patient, a member of the health facility staff or other visitors to the health care facility, or would significantly disrupt the operations of the facility. c. Visitor restriction may also occur when clinically indicated. d. You have told the hospital staff that you no longer want a particular person to visit. e. The Hospital establishes reasonable restrictions upon visitation, including restrictions upon hours or visitation and number of visitors. f. Have your wishes considered, if you lack decision-making capacity, for the purpose of determining who may visit. 2. Review of P1’s MR (medical record) indicated he/she was his/her own decision maker, had no POA (Power of Attorney), nor a documented HCR (Health Care Representative). Nursing Note documentation dated 10/13/2024 indicated P1 had visitation with C1 (Complainant) without issue. P1’s MR lacked documentation of the need for visitor restriction on 10/14/2024. 3. In an interview on 11/27/24 at approximately 3:40 pm with R1 (Receptionist) confirmed the reason C1 was not allowed to visit P1 was d/t P1’s confusion and inability to name C1 as a person he/she would like to visit with. R1 also confirmed that P1 refused to complete consent forms on 10/14/2024 but did complete his/her consent which included an access code and patient visitation rights forms on 10/16/2024. R1 did not feel comfortable letting C1 visit without a positive indication from P1 on 10/14/2024. 4. In an interview on 11/27/24 at approximately 4:30 pm with N1 (Registered Nurse) confirmed P1 received visitors on both 10/12/2024 and 10/13/2024 that included both family members (10/12/2024) and C1 (10/13/2024). On 10/13/2024 during the visitation C1 was concerned about P1 and the sudden decline in his/her health. N1 confirmed there was no reason P1 would not have been allowed to have visitors on 10/14/2024. 5. In an interview on 11/27/24 at approximately 4:45 pm with A1 (Chief Executive Officer) confirmed C1 was not allowed to visit P1 on 10/14/2024 but should have been.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48061 Based on documentation review, observation and interview, facility nursing staff failed to maintain patient personal privacy and dignity during and after toileting, failed to keep patient free from sexual abuse, failed to increase sexually acting out precautions, and failed to report patient abuse to a government agency per policy. See tags A0143 and A0145. The cumulative effects of this systemic problem resulted in the facility’s inability to ensure that Patient Rights were promoted.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 48061 Based on documentation review, observation and interview, facility nursing staff failed to maintain the personal privacy and dignity during and after toileting for 1 of 10 medical records reviewed. (P1) Findings Include: 1. Facility policy titled “Patient Rights and Responsibilities”, PolicyStat ID 13517670, last approved 04/2023, indicated under PROCEDURE: You have the right to: 1. Receive considerate ethical behavior and respectful treatments, services, and business practices. You have the right to made comfortable and be treated with dignity. You have the right to be respected for your personal beliefs and values including cultural, psychosocial, and spiritual values and beliefs. 3. Have your privacy, confidentiality and security needs respected by the organization. 14. Have personal privacy respected. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly. You have the right to be told the reason for the presence of any individual and adequate information about the person(s) responsible for the delivery of your care, treatment and services. 2. MR review for P1 indicated the following: Psychiatric Progress Note documentation dated 9/3/24 indicated P2 reportedly went into P1’s room and inserted his/her finger into P1’s rectum. P1 claimed the incident with P2 took place in his/her bathroom while he/she was on the toilet. 3. MR review for P2 indicated the following : Daily Nursing Narrative documentation dated 9/2/24 at approximately 7:00 pm indicated nursing staff reported P2 put his/her finger in P1’s rectum. P2 stated he put his/her finger in P1’s rectum because “he (P2) was a dog”. MR for P2 lacked documentation in increased observation precautions and/or implementation of sexually acting out precautions. Social Service Documentation Progress noted dated 9/9/24 at 10:00 am indicated the investigation between P1 and P2 had found that both patients state the allegations happened. 4. Video footage reviewed with A2 (Director of Quality and Risk Management) on 9/10/24 at approximately 11:30 pm for 9/2/24 indicated as follows: At 18:52:51 hrs. (hours) P2 can be seen getting out of his/her wheelchair and ambulating into P1’s room. At 18:55:36 hrs. P2 was seen being brought out of P1’s room by BHA1 (Behavior Health Associate) in wheelchair placing P2 in the hallway directly facing P1’s room. At 18:56:53 hrs. P2 can be seen leaving his/her wheelchair again and entering P1’s room. At approximately 18:57 hrs. BHA2 (Behavior Health Associate) can be seen entering P1’s room, leaves P1 to retrieve P2’s wheelchair and then can be seen wheeling P2 out of P1’s room into the hallway directly in front of P1’s door. At 18:58:52 hrs. P2 ambulates from his/her wheelchair into P1’s room. At approximately 18:59 hrs. nursing staff can be seen entering P1’s room. At 19:00 hrs. P2 is brought out of P1’s room and placed in his/her wheelchair directly in front P1’s door. At 19:04 hrs. P2 ambulates from the wheelchair into P1’s room. At 19:05 hrs. P2 removed from P1’s room to wheelchair in hallway directly in front of P1’s room. At 19:07:28 hrs. P2 can be seen looking around before exiting his/her wheelchair and entering P1’s room at 19:07:55 hrs.. Staff members to P1’s room at 19:08:41 hrs. At 19:11 hrs. P2 was brought out into the hallway to wheelchair directly across P1’s door. At 19:15:29 hrs. P2 ambulated into P1’s room. At 19:18 hrs. staff can be seen entering/leaving P1’s room. At 19:19 hrs. P2 can bee seen leaving P1’s room and ambulating the length of both hallways to dispose of a white cloth onto a pile of what appeared to be dirty linen on the floor then ambulating back into P1’s room. At approximately 19:20 hrs. BHA2 and P1 can be seen leaving P1’s room. 5. Incident Report notes dated 9/3/2024 at approximately 3:15 pm, indicated A2’s interview with BHA1: BHA1 said P2 liked helping to the point of getting out of his/her wheelchair. P1 was calling for help because he was cleaning up his own mess and P1 was denying he/she could clean up the mess. P1 continued to ask for help and P2 wanted to help. BHA1 then heard P1 yell “GET OUT” to P2. P1 then told BHA1 that P2 put his/finger up P1’s rectum. BHA1 noted that P1 was seated in his/her walker with his/her pants on. BHA1 stated that they removed P2 from P1’s room redirecting P2 but efforts were unsuccessful.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48061 Based on documentation review and interview, the facility failed to keep patients free from sexual abuse for 1 of 10 medical records (MR) reviewed (P1); and failed to increase sexually acting out precautions for 1 of ten medical records reviewed (P2); and failed to report patient abuse to a government agency per policy for 1 of 10 medical records reviewed. (P2) Findings include: 1. Facility policy titled, “Patient Rights and Responsibilities”, PolicyStat ID 13517670, last approved 04/2023, indicated under PROCEDURE: You have the right to: 18. Receive care in a safe setting, free from verbal or physical abuse or harassment. You have the right to access protective and advocacy services including notifying agencies of neglect, abuse, or exploitation. 2. Facility policy titled, “Sexually Acting Out (SAO) Precautions”, PolicyStat ID 12195131, last approved 08/2022, indicated under RESPONSIBILITIES: A. Responsibilities of ALL Staff: 1. To understand and follow hospital policy. 3. Attempt to protect patients who may be particularly vulnerable to being sexually abused by other patients. 5. To respond appropriately to questions or concerns that patients may have regarding sexual issues or behaviors. 6. To redirect or restrict patients who may be demonstrating sexual behaviors towards other patients. 3. Facility policy titled, “Critical Incident Reporting to Department of Mental Health & Addiction (DMHA)”, no policy number, last revised 05/2024, indicated under PROCEDURE: The procedure for incident reporting will be followed, as defined in Policy lll-B.11 “Incident Reports.” The Risk Manager or designee will determine which incidents require notification to the Department of Mental Health and Addiction (DMHA) per the guidance below; The facility shall also submit a written report, to the division within ten (10) working days of the occurrence of any of the following: Any patient abuse occurring within the facility. 4. MR for P1 indicated in Daily Nursing Narrative documentation dated 9/2/24 at approximately 7:10 pm, indicated P1 stated P2 put his/her finger in P1’s rectum. 5. MR review for P2 indicated Psychiatric Progress Note dated 8/20/24 indicated while on every 15-minute patient observation checks, P2 expressed sexual interest in another same sex peer. The peer was against the sexual advances and the two patients were kept separated. Psychiatric Progress Note dated 8/30/24 indicated P2 was found naked in another patient’s room while the patient was in the shower. Mental Status Examination indicated P2 was noted to be sexually acting out. Daily Nursing Narrative dated 9/2/24 at approximately 7:00 pm indicated nursing staff reported P2 put his/her finger in P1’s rectum. P2 stated he put his/her finger in P1’s rectum because “he (P2) was a dog”. The MR for P2 lacked documented of increased SAO precautions from behaviors displayed on 8/20/24, 8/30/24, and 9/2/24 by P2. 6. In interview on 9/10/24 at approximately 1:00 pm with LS 1 (Licensed Staff) confirmed P2 should have been placed on SAO precautions after his/her actions on 8/30/24 but was not. It would have been prudent to place P2 on SAO precautions, P2 should have been placed on a bed block but was not, bed blocks are discouraged by corporate leadership and 1:1 (one on one) level of observations orders are to be avoided if possible and discouraged by H1 corporate leadership. 7. In an interview on 9/10/24 at approximately 4:10 pm with A2 (Director of Quality & Risk Management) confirmed the incident that took place between P1 an P2 was not reported to G1(Government Agency) because the internal investigation completed by facility was unsubstantiated after speaking with P1, P2, reviewing video footage and conducting staff interviews.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility nursing staff failed to complete incident reports related to sexually acting out behaviors for 1 of 10 medical records reviewed. (P2) Findings Include: 1. The facility policy titled, Incident Reports, PolicyStat ID 13033981, last revised 1/2023, indicated under PURPOSE: It is the policy of the hospital to support a culture of shared accountability for the identification, reporting and management of patient events that may impact the quality of care provided. An incident is defined as: any event which is not consistent with the routine operation of the hospital and that adversely affects or threatens to affect the well-being of the patients, employees, medical staff, visitors, consultants, or property of, regardless of whether and actual injury is involved or not. Any hospital staff member who witnesses, discovers or has direct involvement in and/or knowledge of an event must complete an incident report, or give a detailed report to the person completing the incident report. 2. MR review for P2 indicated Psychiatric Progress Note dated 8/20/24 indicated P2 expressed sexual interest in another same sex peer. The peer was against the sexual advances and the two patients were kept separated. No change to P2’s level of observation was made after this incident. Psychiatric Progress Note dated 8/30/24 indicated P2 was found naked in another patient’s room while the patient was in the shower. The MR for P2 lacked documented incident reports filed for behaviors displayed by P2 on 8/20/24 and 8/30/24. 3. In an interview on 9/10/24 at approximately 4:10 pm with A2 (Director of Quality & Risk Management) confirmed incident reports related to P2 sexually acting out on 8/20/24 and 8/30/24 were not filed and should have been.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 49709 Based on document review and interview, nursing services failed to complete an incident report related to physical and aggressive behaviors against staff and other patients in 1 out of 10 patient MRs (Medical Records) reviewed (patient #1); nursing services failed to document presence of bowel sounds on the Daily Nursing Assessment Form for entire hospitalization in 1 out of 10 patient MRs reviewed (patient #1); and nursing services failed to ensure patient received daily shower and/or grooming for 1 of 10 patient MRs reviewed (patient #1). Findings include: 1. Facility policy titled, “Incident Reports,” PolicyStat ID: 13033981, last approved 01/2023, indicated under Purpose: An incident is defined as: any event which is not consistent with the routine operation of the hospital and that adversely affects or threatens to affect the well-being of the patients, employees, medical staff, visitors, consultants, or property of, regardless of whether an actual injury is involved or not. Any hospital staff member who witnesses, discovers or has direct involvement in and/or knowledge of an event must complete an incident report, or give a detailed report to the person completing the incident report. 2. Facility policy titled, “Bowel Management,” PolicyStatID: 12197203, last approved 08/2022, indicated under Assessment: Nursing Admission Database Form: Once every shift, the nurse will document presence of bowel sounds on the Daily Nursing Assessment form, in the narrative section. 3. Facility policy titled, “Patient Personal Care,” PolicyStatID: 12197137, last approved 08/2022, indicated under General Care: All patients shall be encouraged or assisted in grooming daily or more often as needed. 4. Review of patient #1’s MR indicated the following: a. The patient was admitted on 07/03/24 and discharged on 07/08/24. b. On 07/05/24 at 2100 hours nurse note indicated patient #1 was aggressive towards other patients, hitting other patients, and when redirected patient #1 was physically and verbally aggressive with staff. c. MR lacked documentation of presence of bowel sounds on the Daily Nursing Assessment Form for entire hospitalization. d. MR lacked documentation of shower, grooming and incontinent care on the Patient Observation Rounds Form and Daily Nursing Assessment Form for 4 of 6 days (07/03/24, 07/04/24, 07/05/24, and 07/06/24). 5. Review of incident reports from 2/1/2024 through 7/30/2024 indicated no incident report were completed by staff for patient #1 on 07/05/24 for physical aggression towards other patients and staff. 6. Interview with A5, (BHA, Behavioral Health Assistant) on 08/19/24 at approximately 4:25 p.m., indicated they assisted with patient #1 was verbally and physically aggressive and resistant with care. 7. Interview with A2 (DON, Director of Nursing) on 08/19/24 at approximately 12:30 p.m., indicated that staff reported patient #1 was resistive with care, refused care, wandered in and out of other patients’ rooms, was verbally aggressive to staff and other patients, and at times would attempt to hit others. A2 confirmed charting for incontinence is completed by nursing with their daily charting. A2 confirmed there was no incident reports completed for patient #1’s aggressive and physical behaviors.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing services failed to document reason medications were not administered, failed to notify provider of missed medication administration, and failed to complete incident report for medications not administered for 1 of 10 (Patient 4) patient medical records reviewed Findings include: 1. Facility policy titled, Administration of Medications, PolicyStat ID 11132380, last approved 02/2022, indicated when medications eligible for scheduled dosing time are not administered within the time period: document the reason the dose was missed or delayed. Notify the prescribing/attending physician if the delay poses an immediate patient care issue and for time critical medication delays greater than 3 hours; non-time critical medication scheduled daily, weekly, or monthly delays greater than 8 hours; and verify that the medication is administered at the appropriate time, to ensure adherence to the prescribed frequency and time of administration. 2. Facility policy titled, Incident Reports, PolicyStat ID 13033981, last approved on 01/2023, indicated that an incident is defined as: any event which is not consistent with the routine operation of the hospital and that adversely affects or threatens to affect the well-being of the patients, employees, medical staff, visitors, consultants, or property of, regardless of whether an actual injury is involved or not. 3. Review of Patient 4’s medical record lacked documentation of reasons for the following medications not administered on the following dates and scheduled times, and notification of missed administration to the provider: a. Air Duo one puff by mouth twice a day, ordered on 04/10/2024, for the 9:00 a.m. scheduled dose on 04/13/2024 and the 9:00 a.m. scheduled dose on 04/14/2024. b. Naltrexone 50 milligram by mouth daily, ordered on 04/12/2024, for the 9:00 a.m. scheduled dose on 04/13/2024 and the 9:00 a.m. scheduled dose on 04/14/2024. c. Nicotine Patch 21 milligram/24 hours topically, ordered on 04/10/2024, for the 9:00 a.m. scheduled dose on 04/14/2024. 4. Review of incident reports from 01/01/2024 to 05/10/2024 lacked documentation that an incident report completed for the above missed medications for Patient 4. 5. Interview with A1 (Chief Executive Officer) and A2 (Director of Quality and Infection Control) on 05/14/2024 at approximately 4:15 p.m. confirmed the following: a. Patient 4’s medical record lacked documentation of the reason medications were not administered; the medication administration record indicated that the following medications were not administered: Air Duo one puff by mouth (PO) twice a day ordered on 04/10/2024, medication administration record indicated the scheduled dose at 9:00 a.m. on 04/13/24 and 04/14/24 were not administered; Naltrexone 50 milligram by mouth daily, ordered on 04/12/2024, medication administration record indicated the scheduled dose at 9:00 a.m. on 04/13/24 and 04/14/24 were not administered; Nicotine Patch 21 mg/ 24 hours topically ordered on 04/10/2024, medication administration record indicated the scheduled 9:00 a.m. dose on 04/14/24 was not administered. b. No incident reports were filed for the missed medications for patient 4. c. Unable to confirm when patient 4’s scheduled medications were administered due to lack of time documentation on the medication administration record.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing services failed to administer ordered and scheduled medications for 1 out of 10 (Patient 4) medical records reviewed. Findings include: 1. Facility policy titled, Administration of Medications, PolicyStat ID 11132380, last approved 02/2022, indicated verify that the medication is administered at the appropriate time, to ensure adherence to the prescribed frequency and time of administration. When medications eligible for a scheduled dosing time are not administered within the defined time period: 1. document the reason the dose was missed or delayed (i.e. patient refused, patient off unit, etc.); 2. reschedule missed or delayed doses, as appropriate. 3. Review of Patient 4’s medical record lacked documentation the following medications were administered: a. Air Duo one puff by mouth (PO) twice a day, ordered on 04/10/2024, was not administered on 04/13/24 and 04/14/24 for the 9:00 am scheduled dose. b. Naltrexone 50 milligram by mouth daily, ordered on 04/12/2024, was not administered on 04/13/24 and 04/14/24. c. Nicotine Patch 21 mg / 24 hours topically, ordered on 04/10/2024, was not administered on 04/14/24. 7. Interview with A1 (Chief Executive Officer) and A2 (Director of Quality and Infection Control) on 05/14/2024 at approximately 4:15 p.m. confirmed the following Patient 4’s medical record lacked documentation the following medications were administered: a. Air Duo one puff by mouth (PO) twice a day, ordered on 04/10/2024, was not administered on 04/13/24 and 04/14/24 for the 9:00 am scheduled dose. b. Naltrexone 50 milligram by mouth daily, ordered on 04/12/2024, was not administered on 04/13/24 and 04/14/24. c. Nicotine Patch 21 mg / 24 hours topically, ordered on 04/10/2024, was not administered on 04/14/24.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to document daily cleaning of patient rooms for month reviewed (April/2024). Findings include: 1. Review of the housekeeping record sheets for April 2024, indicated lack of daily patient room cleaning documented from 4/10/2024 through 4/23/2024. 2. Interview with A1 (Chief Executive Officer), on 05/14/2024 at approximately 10:30 a.m., confirmed there were no daily patient room cleaning records from 4/10/2024 through 04/24/2024.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing services failed to complete a pain assessment prior to administration of pain medication for 1 of 10 patient (patient 6) medical records reviewed; and failed to complete a pain reassessment to ensure effective pain management for 1 out of 10 patient (patient 6) medical records reviewed. Findings include: 1. Facility policy titled, Pain Assessment, Reassessment, Management and Care Plan, PolicyStat ID 12197199, last approved 08/2022, indicated ongoing pain assessment and effectiveness of interventions completed by all disciplines participating in the care of the patient. If applicable, efficacy of intervention shall be documented prior to the end of the shift. 2. Review of Patient 6’s medical record lacked documentation of a pain assessment on 04/06/2024 and 04/07/2024 and the efficacy of intervention, pain reassessment, after pain medication administration on 04/04/2024, 04/06/2024, and 04/07/2024. 3. Interview with A1 (Chief Executive Officer) and A2 (Director of Nursing) on 05/01/2024 at approximately 5:45 p.m. confirmed that patient 6 MR lacked documentation of pain assessment prior to pain medication on 04/06/2024 and 04/07/2024 and reassessment after pain medication administration on 04/02/2024, 04/04/2024, 04/06/2024 and 04/07/2024.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48061 Based on documentation review and interview ,the nursing staff failed to offer and/or document daily shower, bath, and/or grooming for 1 of 10 medical records (MR) reviewed. (P1) Findings include: 1. The facility policy titled, “Patient Personal Care”, PolicyStat ID 12197137, last approved 08/2022, indicated under Policy: All patients admitted to the hospital will be supported and educated in activities of daily living (ADLs), focusing on personal hygiene and grooming. Articles for grooming and personal hygiene are available and accessible. Procedure: CMS defines ADLs as activities related to person care, which includes the following: Bathing/showering, Dressing, Getting in and out of bed/chair, Walking, Using the toilet, and Eating. All patients shall be encouraged or assisted in grooming daily or more often as needed. 2. MR documentation indicated P1 did not receive a daily shower, bath, and/or grooming (which includes a change in clothes and bed linen change) by facility staff for dates 2/29/24, 3/2/24, 3/3/24, 3/4/24, 3/5/24, 3/6/24, 3/17/24, 3/18/24, 3/19/24, 3/22/24, 3/23/24, 3/24/24, 3/31/24, 4/1/24, and 4/5/24. 3. In an interview on 4/16/24 at approximately 1:10 pm with B1 (Behavioral Health Associate-BHA) confirmed showers/bathing/grooming are offered daily, daily linen changes are to occur daily, facility BHA’s are to document on the 15-minute observation rounding sheet when the patients have a shower/bath/grooming. 4. In an interview on 4/22/24 at approximately 1:15 pm with A1 (Director of Nursing) P1’s chart lacked documentation of daily showers and/or grooming for numerous days. P1’s showers/bathing/grooming should have been documented daily and were not.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 48061 Based on document review, observation, and interview, the facility failed to ensure the safety and/or quality of facility linen in 1 of 1 areas toured. (Clean Linen Room) Findings include: 1. The facility policy titled, “Storage and Transportation of Clean Linen”, PolicyStat ID 12507957, last approved 10/2022, indicated all linens will be stored, handled, transported, and processed in a manner that prevents the transmission of micro-organisms to other patient areas. 2. During facility tour on 4/22/24 at approximately 12:55 pm with A1 (Director of Nursing), facility clean linen room was observed to have a non-facility single air mattress donned with blankets and pillow on the floor that appeared to be recently used. 3. In an interview on 4/22/24 at approximately 2:15 pm with N1 (Registered Nurse) confirmed he/she brought the air mattress, pillow, and blanket to the facility’s clean linen room to rest between shifts on 4/22/24 from 3:00 am to 7:00 am. 4. In an interview on 4/22/24 at approximately 2:45 pm with A3 (Chief Executive Officer), confirmed N1 should not have been using the facility’s clean linen room to rest between shifts and therefore cannot ensure the safety and quality of linen stored in the clean linen room.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48061 Based on documentation review and interview, the facility failed to complete and/or document daily room cleaning for 1 of 10 patient room cleaning logs reviewed. (P1) Findings include: 1. The facility policy titled, “Cleaning Occupied Rooms”, PolicyStat ID 12508564, last approved 10/2022, indicated under Policy: All patient rooms will be cleaned on a daily basis. 2. In an interview on 4/22/24 at approximately 2:45 pm with A3 (Chief Executive Officer) confirmed the facility should have had record of P1’s daily room cleanings for the length of the hospitalization, but does not. P1’s room should have been cleaned daily but the facility does not have documentation that the patient’s room was cleaned each day per policy.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48704 Based on document review and interview, nursing staff failed to complete the Transport/Transfer Order Form and lacked documentation of a nurse to nurse phone report with the accepting facility for 9 of 10 (patients 1, 2, 3, 4, 6, 7, 8, 9, and 10) medical records reviewed. The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner in regards to patient transfers.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing staff failed to complete the Transport/Transfer Order Form and lacked documentation of a nurse to nurse phone report with the accepting facility for 9 of 10 (patients 1, 2, 3, 4, 6, 7, 8, 9, and 10) medical records reviewed. Findings include: 1. Facility policy titled, “Transfer of Patient”, PolicyStat ID 10623375, last reviewed 06/2023, indicated that the following information shall be completed when transferring the patient: transfer order and the nurse shall conduct a Nurse to Nurse phone report with the accepting facility and document the report in the nurse’s notes. 2. Review of the medical record transfer documentation for patients 1, 2, 3, 4, 6, 7, 8, 9, and 10’s lacked documentation of the Transfer/Transport Order Form and of a nurse to nurse phone report with the accepting facility. 3. Interview with A1 (Chief Executive Officer), A2 (Director of Clinical Services), and S1 (Registered Nurse and Nursing Supervisor) on 04/04/24 at approximately 4:00 p.m. all confirmed Patients 1, 2, 3, 4, 6, 7, 8, 9, and 10’s medical record lacked documentation of the Transfer/Transport Order Form and the Form should be completed and placed in the patient’s medical record.”

“Progress Notes - Frequency CFR(s): The frequency of progress notes is determined by the condition of the patient but must be recorded at least weekly for the first 2 months and at least once a month thereafter, This Standard is not met as evidenced by: 48704 Based on document review and interview, social services failed to complete timely progress notes for 4 of 10 patients. (patients #1, #2, #3, and #7) Findings include; 1. Review of patient #1 medical record (MR) indicated the patient was admitted on 1/2/24 and discharged on 3/7/24. The MR lacked social services progress notes after 1/25/24. 2. Review of patient #2 MR indicated the patient was admitted on 1/2/24 and discharged on 2/9/24. The MR lacked social services progress notes after 1/26/24. 3. Review of patient #3 MR indicated the patient was admitted 1/3/24 and discharged 1/24/24. The MR lacked social services progress notes after 1/8/24. 4. Review of patient #7 MR indicated the patient was admitted on 1/11/24 and discharged on 3/1/24. The MR lacked social services progress notes after 1/18/24. 5. Staff member #A1 (Chief Operating Officer) and staff member #S1 (Registered Nurse and Clinical Supervisor) verified in interview on 4/4/24 at approximately 4:00 p.m. the medical records lacked social services progress notes for above patients.”

“Social Services Staff Responsibilities CFR(s): Social service staff responsibilities must include, but are not limited to, participating in discharge, planning, arranging for follow-up care, and developing mechanisms for exchange of appropriate information with sources outside the hospital. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to document complete Social Services progress notes related to discharge in 7 of 10 (patients 1, 2, 3, 4, 5, 7, and 9) medical records reviewed. Findings include: 1. Facility policy titled, “Discharge Planning”, PolicyStat ID 10827863, last approved 12/2021, indicated the social worker documents discharge information on social service notes and the Master Treatment Plan. 2. Review of Patients 1, 2, 3, 4, 5, 7, and 9’s medical records lacked discharge information in Social Services progress notes. 3. Interview with A1 (Chief Operating Officer), A2 (Director of Clinical Services), and S1 (Registered Nurse and Clinical Supervisor) on 04/04/24 at approximately 4:00 p.m. confirmed Patients 1, 2, 3, 4, 5, 7, and 9’s medical record lacked discharge information in the Social Services progress notes. 4. Interview with A2 at approximately 4:00 p.m. confirmed Social Services should document all patient and family interactions and discharge planning in the Social Services progress notes.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing services failed to document reassessment and notification of abnormal temperature vital signs to provider in 7 of 10 (Patients 1, 2, 3, 6, 7, 8, and 9) medical records reviewed; failed to ensure that provider orders were noted and failed to document neurological assessments per provider order in 1 of 10 (patient 6) medical record reviewed. Findings include: 1. Facility policy titled, “Vital Signs and Weights”, PolicyStat ID 12386461, last approved 09/2022, indicated staff will report abnormal findings to the nurse and the nurse will notify the provider of findings. 2. Facility policy titled, “Assessment/Reassessment”, PolicyStat ID 12386392, last approved 09/2022, indicated nursing staff will reassess each patient as warranted by the patient’s medical condition and document findings. 3. Facility policy titled, “Assessment-Neurological”, PolicyStat ID 12197156, last approved 08/2022, indicated nursing staff will evaluate the patient’s neurological condition after suspected head injury or when requested by a provider and document on the Neurological Flow Sheet. 4. Facility policy titled, “Physician Orders/Receipt and Notation”, PolicyStat ID 12197185, last approved 08/2022, indicated provider orders are to be noted and transcribed by nursing. 5. Review of Patient 1’s medical record lacked documentation of reassessment or notification to the provider of abnormal temperature vital signs (normal value 97.5 Fahrenheit (F) to 99.9 F) as follows: a. 06/23/23 night shift, 97.2 F b. 06/24/23 day shift, 97.1 F c. 06/24/23 night shift, 97.1 F d. 06/30/23 day shift, 96.8 F e. 07/03/23 day shift, 97.4 F f. 07/07/23 night shift, 97.4 F 6. Review of Patient 2’s medical record lacked documentation of reassessment or notification to the provider of abnormal temperature vital signs as follows: a. 07/13/23 night shift, 97.3 F b. 07/15/23 night shift, 97.3 c. 07/19/23 day shift, 96.1 F d. 07/20/23 night shift, 97.3 F 7. Review of Patient 3’s medical record lacked documentation of reassessment or notification to the provider of abnormal temperature vital signs as follows: a. 07/06/23 admission, 97.1 F b. 07/08/23 day shift, 97.2 F c. 07/08/23 night shift, 97.2 F d. 07/12/23 night shift, 97.1 F e. 07/20/23 day shift, 97.3 F f. 07/21/23 night shift, 96.9 F g. 07/22/23 night shift, 97.2 F h. 08/04/23 day shift, 97.3 F i. 08/23/23 day shift, 97.3 F j. 08/25/23 day shift, 97.2 F k. 08/26/23 day shift, 97.3 F l. 08/26/23 night shift, 97.1 F m. 08/27/23 night shift, 97.0 F n. 08/28/23 day shift, 96.5 F o. 08/28/23 night shift, 96.0 F p. 09/02/23 day shift, 96.7 F q. 09/03/23 night shift, 97.3 F r. 09/11/23 day shift, 97.2 F s. 09/20/23 day shift, 97.3 F 8. Review of Patient 6’s medical record indicated neurological assessments per fall protocol were ordered on 08/31/2023 after patient fell and MR lacked documentation of neurological assessments; provider admission orders dated 08/25/23 for laboratory orders for a complete blood count, complete metabolic panel, thyroid stimulating hormone, Hemoglobin A1c, ammonia level, and urinalysis with culture and sensitivity lacked documentation of nursing notation and were not carried out during hospital stay; medical record lacked documentation of reassessment or notification to the provider of abnormal temperature vital signs as follows: a. 08/28/23 day shift, 97.1 F b. 08/30/23 day shift, 97.1 F 9. Review of Patient 7’s medical record lacked documentation of reassessment or notification to the provider of abnormal temperature vital signs as follows: a. 08/30/23 day shift, 96.4 F b. 09/04/23 day shift, 97.4 F 10. Review of Patient 8’s medical record lacked documentation of reassessment or notification to the provider of abnormal temperature vital signs as follows: a. 08/27/23 night shift, 97.0 F b. 08/29/23 night shift, 97.4 F c. 08/30/23 day shift, 97.4 F d. 09/07/23 night shift, 96.2 F e. 09/09/23 day shift, 96.4 F f. 09/11/23 day shift, 96.4 F g. 09/18/23 day shift, 96.6 F h. 09/19/23 day shift, 95.5 F i. 09/22/23 day shift, 97.4 F j. 09/25/23 night shift, 97.2 F k. 09/29/23 day shift, 97.1 F l. 09/29/23 night shift, 97.0 F m. 10/04/23 day shift, 96.6 F n. 10/07/23 day shift, 96.6 F o. 10/11/23 day shift, 96.6 F p. 10/11/23 night shift, 97.1 F 11. Review of Patient 9’s medical record lacked documentation of reassessment or notification to the provider of abnormal temperature vital signs as follows: a. 08/30/23 day shift, 96.5 F b. 09/01/23 day shift, 97.0 F c. 09/01/23 night shift, 96.9 F d. 09/07/23 day shift, 97.6 F e. 09/07/23 night shift, 96.4 F f. 09/09/23 day shift, 97.4 F g. 09/14/23 night shift, 97.4 F 12. Interview with A3 (Director of Nursing) on 03/18/24 at approximately 3:30 p.m. confirmed that normal temperature range for patients is 97.5 degrees Fahrenheit (F) to 99.9 degrees F, if staff obtain an abnormal vital sign, they are to reassess vital sign and notify the provider of any abnormal vital sign findings. 13. Interview with A3 on 03/18/24 at approximately 5:20 p.m. confirmed that neurological assessments are done with a suspected head injury or per provider order; confirmed patient 6 had order for neurological assessments per policy. A3 at approximately at 6:30 p.m. confirmed patient 6 had an order for laboratory work and order was not noted nor completed as ordered; and patient 6 did not have a Neurological Assessment Form in their medical record. 14. Interview with A1 (Chief Executive Officer) and A3 on 03/18/24 at approximately 6:15 p.m. confirmed that patients 1, 2, 3, 6, 7, 8, and 9 had documentation of abnormal temperature vital signs documented in their medical records and medical records lacked reassessment of temperature or notification to provider of abnormal vital signs. 15. Interview with A2 (Risk Director) on 03/18/24 at approximately 6:35 p.m. confirmed that there was not a copy of the Neurological Assessment Form for patient 6.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 41134 Based on document review and interview, the nursing staff failed to report a patient-staff physical altercation and complete an incident report per policy for 1 of 10 patient medical records reviewed. (P1) Findings Include: 1. Facility policy titled “Incident Reports”, PolicyStat ID: 13033981, last revised 01/2023, indicated any hospital staff member who witnesses, discovers or has direct involvement in and/or knowledge of an event must complete an incident report, or give a detailed report to the person completing the incident report. 2. Review of P1’s medical record on 2/7/2024, daily nursing assessment indicated that P1 punched the staff nurse in the chest while the staff nurse attempted to draw labs the morning of 11/22/2023. 3. At 1740 hours on 02/07/2024, per interview with S5, Risk Manager, confirmed no report was completed on 11/22/2023 detailing a patient altercation with a staff member. S5 confirmed this as a reportable event, and that no information was available about the incident.”

“IC PROFESSIONAL ADHERENCE TO POLICIES CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by hospital personnel. This Standard is not met as evidenced by: 48061 Based on document review and interview the facility failed to follow Covid-19 protocol and document test results, lot number and expiration dates of home test kits for 5 of 5 employees/staff. (N1-N5) Findings include: 1. The facility policy titled, “COVID-19 Employee Testing”, no policy number, Approval Date date 8/11/2023, indicated if an employee utilizes a home testing kit; the employee will need to provide a photograph of the lot number, expiration date and test results. If the employee utilizes a health care provider or testing location; the employee will need to provide a copy of the test results. All testing results should be sent to the Human Resources Department. 2. In Interview on 12/7/23 at 12:00 pm with staff member A2 (Risk Management) identified N1-N5 as the staff members who tested positive for Covid-19. 3. In interview on 12/7/23 at 12:00 pm with staff member A2 (Risk Management) indicated H1 should have had but does not have record of including photo results of test results, lot numbers and expiration dates for staff members N1-N5 who were positive for Covid-19. 4. In interview on 12/7/23 at 5:00 pm with staff member A1 (Market Chief Executive Officer) indicated the facility did not follow its policy for staff members N1-N5 who tested positive for Covid-19 in regards to documentation of test results, lot numbers, and expiration dates of testing kits.”