Neuro Behavioral Hospital

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 14445 Based on document review, facility failed to complete and submit a patient/family member complaint related to behavior of a roommate for 1 of 10 MRs (Medical Records) reviewed. (Patient # 2). Findings Include: 1. Facility policy titled Patient Rights and Responsibilities, PolicyStat ID: 13517670, last revised: 9/2021, under You have the right to: 26. File a grievance or complaint verbally, by phone or in writing to any staff member. All grievances will be addressed in a timely manner. This organization will make every attempt to provide a response within seven (7) days of receiving grievance. All grievances will be investigated with efforts made toward resolution within seven (7) days of receiving a grievance. You may file a grievance or complaint with the hospital or any of the agencies listed below whether or not you use the hospital’s complaint/grievance process. 2. Review of event logs (complaint/grievance) for September 2025 through November 2025. No report entry on logs for patient # 2’s complaint on 9/14/2025 related to inappropriate behavior of his/her roommate. 3. Review of MR for patient # 2, indicated the following: a. Patient # 2, admitted on 9/10/2025, for Schizoaffective disorder, Bipolar. b. Psychiatric progress note on 9/14/2025, by NP (Nurse Practitioner - Psychiatric) reflected family members came to visit and patient told them he/she hasn’t slept because his/her roommate is doing sexual things - but that is not true.”

“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: 14445 Based on document review and interview, nursing services failed to complete laboratory orders in a timely manner for 1 of 10 MRs (medical records) reviewed. (Patient # 2). Findings include: 1. The hospital policy Laboratory Process, PolicyStat ID 12197196, indicated on page 1, under Policy, obtain laboratory results and place them on the chart for provider review in a timely manner; under Procedure, 2. Nurse transcribes order onto patient lab (laboratory) sheet, which is with the patient’s MAR (Medication Administration Record); 4. Nurse obtains specimen for ordered tests; 9. Nurses/Unit Clerks place printed results in the patient’s medical record for the provider to review. Last revised 5/2021. 2. Review of Patient # 2’s MR (Medical Record) indicated the following: (a). Patient # 2 admitted to APH # 40 (Acute Psychiatric Hospital) on 9/10/2025. (b). Provider admission orders on 9/11/2025 at 1:00 am; included Laboratory (lab) orders: CBC (complete blood count), TSH (Thyroid stimulating hormone), Lipid panel, Urinalysis and Lithium level. (c). Blood test - lab document reflected the following: Lab (CBC, Panels, Lithium & TSH) - collected on 9/16/2025; resulted/reported on 9/17/2025. (d). Social service progress note on 9/17/2025 at 4:00 pm, by FS # 2 (LSW {Licensed Social Worker} - former staff), indicated NP # 50 (Nurse Practitioner - Psychiatric) explained a UA (Urinalysis) was ordered but never collected, she/he stated would follow up on this. (f). Provider order on 9/17/2025 at 5:00 pm, by NP # 50 reflected collect UA, C&S (culture & sensitivity) ASAP (as soon as possible). (g). UA lab document reflected: UA collected on 9/18/2025 and final report on 9/20/2025. 3. In interview on 1/7/2026 at approximately 10:30 am, with A # 4 (Director of Nursing), confirmed the following: a. Lab draws should be done within shift that it was ordered, or within 24 hours of less. b. Nurse to document on sheet for draw completed. And make note for attempts if needed. 4. In interview on 1/7/2026 at approximately 11:20 am, with A # 1 (Chief Executive Officer), confirmed the following: a. Five days, not a timely manner for patient draw (blood) for lab. b. Lab policy not followed by staff.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 14445 Based on document review and interview, the hospital staff failed to ensure that policies for discharge planning and social services were followed for a patient’s discharge, for continuity of care and a safe discharge, for 1 of 10 MRs (Medical Record) reviewed. (Patient # 2). Findings include: 1. Review of hospital policy Discharge Planning, policy number: none listed, indicated on page 1, discharge planning, based on input from patient; under Procedure; information from family/support system; follow-up care, and on page 2, under documentation, Social worker documents discharge information on social service notes. Last revised 3/2022. 2. Review of hospital policy Social Services, Policy Stat ID 12197125, indicated on page 1, Social work contact & interventions for discharge planning activities; follow-up efforts, and on page 2, 1st paragraph, for continuity of care, major role in discharge planning; may include contact with patient’s family. Last revised 1/2020. 3. Review of MR for patient # 2, reflected the following: (a). Patient admitted on 9/10/2025 to APH # 40 (Acute Psychiatric Hospital) for diagnosis of: Schizoaffective disorder, Bipolar. Discharge diagnosis included: Dementia. (b). Social service progress note on 9/16/2025 at 2:47 pm, by FS # 2 (LSW {Licensed Social Worker} - former staff) - reflected spoke with FM # 2 (family member). FM # 2 expressed concerns about the patient’s ability to discharge home because he/she lives alone and his/her inability to take medications; forgetfulness and delusional thoughts. (c). Interdisciplinary discharge plan/order on 9/30/2025 (signed for social services by FS # 1 {LCSW {Licensed Clinical Social Worker} - DCS {Director Clinical Services} - former staff), reflected discharge location: FM # 2’s home. Dates of scheduled follow-up appointments. Durable medical equipment needs: wheelchair and walker. Discharge patient via transport service. (d). Nurse note on 9/30/2025 at 1:10 pm, reflected patient discharged home; belongings and paperwork sent with patient. 1. MR documentation lacked entries by social service staff for discharge planning; for communication/contact with FM # 2 for patient’s discharge on 9/30/2025 to FM # 2’s home and need for DME’s (durable medical equipment). 2. MR documentation lacked entries by social service staff for safe discharge. 4. In interview on 1/7/2026 at approximately 11:35 am, with A # 2 (Director Clinical Services), confirmed the following: a. Social workers are to document every communication with patient and/or family member. b. Verified MR for patient # 2 was lacking documentation for discharge plan; for patient to be discharged and transport provided to FM # 2’s house. No discharge communication notes after 9/17/2025 in MR. c. Policy for discharge planning was not followed. d. Documentation in patient # 2’s MR, also lacked need for walker and wheelchair in a discharge plan note. Not able to be known if was discussed with FM # 2, by previous staff for patient’s discharge.”

“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: 47186 Based on document review and interview nursing staff failed to document a completed Patient Personal Effects Inventory in 1 of 11 patient MR’s reviewed (Patient 4). Findings include: 1. Facility policy titled: Management of Patient Belongings, PolicyStat ID: 13950524, last approved 07/2023, indicated under Policy: The hospital employee’s will make every effort to ensure all belongings are described thoroughly and noted on the Personal Belongings Inventory. Under Admission: 4. Upon admission, staff will inventory all patient belongings, and sign the Personal Belongings Inventory Form. Patient will then sign the form. 2. P4’s MR lacked admitting staff and/or patient’s signature/date/time on Patient Personal Effects Inventory and/or a description of patient’s (4) bottles of medication. 3.In interview on 12/02/25 at approximately 2:23 pm, A1 (Director of Quality) confirmed P4’s MR Patient Personal Effects Inventory lacked a thorough description of (4) bottles of medication, date and time of admitting staff, and patient’s signature of items inventoried and/or returned to patient.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 47186 Based on document review and interview facility failed to update a discharge plan based on patient’s re-evaluation of condition and needs at discharge in 1 of 11 patient MR’s reviewed (Patient 4). Findings include: 1. Facility policy titled: Discharge Planning, last approved 03/2024, under Policy: Based on input from the patient/family/Guardian/POA, physician, and members of the multidisciplinary team, a discharge plan is developed. Under Procedure: Information will be obtained from the patient and/or family member/Guardian/POA, provider, medical record and other information available. Information may include: The patient’s home environment. The patient’s ability to function independently before current hospitalization. What type of situation the patient will be discharged to. Patient’s optimal level of functioning outside of the hospital. Patient’s current support system. Potential for out-of-home placement will be assessed and appropriate level of care options for longterm care will be explored with the patient and patient’s identified support system. 2. P4’s MR indicated the following: a. P4 was referred from another facility on 9/26/25, voluntarily admitted self to facility the same day with major depressive disorder, and suicidal ideation (SI). P4’s MR indicated patient was treated as an inpatient at another facility on 9/06/25 following a suicide attempt and was discharged home on 9/22/25. P4’s MR indicated patient returned to his/her home on 9/22/25 and was locked out of the residence by C1 (complainant), who no longer wished to care for this patient. P4’s MR indicated C1 blocked patent’s phone number cutting off all communication and support. P4’s MR indicated patient returned to the other facility on 9/26/25, seeking assistance with access to food, water, and shelter. P4’s MR indicated given patient’s recent SI and attempt, patient was a clear/eminent danger to themselves. P4’s MR indicated patient met criteria for emergent inpatient services at facility and voluntarily admitted themselves to the facility for stabilization, safety, and medication management. b. 9/27/25 - Psychiatric Evaluation note indicated plan to include social services and discharge planning with family meeting, if possible. Social Services to assess P4 and determine appropriate placement upon discharge. c. 9/29/25 at 11:30 am - N2’s (Licensed Social Worker [LSW]) BioPsychoSocial Assessment note indicated P4 was homeless and Social/Community Needs were indicated as “none”. d. 10/04/25 - Psychiatric Progress note indicated P4 clear for discharge to appropriate structured setting as patient unable to care for self and would be at substantial risk in the community and continue inpatient monitoring until safe and appropriate discharge can be planned/barriers for placement resolved. e. At 1:00 pm on 10/13/25 the Interdisciplinary Discharge Planning note indicated P4 was discharged to home with C1 listed as the contact. f. P4’s MR lacked documentation of Social Work communication with patient’s family for discharge planning. g. P4’s MR lacked documentation of additional Biopsychosocial Assessments for patient after 9/29/25. 3. In interview on 12/02/25 at approximately 2:23 pm, A1 (Director of Quality) confirmed P4’s MR indicated patient’s discharge to be in a structured environment, per provider’s evaluation on 10/12/25. A1 confirmed P4’s MR lacked documentation of social worker’s notes of how/with whom patient’s discharge care was coordinated with family and the home environment assessment.”

“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: 47186 Based on document review, observation, and interview nursing staff failed to ensure all patients in facility received an identification band on admission, failed to replace missing identification bands as a routine component of patients daily assessment process for 10 of 60 patients observed (Patient’s 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21), failed to obtain lab tests, as ordered, in a timely manner, and failed to document laboratory results in the medical record in 1 of 11 patient MR’s reviewed (Patient 4). Findings include: 1. Facility policy titled: Patient Identification for Clinical Care and Treatment, PolicyStat ID: 12197172, last approved 08/2022, indicated under Patient Identification Policy: Hospital Wristband: A tamperproof, nontransferable identification band shall be prepared and affixed to the patient in the admitting department. The identification band will include the patient’s name, hospital identification number, and medical record number, date of birth, age, sex, and attending physician. Before any procedure is carried out, the identification band shall be on the patient and will be checked by the responsible care provider for the follow two (2) identifiers to ensure that the right patient is involved: Patient name. Patient date of birth. Patient identification must be confirmed using the two (2) identifier system prior to conducting any healthcare procedures. Procedures may include, but are not limited to: Administration of medication. Defective or missing bands shall be replaced immediately with new bands. Each healthcare provider conducting assessments on the patient shall include a check of the patient’s identification band to assure the band is present and legible, as a routine component of the patient assessment process. The daily nursing staff rounds shall include spot checking the patients to ensure they they are wearing identification bands and the information is legible. 2. Facility policy titled: Laboratory Process, PolicyStat ID: 12197196, last approved 08/2022, indicated under Policy: To obtain laboratory results and place them on the chart for provider review in a timely manner. Procedure: 1. Provider orders lab. 4. Nurses and/or phlebotomist obtains specimen for ordered tests. 8. Nurses/Unit Clerks obtain laboratory results from lab website and print results. 9. Nurses/Unit Clerks place printed results in the patient’s medical record for the provider to review. 3. P4’s MR documented the following lab orders on admission (6/02/25) as follows: CBC (complete blood count) with differential, CMP (complete metabolic panel), TSH (thyroid stimulating hormone), and U/A (urinalysis) with C & S (culture & sensitivity) test. On 6/3/25 at approximately 8:14 am, MD1 (Nurse Practitioner [NP]) note documented patients medical regimen and follow up based on pending labs. On 6/19/25 at approximately 10:30 pm, P4’s MR documented patient cooperative for blood draw and was sent to lab for pick-up. P4’s MR lacked any previous blood draw attempts and/or any further lab draws. P4’s MR lacked documentation of lab results during facility stay or provider notification of missing labs. On 7/8/25, MD2’s (Nurse Practitioner [NP]) note documented labs ordered on admission and pending. P4 was discharged on 7/08/25. 4. On 8/12/25 at approximately 11:43 am to 12:15 pm, this writer accompanied by A2 toured facility 100, 200, and 300 Unit specifically to count patient identifier armbands. a. Unit 200 - Census 25, identification bands were missing from Patient’s 14, 18, 19, 20, and 21. c. Unit 300 - Census 13, identification bands were missing from Patient’s 12, 13, 15, 16, and 17. 5. In interview on 8/11/25 at approximately 1:05 pm to 1:16 pm, N6 (RN, Unit 100) indicated that all labs are done on admission or within 2-3 days but did not recall a specific policy or timeframe. N6 indicated if labs were refused or unable to obtain would notify the provider and document in the patient’s MR. 6. In interview on 8/12/25 at approximately 11:45 am, P12 (Current Patient, 300 Unit) indicated he/she did not have an identification band on and was not given one on admission. 7. In interview on 8/12/25 at approximately 11:46 am, P13 (Current Patient, 300 Unit) indicated he/she did not have an identification band on and was not given one on admission. 8. In interview on 8/12/25 at approximately 11:46 am, P15 (Current Patient, 300 Unit), confirmed an identification band was placed on admission but that he/she took it off and did not want to wear anything on the arms. 9. In interview on 8/12/25 at approximately 11:47 am, P16 (Current Patient 300 Unit) confirmed received an identification band on admission but since took it off and is in his/her pocket in room. P16 indicated did not want to wear the armband. 10. In interview on 8/12/25 at approximately 11:55 am, P14 (Current Patient, 200 Unit) indicated he/she did not have an identification band on and was not given one on admission. 11. In interview on 8/12/25 at approximately 12:20 pm, A1 (Director Clinical Services) confirmed there were 5 patients on the 200 Unit missing identification bands and 5 patients on the 300 Unit missing identification bands at the time of tour, on 8/12/25 at approximately 11:43 am to 12:15 pm.”

“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: 47186 Based on document review and interview nursing staff administered medications discontinued by the provider in 1 of 11 patient MR’s reviewed (Patient 1). Findings Include: 1. Facility policy titled: General Medication Administration, PolicyStat ID: 12386373, last approved 09/2022, indicated under Administration of Medication: The person administering the medication will verify that the selected medication is correct, based on the medication order and the medication product label. 2. MR review of P1 indicated on 3/24/25 at approximately 12:00 pm a provider order was documented in P1’s MR to discontinue Xanax, 0.25 mg (milligrams), by mouth, twice daily. P1’s MAR (Medication Administration Record) lacked documentation that the order had been discontinued. P1’s MAR documented patient received the following doses of Xanax, 0.25 mg, by mouth, after the order had been discontinued as follows: 10:14 pm on 3/24/25, 8:37 am and 10:55 pm on 3/25/25, and at 7:48 am on 3/26/25. 3. Facility Incident Report dated 3/26/25, indicated P1 had a medication variance with no injury/adverse outcome to patient when a medication was discontinued by provider and the order was not transcribed appropriately on the patient’s MAR. Patient received 4 doses of Xanax, 0.25 mg, by mouth, after the order was discontinued. The report noted physician/supervisor/patient family were notified, transcription error corrected, related causes and factors: policy/procedure not followed, and the resolution was reviewed by the CEO (Chief Executive Officer).”

“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: 47186 Based on document review and interview nursing staff failed to sign/date Patient Personal Effects Inventory in 1 of 10 patient MR’s reviewed (Patient 1). Findings include: 1. Facility policy titled: Admission of Patients (IN), PolicyStat ID: 12508272, last approved 10/2024, indicated under Documenation: The patient’s belongs are documented and signed for on the Patient Belongings Inventory by the nurse or designated mental health staff member. 2. P1’s MR lacked admitting staff and/or discharging staff signature/date/time on Patient Personal Effects Inventory. 3. In interview on 7/31/25 at approximately 9:02 am, A2 (Director Clinical Services) confirmed staff signature/date/time was missing from P1’s personal effects inventory record.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 14445 Based on document review and interview the facility failed to ensure a patient received care in a safe setting related to a transfer in one instance. (Patient # 5). Findings include: 1. Review of policy Patient Rights and Responsibilities, Policy Stat ID 13517670, indicated on page 1, under PROCEDURE, 1. Receive respectful care; on page 3, 18. Receive safe care. Last approved 4/2023. 2. Review of policy Advanced Directives in Hospital, Policy Stat ID 13517664, indicated on page 1, under PROCEDURE, 11. If the patient is transferred to another organization, the existence of any Advance Directives for care is communicated to the receiving organization. Last approved 4/2023. 3. Review of policy Patient Care Management, Policy Stat ID 12197166, indicated on page 4, under Safety, Standard of Care I: Pertinent patient medical information is communicated to ensure safe delivery of care. Last approved 8/2022. 4. Review of MR for patient # 5, reflected the following: a. Patient # 5, an 84 year old; admitted on 6/1/2025 for Psychosis with paranoid behaviors. b. DNR (Do not resuscitate) documentation noted. Dated 10/18/2023. c. Admission orders on 6/1/2025 at 11:20 pm reflected Code Status: DNR. d. H&P (History & Physical) on 6/2/2025, by NP # 51 (Nurse Practitioner - Medical) reflected Code Status: Do not Resuscitate. e. Provider order on 6/6/2025 at 7:31 am, by NP # 50 (Nurse Practitioner - Medical) - send patient to the hospital - indication: Hypoxia & Failure to thrive. f. Nurse note on 6/6/2025 at 9:00 am, by N # 1 (Licensed Practical Nurse) reflected patient’s vitals were BP (Blood pressure) = 101/61, Pulse = 35, Respirations = 26, Temperature = 96.7 F (Fahrenheit) and O2 (oxygen) saturation = 62%. NP # 50 ordered the nurse to send the patient out to AH # 60 (Acute Care Hospital) via 911 (Emergency Medical Services). Paramedics transported patient to AH # 60. g. MR lacked documentation by N # 1 for the following 1. For any return call from AH # 60’s ER provider for information requested. 2. That the wrong patient medical record information (patient # 11 - was a full code) was sent with EMS for patient # 5 to AH # 60’s ER/ED, and that N # 1 then faxed over to AH # 60’s ER/ED the correct patient medical record information for patient # 5, after the call with the ER provider. 5. Review of MR for patient # 5 from AH # 60 (Acute Care Hospital) reflected the following: a. ER/ED (Emergency Room/Emergency Department) provider note on 6/6/2025 reflected that patient # 5 who presents with altered mental status. Here on arrival, he/she is on a nonrebreather from EMS (Emergency Medical Services); tachypnea, using accessory muscles, not responsive to verbal stimuli or ED nurses placing IV (Intravenous) lines. He/she does have slight gag but is not making any purposeful movements. Per EMS, patient is a full code. Per review of paperwork from sending facility, patient is also full code. No family or emergency contact listed in paperwork and when ER/ED provider called the sending facility (APH # 40 - Acute Psychiatric Hospital); was placed on extensive hold. At this time, patient is in respiratory distress, unable to protect his/her airway, he/she was intubated for airway protection. Later told by ED staff that the paperwork that was sent was incorrect and they are now putting information in the computer for the correct patient. APH # 40 able to send in paperwork and he/she is a DNR. Will discuss case with family. b. ED course: note at 8:25 am, after patient intubated, ED clerk informed ER/ED provider that she/he talked to sending facility and they said they had given the wrong paperwork with wrong name. Says they are sending over patient’s correct information now. 6. In interview on 6/30/2025 at approximately 4:10 pm, with N # 1 (Licensed Practical Nurse), confirmed the following: a. Might have forgot to send copy of transfer form. b. Received call from AH #60 ER nurse; realized had sent wrong paperwork for patient.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 14445 Based on document review and interview, the facility failed to ensure the patient care units were adequately staffed to provide nursing care to all patients as needed on two patient care units. (100 unit & 200 unit). Findings include: 1. The facility policy titled: Clinical Staff (Nurse) Staffing Plan, policy number: none listed, indicated on page one (1) - Section - Purpose - This policy is to establish guidelines for providing sufficient numbers and mix of staff necessary to provide multidisciplinary patient care that is consistent with the assessed needs of the population served. Last revised 09/2024. 2. The facility Staffing Grid by shift, indicated nurses work a twelve (12) hour shift and BHA’s (Behavioral Health Associate) work eight (8) hour shifts. For Day shift - for Nurses - 7:00 am to 7:00 pm & BHA’s - 7:00 am to 3:30 pm. For Evening shift - BHA’s - 3:00 pm to 11:30 pm; for Night shift for Nurses - 7:00 pm to 7:00 am. Required staff for census-patients of 22 for Day shift = 2 Nurses & 3 BHA’s; Night shift = 2 Nurses & 1 BHA. Required staff for census-patients of 23 for Day shift = 2 Nurses & 4 BHA’s; Evening shift = 2 Nurses & 4 BHA’s; Night shift = 2 Nurses & 1 BHA. Required staff for census-patients of 24 for Day shift = 2 Nurses & 4 BHA’s; Night shift = 2 Nurses & 1 BHA. Required staff for census-patients of 25 for Day shift = 2 Nurses & 4 BHA’s; Evening shift = 2 Nurses & 4 BHA’s; Night shift = 2 Nurses & 2 BHA’s. 3. Review of staffing data worksheet for 100 unit & 200 unit, for weeks of 6/1/2025 - 6/7/2025 & 6/8/2025 - 6/14/2025, indicated the following: a. 100 unit - total 15 shifts were noted as short: 1. Day shift: 6/2/2025: Census = 22 patients; Staff = 1 Nurse & 2 BHA’s. Short 1 Nurse. 2. Day shift: 6/3/2025: Census = 24 patients; Staff = 1 Nurse & 4 BHA’s. Short 1 Nurse. Night shift: Census = 24 patients; Staff = 2 Nurses and 0 BHA’s. Short 1 BHA. 3. Day shift: 6/6/2025: Census = 23 patients; Staff = 1 Nurse (a LPN {Licensed Practical Nurse}) & 4 BHA’s. Short 1 Nurse. Night shift: Census = 23 patients; Staff = 1 Nurse & 1 BHA. Short 1 Nurse. 4. Evening shift: 6/7/2025: Census = 23 patients; Staff = 2 Nurses & 3 BHA’s. Short 1 BHA. 5. Evening shift: 23 patients; Staff = 2 Nurses & 3 BHA’s. Short 1 BHA. Night shift: 6/8/2025: Census = 23 patients; Staff = 1 Nurse & 1 BHA. Short 1 Nurse. 6. Day shift: 6/9/2025: Census = 23 patients; Staff = 1 Nurse (a LPN) & 4 BHA’s. Short 1 Nurse. Evening shift: Census = 23 patients; 1 Nurse & 3 BHA’s. Short 1 Nurse & 1 BHA. Night shift: Census = 23 patients; Staff = 1 Nurse & 2 BHA’s. Short 1 Nurse. 7. Evening shift: Census = 25 patients; Staff 2 Nurses & 3 BHA’s. Short 1 BHA. Night shift: 6/11/2025: Census = 25 patients; Staff = 1 Nurse & 2 BHA’s. 8. Evening shift: Census = 25 patients; Staff 2 Nurses & 3 BHA’s. Short 1 BHA. Night shift: 6/13/2025: Census = 25 patients; Staff = 1 Nurse & 2 BHA’s. Short 1 Nurse. b. 200 unit - total 3 shifts were noted as short: 1. Night shift: 6/3/2025: Census = 21 patients; Staff = 1 Nurse & 1 BHA. Short 1 Nurse. 2. Night shift: 6/4/2025: Census = 21 patients; Staff = 1 Nurse & 2 BHA’s. Short 1 Nurse. 3. Night shift: 6/13/2025: Census = 21 patients; Staff = 1 Nurse & 2 BHA’s. Short 1 Nurse. 4. In interview on 7/1/2025 at approximately 2:10 pm, with A # 3 (Director Quality), confirmed/ verified staffing shortages for 100 unit and for 200 unit for weeks reviewed. Staffing grid not followed.”

“RN/LPN STAFFING CFR(s): 482.23(b)(1) The hospital must provide 24-hour nursing services furnished or supervised by a registered nurse, and have a licensed practical nurse or registered nurse on duty at all times, except for rural hospitals that have in effect a 24-hour nursing waiver granted under o488.54(c) of this chapter. This Standard is not met as evidenced by: 14445 Based on document review and interview the hospital failed to provide nursing services supervised by a registered nurse for 2 of 28, unit 100, Nursing (12 hour shifts) shifts reviewed. (Day shift 6/6/2025 & Day shift 6/9/2025). Findings include: 1. Review of policy Clinical Staff (Nurse) Staffing Plan, policy number: none listed, last revised 9/2024, indicated on page 4. under Staffing Plan, B., first point - There must be at least one (1) RN (Registered Nurse) on every unit at all times. C. The hospital utilizes twelve (12) hour shifts for nurses. 2. Review of APH # 40’s (Acute Psychiatric Hospital) unit 100 Staffing Sheets, indicated the following: a. Day shift on 6/6/2025 - 1 LPN (N # 1) and 4 BHA’s. Lacked 1 RN on unit. b. Day shift on 6/9/2025 - 1 LPN (N # 1) and 4 BHA’s. Lacked 1 RN on unit. 3. In interview on 6/30/2025 at approximately 4:10 pm, with N # 1 (LPN), confirmed the following: a. That has worked 100 unit by herself/himself - the only nurse for the shift. b. That this has occurred more than once; worked with no RN on unit. c. It was a busy morning on 6/6/2025; I was the only nurse for 20 + patients. d. Not enough help on unit. 4. In interview on 7/1/2025 at approximately 2:10 pm, with A # 3 (Director of Quality), confirmed the following: a. That the 100 unit was short staffed on 6/6/2025 & 6/9/2025. b. That there was only one (1) nurse a LPN - on day shift for 6/6/2025 & 6/9/2025, with no RN staffed on unit.”

“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: 14445 Based on document review and interview, the nursing services failed to complete a transfer/transport report form per policy/procedure for 1 of 10 MRs (Medical Records) reviewed. (Patient # 5). Findings include: 1. Review of policy Transfer of Patient, Policy Stat ID 10623375, indicated on page 1, under PURPOSE, guidelines to follow to help assure continuity of care and communication of vital patient information. Definition: Transport: when a patient is sent to either another health care institution for medical services. Appropriate patient information will accompany the patient during transfer/transport. Last reviewed 6/2023. 2. Review of MR for patient # 5, reflected the following: a. Patient # 5, an 84 year old; admitted on 6/1/2025 for Psychosis with paranoid behaviors. b. Provider order on 6/6/2025 at 7:31 am, by NP # 50 (Nurse Practitioner - Medical) - send patient to the hospital - indication: Hypoxia & Failure to thrive. c. MR lacked documentation by N # 1 for the following: - The completion of a Patient Transfer/Transport Report form for patient # 5’s send out to AH # 60’s (Acute Care Hospital) ER/ED (Emergency Room/Emergency Department) on 6/6/2025 am (morning). 3. Review of Transfer log binder on 100 unit for June 2025, lacked an entry by N # 1 for patient #5’s transfer/transport to AH # 60 on 6/6/2025 am (morning). 4. In interview on 6/30/2025 at approximately 4:10 pm, with N # 1 (Licensed Practical Nurse), confirmed that N # 1 might have forgot to send copy of transfer/transport report form.”

“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: 14445 Based on document review and interview, nursing services failed to complete and submit an incident report per policy/procedure, for a patient send out to Acute Care Hospital via EMS (Emergency Medical Services) for 1 of 10 MRs (Medical Records) reviewed. (Patient # 5). Findings include: 1. Review of policy Incident Reports, Policy Stat ID 13033981, indicated on page 1, under PROCEDURE, A. hospital staff must complete and submit an incident report as soon as possible, but no later than twenty-four (24) hours from the time the event occurred, and on page 2. under Completing an Incident Report: A. This should be done by the employee who witnessed or was informed of the incident; under Responsibilities: Supporting documentation will by ready for review by the Risk Manager within 7 days of the incident. The Administrator On-call is to be notified as soon as possible after any incident. Last revised 1/2023. 2. Review of incident/event logs for June 2025, lacked an entry for the incident/event report for patient # 5’s send out to AH # 60 (Acute Care Hospital) on 6/6/2025. 3. In interview on 6/30/2025 at approximately 4:05 pm, with A # 2 (LCSW {Licensed Clinical Social Worker} - Director of Clinical Services), confirmed that no incident report for patient # 5, for send out to ER at AH # 60 on 6/6/2025. There should have been one completed by nurse. Policy not followed. 4. In interview on 6/30/2025 at approximately 4:10 pm, with N # 1 (Licensed Practical Nurse), confirmed the following: a. Would - suppose to fill out incident report, but not done; forgot and exhausted; was short staffed, and forgot then next day to complete one. b. Thought texted A # 5 (Chief Executive Officer), but must have not.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 35731 Based on document review and interview, the facility failed to ensure the patient care unit was adequately staffed to provide nursing care to all patients as needed on one (1) patient care units. (Unit - 200) Findings include: 1. The facility policy titled, Clinical Staff (Nurse) Staffing Plan, no policy number, indicated on page one (1) - Section - Purpose - This policy is to establish guidelines for providing sufficient numbers and mix of staff necessary to provide multidisciplinary patient care that is consistent with the assessed needs of the population served. This policy was last revised on 09/2024. 2. The facility Sample Staffing Grid by shift, indicated nurses work a twelve (12) hour shift and BHA’s (Behavioral Health Associate) work eight (8) hour shifts. The Staffing Grid for Days/Evening shift indicated the following: Census 20 - 26 patients = one (1) Registered Nurse (RN), 20 - 25 patients = one (1) Licensed Practical Nurse (LPN), 26 patients = two (2) LPN’s, Night shift 20-26 patients = one (1) RN, and one (1) LPN. The Staffing Grid for Days/Evening shift indiacated the following: Census 20-22 patients = three (3) Behavioral Health Associates (BHA’s), 23-25 patients = four (4) BHA’s, 26 patients = three (3) BHA’s. Night shift 20 -24 patients = one (1) BHA, and 25-26 patients = two (2) BHA’s. 3. Review of H # 2’s (Psychiatric Hospital) “staffing pattern worksheet” and “daily census sheet” provided by the facility, indicated the 200 unit was short staffed by staffing guidelines during the weeks of 04/20/2025 through 05/03/2025 on the following dates/shifts: a. On 04/22/2025 - Patient Census - 22 - Day shift (7:00 am - 3:00 pm) was staffed with three (3) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed one (1) BHA. b. On 04/23/2025 - Patient Census - 26 - Day shift was staffed with three (3) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed one (1) BHA. Evening shift (3:00 pm - 11:00 pm) was staffed with three (3) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed one (1) BHA. c. On 04/24/2025 - Patient Census - 20 - Day shift was staffed with two (2) BHA’s and per facility guidelines they should have had three (3) BHA’s. The shift was short staffed one (1) BHA. d. On 04/25/2025 - Patient Census - 24 - Day shift was staffed with two (2) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed two (2) BHA’s. Evening shift was staffed with three (3) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed one (1) BHA. e. On 04/26/2025 - Patient Census - 24 - Day shift was staffed with two (2) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed two (2) BHA’s. Evening shift was staffed with two (2) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed two (2) BHA’s. f. On 04/27/2025 - Patient Census - 26 - Nursing day shift (7:00 am - 7:00 pm) - was staffed with two (2) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one (1) nurse. Nursing night shift (7:00 pm - 7:00 am) - was staffed with two (2) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one (1) nurse. Evening shift was staffed with two (2) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed two (2) BHA’s. g. On 04/28/2025 - Patient Census - 26 - Nursing day shift was staffed with two (2) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one (1) nurse. Nursing night shift - was staffed with two (2) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one (1) nurse. Evening shift was staffed with two (2) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed two (2) BHA’s. h. On 04/29/2025 - Patient Census - 25 - Day shift was staffed with three (3) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed one (1) BHA. Evening shift was staffed with three (3) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed one (1) BHA. i. On 04/30/2025 - Patient Census - 23 - Nursing night shift - was staffed with one (1) nurse and per facility guidelines they should have had two (2) nurses. The shift was short staffed one (1) nurse. 4. In interview on 06/20/2025 at approximately 3:00 pm with administrative staff member A # 2 (Director of Clinical Services), confirmed H # 2 had been short staffed for the shifts indicated above.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 35731 Based on document review and interview the facility failed to ensure a patient was free from abuse in one (1) instance (Patient # 10), failed to ensure a patient was free from abuse in one (1) instance (patient # 10), and failed to ensure an employee completed a refresher course related to appropriate hold/restraint techniques in one (1) instance. (D # 2-Interim Director of Nursing) The cumulative effect of this systemic problem resulted in the facility’s inability to ensure that Patient Rights were promoted.”

“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: 35731 Based on document review and interview, the facility failed to ensure a patient was free from abuse in one (1) instance (Patient # 10); failed to ensure an allegation of physical abuse toward a patient was appropriately investigated, analyzed and reported to the necessary agencies in accordance with applicable laws in one (1) instance. (Patient # 10) Findings include: 1. The facility policy titled, Patient Rights and Responsibilities, PolicyStat ID 13517670, indicated on page three (3) - section Procedure - number eighteen (18) - Receive care in a safe setting free from verbal or physical abuse or harassment. This policy was last revised on 09/2021. 2. The facility policy titled, Patient Abuse and Neglect, no policy number, indicated on page one (1) - section - Purpose - To provide procedures for reporting, investigating, and following up on an allegation of patient abuse - on page two (2) - section - Definitions - Investigator - The person or persons assigned to find facts about an incident or allegation of abuse - on page three (3) - Procedure - Obtain initial written statements; an internal investigation form will be completed by the Hospital CEO, Human Resource Director, and/or Director of Quality. Copies of the completed internal investigation form, video clip, written statements, incident report, nursing notes (if applicable) - on page four (4) - will be reviewed by the Hospital Director of Quality and CEO no more than 24 hours after the initial 72 hours investigation period for review and signature after verifying accuracy - section - Reporting - The Director of Quality or Designee will notify their State Department of Mental Health and Addiction Licensing Agency and any additional required accrediting or licensing bodies if patient abuse and/or neglect is substantiated. Addiditionally, this policy does not remove the requirement of a mandated reporter to report incidents of abuse, neglect, etc. of an endangered or at risk patient (as defined by State Law) to all required social service agencies and other entitiies, including but not limited to APS, CPS, the State Attorney General, etc. This policy was last revised on 04/2024. 3. The facility policy titled, Restraint or Seclusion Use, Policy ID 13483128, indicated on page one (1) - section Policy - interventions, holds, and seclusion only to protect the immediate physical safety of the patient. This policy was last revised on 01/2025. 4. Incident Report dated 03/03/2025 at 10:35 am indicated while on one (1) to one (1) - 300 unit - unprovoked act - intentional act - supervisor/family notified - patient # 10 began peeling the window covering off the windows and placing it around his/her neck. Staff responded immediately, patient became aggressive attempting to continue self-harm. Patient # 10 refused oral medication for anxiety then became aggressive with intramuscular (IM) injection attempts. The patient took himself/herself to the ground during his/her aggressive behavior. He/she began hitting, kicking and reportedly biting staff. Staff used the physical hold Handle with Care (HWC) technique while the patient was on his/her back. The patient began spitting at staff. The patient continued to display aggression while on the floor in the hold which lasted over an hour because the patient would not calm down even with IM’s. Patient was placed in seclusion at 11:33 am. The incident report lacked any documentation of improper hold/technique/patient abuse. 5. Review of the closed medical record for patient # 10 indicated the patient was a 20 y/o (year/old) admitted to H # 2’s (Psychiatric Hospital) inpatient unit on 01/27/2025. The patient’s diagnoses included, but were not limited to, major depressive disorder, severe without psychotic features, suicidal ideation, and attention deficit hyperactivity disorder (ADHD). The Daily Nursing Assessment dated 03/03/2025 at 10:20 am the patient began hitting, kicking, and attempting to bite staff. Patient took self to floor during aggression and snatched a staff member around the head. The patient began spitting at staff. At 10:52 am the patient was administered another IM injection, but he/she became increasingly aggressive with failed attempts to de-escalate. At 11:15 am the patient remained on the floor with staff assisting (holding arms and legs) due to the increased aggression displayed by the patient. The patient was swinging arms, kicking staff while he/she continued to spit/attempt to bite. At 11:32 am another IM injection was administered. The patient agreed to cooperate with staff by getting up and once standing up he/she became aggressive, seclusion was ordered, and patient was placed in seclusion. 6. In interview on 04/03/2025 at approximately 11:45 am with unlicensed staff member B # 2, confirmed he/she was at the code with patient # 10, and witnessed D # 2 (Interim Director of Nursing-DON) place his/her hands on the patient’s throat choking him/her. The patient’s face turned dark red. 7. In interview on 04/03/2025 at approximately 12:30 pm with unlicensed staff member H # 11, confirmed he/she was assisting with the physical hold of patient # 10 on 03/03/2025. D # 2 was trying to put a mask on patient # 10 when he/she tried to bite D # 2. The patient was wheezing, and I heard D # 2 say, “you will be okay ...you will be able to breathe once I let you go”. H # 11 looked up because what D # 2 said and the patient’s face was purple/blue. We all have been bit before but never took it that far. That was too far. 8. In interview on 04/03/2025 at approximately 1:45 pm with unlicensed staff member P # 2, confirmed he/she was present for the code on 03/03/2025 with patient # 10. The patient was spitting so he/she wasn’t looking at the patient but heard the patient gasping for air and wheezing. 9. In interview on 04/03/2025 at approximately 3:45 pm with administrative staff member A # 1 (Chief Executive Officer-CEO), confirmed he/she should have looked/reviewed at the collected information related to the 03/03/2025 accusation of patient abuse before telling Human Resources it was okay for D # 2 to return to work. 10. In interview on 04/04/2025 at approximately 8:45 am with administrative staff member A # 1, confirmed H # 2 references the Abuse and Neglect policy when allegations of abuse between staff and patients occur. H # 2 changed staff training from CPI to HWC training. It’s all the same intervention/prevention/de-escalation/hold techniques. 11. In a phone interview on 04/04/2025 at approximately 11:20 am with licensed staff member A # 6, confirmed he/she reported the abuse allegation to A # 1, A # 3 (Director of Quality), and A # 5 (Human Resource Director) immediately. B # 2 was shaken up when he/she was telling me what happened during the code. The week before the abuse allegation occurred, I sent an email to A # 1 which indicated that I believed that D # 2 was acting inappropriately to patient # 10 and suggested that D # 2 work on a different unit. 12. In interview on 04/04/2025 at approximately 12:12 pm with unlicensed staff member B # 5, confirmed he/she was present at the code for patient # 10 was in the physical hold on 03/03/2025. D # 2 was holding the patient’s jaw/upper throat and told the patient that he/she could breathe once he/she let go. The patient sounded like they couldn’t breathe, and the patient’s face was red/blue. It seemed like it lasted for about two (2) minutes. B # 5 stated that he/she was not taught to hold a patient on or near the throat. 13. In interview on 04/07/2025 at approximately 3:07 pm with administrative staff member A # 1, confirmed he/she should have been more involved with the investigation of patient # 10’s abuse allegation which occurred on 03/03/2025. The witness statements were not obtained correctly regarding the allegation of patient abuse. We should have completed an incident report, and we should have reported the abuse to the necessary agencies (licensing board, APS, Attorney General and DMHA),”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(1) Training intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion- (i) Before performing any of the actions specified in this paragraph; (ii) As part of orientation; and (iii) Subsequently on a periodic basis consistent with hospital policy. This Standard is not met as evidenced by: 35731 Based on document review and interview the registered nurse failed to complete a mandated refresher course related to Handle with Care (HWC) in one (1) instance. (D # 2 - Interim Director of Nursing) Findings include: 1. The facility policy titled, Staff Competencies, PolicyStat ID: 12507941, indicated on page one (1) - section - Policy - Competence may be assessed through discipline specific skills check lists - on page two (2) - section - Consequences for Not Meeting Competency Requirements - number one (1) - When a staff member’s competency does not meet the requirements, the employee will be given education and may be placed on a performance improvement plan. This policy was last revised on 01/2020. 2. Review of Personnel files for D # 2 (Interim DON), indicated a Disciplinary Action Notice Form dated 03/03/2025 - Counseling - Findings - During a patient restraint, the use of an incorrect hold was performed. As a result of the violation of proper procedure, D # 2 is required to complete a refresher course with HWC (Handle with Care) before assisting with any future codes. Attendance is mandatory. The Personnel file for D # 2 lacked documentation of a completed refresher course. 3. In interview on 04/07/2025 at approximately 4:40 pm with administrative staff member A # 5, confirmed D # 2 stated that he/she was not going to complete the HWC refresher course, even though it had been mandated. D # 2 had been on over six (6) codes since 03/03/2025.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 35731 Based on document review and interview, the facility failed to ensure the patient care units were adequately staffed to provide nursing care to all patients as needed on three (3) patient care units. (Units-100, 200 & 300) Findings include: 1. The facility policy titled, Clinical Staff (Nurse) Staffing Plan, no policy number, indicated on page one (1) - Section - Purpose - This policy is to establish guidelines for providing sufficient numbers and mix of staff necessary to provide multidisciplinary patient care that is consistent with the assessed needs of the population served. This policy was last revised on 09/2024. 2. The facility Sample Staffing Grid by shift, indicated nurses work a twelve (12) hour shift and BHA’s (Behavioral Health Associate) work eight (8) hour shifts. 3. Review of the facilities “staffing pattern worksheet” and “daily census sheet” provided by the facility, indicated the 100, 200, and 300 units were short staffed by staffing guidelines during the week of 03/02/2025 through 03/08/2025 and during the week of 04/03/2025 through 04/07/2025 on the following dates/shifts: 100 Unit: a. On 03/02/2025 - Day shift (7:00 am - 7:00 pm) - Patient Census - 26 - the unit was staffed with two (2) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one (1) nurse. Night shift (11:00 pm - 7:00 am) - the unit was staffed with one and a half (1.5) BHA’s (Behavioral Health Associate) and per facility guidelines they should have had two (2) BHA’s. The shift was short staffed one (1) BHA. b. On 03/03/2025 - Day shift - Patient Census - 26 - the unit was staffed with one and a half (1.5) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one and a half (1.5) nurses. Night shift - the unit was staffed with one (1) BHA and per facility guidelines they should have had two (2) BHA’s. The shift was short staffed one (1) BHA. c. On 03/04/2025 - Day shift - Patient Census - 26 - the unit was staffed with two (2) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one (1) nurse. Evening shift (3:00 pm - 11:00 pm) - the unit was staffed with two and a half (2.5) BHA’s and per facility guidelines they should have had three (3) BHA’s. The shift was short staffed a half (0.5) BHA. d. On 03/06/2025 - Day shift - Patient Census - 26 - the unit was staffed with two (2) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one (1) nurse. e. On 03/07/2025 - Day shift - Patient Census - 25 - the unit was staffed with three (3) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed one (1) BHA. Evening shift - the unit was staffed with two and a half (2.5) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed by one and a half (1.5) BHA’s. Night shift - the unit was staffed with one (1) BHA and per facility guidelines they should have had two (2) BHA’s. The shift was short staffed one (1) BHA. f. On 03/08/2025 - Day shift - Patient Census - 25 - the unit was staffed with three (3) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed one (1) BHA. Evening shift - the unit was staffed with two (2) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed two (2) BHA’s. Night shift - the unit was staffed with one (1) BHA and per facility guidelines they should have had two (2) BHA’s. The shift was short staffed one (1) BHA. g. On 04/05/2025 - Day shift (7:00 am - 3:00 pm) - Patient Census - 21 - the unit was staffed with two (2) BHA’s (Behavioral Health Associate) and per facility guidelines they should have had three (3) BHA’s. The shift was short staffed one (1) BHA. h. On 04/06/2025 - Day shift - Patient Census - 23 - the unit was staffed with two (2) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed two (2) BHA’s. 200 Unit: a. On 03/02/2025 - Day shift (7:00 am - 7:00 pm) - Patient Census - 26 - the unit was staffed with two (2) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one (1) nurse. Day shift (7:00 am - 3:00 pm) was staffed with two (2) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed two (2) BHA’s. Evening shift (3:00 pm - 11:00 pm) - the unit was staffed with one (1) BHA and per facility guidelines they should have had three (3) BHA’s. The shift was short staffed two (2) BHA’s. Night shift (11:00 pm - 7:00 am) - the unit was staffed with one (1) nurse (working as BHA) and per facility guidelines they should have had two (2) BHA’s. The shift was short staffed one (1) BHA. b. On 03/03/2025 - Day shift - Patient Census - 26 - the unit was staffed with two (2) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one (1) nurse. Day shift - the unit was staffed with two and a half (2.5) BHA’s and per facility guidelines they should have had three (3) BHA’s. The shift was short staffed by a half (0.5) BHA. Night shift (11:00 pm - 7:00 am) - the unit was staffed with one (1) nurse (working as BHA) and per facility guidelines they should have had two (2) BHA’s. The shift was short staffed one (1) BHA. c. On 03/04/2025 - Day shift - Patient Census - 26 - the unit was staffed with two (2) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one (1) nurse. Night shift - the unit was staffed with one (1) BHA and per facility guidelines they should have had two (2) BHA’s. The shift was short staffed one (1) BHA. d. On 03/05/2025 - Day shift - Patient Census - 25 - the unit was staffed with three (3) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed one (1) BHA. Evening shift - the unit was staffed with three (3) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed one (1) BHA. e. On 03/06/2025 - Day shift - Patient Census - 24 - the unit was staffed with three (3) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed one (1) BHA. Evening shift - the unit was staffed with three (3) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed one (1) BHA. f. On 03/07/2025 - Evening shift - Patient Census - 20 - the unit was staffed with one and a half (1.5) BHA’s and per facility guidelines they should have had three (3) BHA’s. The shift was short staffed by one and a half (1.5) BHA’s. g. On 03/08/2025 - Day shift - Patient Census - 20 - the unit was staffed with two (2) BHA’s and per facility guidelines they should have had three (3) BHA’s. The shift was short staffed one (1) BHA. h. On 04/03/2025 - Evening shift (3:00 pm - 11:00 pm) - Patient Census - 22 - the unit was staffed with two (2) BHA’s and per facility guidelines they should have had three (3) BHA’s. The shift was short staffed one (1) BHA. i. On 04/04/2025 - Evening shift - Patient Census - 23 - the unit was staffed with two (2) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed two (2) BHA’s. j. On 04/04/2025 - Night shift (11:00 pm - 7:00 am) - Patient Census - 23 - the unit was staffed with zero (0) BHA’s and per facility guidelines they should have had one (1) BHA. The shift was short staffed one (1) BHA. k. On 04/05/2025 - Day shift - Patient Census - 23 - the unit was staffed with one (1) nurse and per facility guidelines they should have had two (2) nurses. The facility was short staffed one (1) nurse. Evening shift - the unit was staffed with two (2) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed two (2) BHA’s. l. On 04/06/2025 - Day shift - Patient Census - 25 - the unit was staffed with two (2) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed two (2) BHA’s. Evening shift - the unit was staffed with two (2) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed two (2) BHA’s. Night shift - the unit was staffed with one (1) BHA and per facility guidelines they should have had two (2) BHA’s. The shift was short staffed one (1) BHA. m. On 04/07/2025 - Day shift - Patient Census - 25 - the unit was staffed with one (1) nurse and per facility guidelines they should have had two (2) nurses. The shift was short staffed one (1) nurse. Day shift - the unit was staffed with two (2) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed two (2) BHA’s. Evening shift - the unit was staffed with two (2) BHA’s and per facility guidelines they should have had four (4) BHA’s. The shift was short staffed two (2) BHA’s. 300 Unit: a. On 03/02/2025 - Evening shift (3:00 pm - 11:00 pm) - Patient Census - the unit was staffed with one and a half (1.5) BHA’s and per facility guidelines they should have had two (2) BHA’s. The shift was short staffed by a half (0.5) BHA. b. On 04/03/2025 - Evening shift - Patient Census - 11 - the unit was staffed with one (1) BHA and per facility guidelines they should have had two (2) BHA’s. The shift was short staffed one (1) BHA. c. On 04/04/2025 - Evening shift - Patient Census - 12 - the unit was staffed with one (1) BHA for the entire shift and one (1) BHA for half of the shift (until 7:00 pm) and per facility guidelines they should have had two (2) BHA’s. The shift was short staffed one (1) BHA for four (4) hours. d. On 04/05/2025 - Day shift - Patient Census - 10 - the unit was staffed with one (1) BHA and per facility guidelines they should have had two (2) BHA’s. The shift was short staffed one (1) BHA. Evening shift - the unit was staffed with one (1) BHA and per facility guidelines they should have had two (2) BHA’s. The shift was short staffed one (1) BHA. 4. In interview on 04/04/2025 at approximately 12:34 pm with patient care staff member B # 4 (BHA), confirmed . we (BHA’s) are always short staffed. 5. In interview on 04/04/2025 at approximately 3:40 pm with patient care staff member B # 6 (BHA), confirmed lot of people have been fired or resigned and we are short on nights. 6. In interview on 04/07/2025 at approximately 12:20 am with administrative staff member A # 5 (Human Resource Director), confirmed that H # 2 has been short staffed. 7. In interview on 04/07/2025 at approximately 2:44 pm with nursing staff member D # 3 (New Interim Director of Nursing-DON), confirmed the units have been short staffed. We need to hold admissions. 8. In interview on 04/07/2025 at approximately 3:07 pm with administrative staff member A # 1 (Chief Executive Officer-CEO), confirmed the facility has had a lot of staff call-offs, which leaves the patient care units short staffed.”

“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: 35731 Based on document review and interview, the nurse failed to ensure a weekly skin assessment was completed in six (6) instances. (Patient # 10) Findings include: 1. The facility policy titled, Skin Assessment, PolicyStat ID: 12385990, indicated on page one (1) - Procedure - Assessment - number one (1) skin assessments should be completed one (1) time per week. This policy was last revised on 09/2022. 2. Review of the closed medical record for patient # 10 indicated the patient was a 20 year old admitted to the inpatient unit on 01/27/2025 with a diagnoses which included, but were not limited to, major depressive disorder, severe without psychotic features, suicidal ideation, and attention deficit hyperactivity disorder (ADHD). Weekly Skin Assessment form dated 01/27/2025 indicated the patient had bruising on his/her left forearm and blisters to the bottom of both feet. The form lacked a patient skin assessment on 02/04/2025, 02/11/2025, 02/18/2025, 02/26/2025, 03/04/2025, and 03/11/2025. 3. In interview on 04/07/2025 at approximately 2:44 pm with nursing staff member D # 3 (Interim Director of Nursing), confirmed nurses should be completing weekly skin assessments every Tuesday on the Skin Assessment Form.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 26641 Based on document review, observation and interview, the facility failed to ensure patient care in a safe setting by failing to implement Q (every) 15 minutes and/or 1:1 (one-to-one) observations for 7 patients (#3, #4, #5, #6, #7, #8 and #10); failed to ensure freedom from patient-to-patient assaultive-combative behavior for 7 patients (#3, #4, #5, #6, #7, #8 and #10); failed to ensure freedom from patient-to-staff assaultive-combative behavior from 1 patient (#3); and failed to ensure freedom from sexual abuse for 2 patients (#10 and unable to determine female patient). (See Tag 144) The cumulative effect of these systemic problems resulted in the facility’s inability to ensure that Patient Rights were promoted.”

“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: 26641 Based on document review and interview, the facility failed to ensure adequate staffing per policy for 2 patient care units (Units 200 and 300); and failed to supervise accurate Incident Report documentation for 16 (#616, #966, #969, #970, #971, #982, #983, #984, #985, #986, #990, #991, #992, #997, #998 and #1004) Incident Reports reviewed. (See Tag 392 and 398) The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 26641 Based on document review, observation and interview, the facility failed to ensure patient care in a safe setting by failing to implement Q (every) 15 minutes and/or 1:1 (one-to-one) observations for 7 patients (#3, #4, #5, #6, #7, #8 and #10); failed to ensure freedom from patient-to-patient assaultive-combative behavior for 7 patients (#3, #4, #5, #6, #7, #8 and #10); failed to ensure freedom from patient-to-staff assaultive-combative behavior from 1 patient (#3); and failed to ensure freedom from sexual abuse for 2 patients (#10 and unable to determine female patient). Findings include: 1. The facility policy titled, “Patient Rights and Responsibilities”, PolicyStat ID 13517670, revised 9/2021, indicated on page 3 of 6, under Procedure section, You have the right to ...18. Receive care in a safe setting, free from verbal or physical abuse or harassment. 2. The facility policy titled, “Assaultive-Combative Patients”, PolicyStat ID 12195122, revised 1/2020, indicated on page 2 of 2, under Policy section, In the event that a patient escalates and becomes assaultive/combative, all safety measures shall be provided to the patient, other patients and staff, with the least restrictive interventions possible based on the level of acuity and patient needs. 3. The facility policy titled, “Patient Observation”, PolicyStat ID 12931622, revised 1/2023, indicated: A. On page 1 of 3, under Procedure section, point 1. All patients will be admitted to the patient care unit with a minimum of “every 15 minutes” observation level. B. On page 2 of 3, under 3. Level III - 1:1 Observation, point 1. The patient is to be under constant visual observation by an assigned staff member, regardless of other unit activities. 4. The facility policy titled, “Patient Abuse and Neglect”, PolicyStat ID (none listed on policy), revised 4/2024, indicated on page 1 of 4, under Policy section, All patients have the right to be free from abuse or neglect as well as the fear of being abused or neglected. Allegations or information indicating that abuse or neglect may have occurred will be thoroughly and promptly investigated with appropriate action taken. 5. Review of patient Medical Records (MRs) on 12/19/2024 beginning at approximately 12:30 pm and as needed throughout the entire survey, indicated: A. Patient #3 was admitted on 11/24/2024 for autism with intermittent explosive disorder; presenting with acute physical aggression, verbal aggression, and impulsive behaviors. a. Patient Safety Observation Rounds indicated 1:1 observation. b. IR (Incident Report) #616 dated 11/24/2024 at 8:30 am indicated patient #3 attempted to physically attack another patient (unable to determine which patient from the IR). c. IR #966 dated 11/25/2024 at 9:32 am indicated patient #3 was physically aggressive toward staff (unable to determine which staff from the IR). d. IR #969 dated 11/26/2024 at 10:50 am indicated patient #3 was physically aggressive toward provider. e. IR #970 dated 11/27/2024 at 8:45 am indicated patient #3 was physically aggressive toward staff (unable to determine which staff from the IR). f. IR #971 dated 11/28/2024 at 1:40 pm indicated patient #3 was physically aggressive toward two other patients (unable to determine which patients from the IR). g. IR #985 dated 12/6/2024 at 9:30 pm indicated patient #3 slapped patient #8 across the face. h. IR #992 dated 12/7/2024 at 9:00 pm indicated patient #3 had multiple incidents of impulsive, threatening, aggressive and destructive behaviors. After staff placed patient into seclusion room per provider order, patient ran into the seclusion room door until it broke. Agitation continued to progress, unable to be redirected and 911 called. Patient taken into custody by police officers. B. Patient #4 was admitted on 12/6/2024 for bipolar disorder and physically, verbally aggressive. a. Patient Safety Observation Rounds indicated Q15 minutes observation. b. IR #990 dated 12/7/2024 at 8:30 pm indicated patient #4 choked a patient and pulled out a plug of patient’s hair (unable to determine which patient from the IR). c. IR #997 dated 12/11/2024 at 8:30 pm indicated patient #4 physically attacked patient #7 and after being put into the seclusion room on Unit 100, patient #4 broke down the seclusion room door, kicked ambulance bay door window repeatedly until it broke and crawled through the opening, punched fire alarm box until alarm went off and all the doors in the facility opened. Eloped into parking lot and was apprehended by police. C. Patient #5 was admitted on 12/6/2024 for suicidal ideation, impulsive behaviors, harm to self and others. a. Patient Safety Observation Rounds indicated Q15 minutes observation. b. IR #983 dated 12/6/2024 at 2:10 am indicated patient #5 got into an altercation with another patient (unable to determine which patient from the IR). c. IR #991 dated 12/7/2024 at 8:30 pm indicated patient #5 got into an altercation with two other patients (unable to determine which patients from the IR). D. Patient #6 was admitted on 11/28/2024 for suicidal ideation. a. Patient Safety Observation Rounds indicated Q15 minutes observation. b. IR #984 dated 12/6/2024 at 2:10 am indicated patient #6 walked up to another patient and punched patient in the head (unable to determine which patient from the IR). E. Patient #7 was admitted on 11/24/2024 for acute verbal aggression, impulsive behaviors. a. Patient Safety Observation Rounds indicated Q15 minutes observation. b. IR #998 dated 12/11/2024 at 8:30 pm indicated patient #7 was physically attacked by patient #4 who was put into seclusion room on Unit 100. Patient #4 broke down seclusion room door, kicked out ambulance bay door window, punched fire alarm box until alarm went off and all the doors in the facility opened. Eloped into the parking lot and apprehended by police. F. Patient #8 was admitted on 12/6/2024 for suicidal ideation. a. Patient Safety Observation Rounds indicated Q15 minutes observation. b. IR #986 dated 12/6/2024 at 9:30 pm indicated patient #3 slapped patient #8 across the face. G. Patient #10 was admitted on 12/17/2024 for suicidal ideation. a. Patient Safety Observation Rounds indicated Q15 minutes observation. b. IR #1004 dated 12/17/2024 at 7:40 pm, indicated patient was seen by staff in bed with a female patient (unable to determine from IR who this patient was). 6. Video review on 12/19/2024 at approximately 5:18 pm, showed patient #4 on 12/11/2024 at approximately 10:08 pm to 10:10 pm pacing around in the area by the Ambulance Bay of Unit 100 after breaking out of the seclusion room door on Unit 100. Patient picked up garbage can and threw it across the area, then kicked the ambulance bay door window repeatedly until it broke and crawled through the opening. Patient continued to punch the fire alarm box until the alarm went off and all the doors in the facility opened. Patient eloped into the parking lot. Four Nursing Staff: P19 (Nurse Supervisor), P20 (Nurse Supervisor), P21 Behavioral Health Associate [BHA], and P22, BHA remained in the Nurses Station with the doors closed during this incident, opening the doors once for several seconds at approximately 10:09 pm to allow in P12 (BHA) who came from Unit 200. 7. Staff P3 (Chief Executive Officer) was interviewed on 12/20/2024 at approximately 1:50 pm and confirmed: A. After the incident with patient #3 on 12/7/2024, “none” no staff education has been provided related to the incident. What was put into place, was assessing the seclusion room (SR) doors on Unit 100 & 200 and ordering the doors that will be installed next week. B. After the incident with patient #4 on 12/11/2024, no staff education has been provided related to the incident. P3 Spoke with P19, P20, and P15 (Registered Nurse) about engaging SR deadbolt after a patient is put in SR. This information was not provided to other staff and/or staff has not been educated pertaining to engaging the SR deadbolt. 8. Staff P3 was interviewed on 12/20/2024 at approximately 2:52 pm and 3:50 pm and questioned about why nursing staff stayed in the Nurses Station and did not attempt to de-escalate the situation with patient #4 on 12/11/2024, but instead watched the destruction and elopement unfold while watching through the glass doors of the Nurses Station. P3 replied cannot 100% (percent) prevent these incidents from happening again and that it’s stated in the Code of Conduct policy if staff don’t feel safe they may call security, which is 911. This is what staff was doing while in the Nurses Station. We don’t have security staff on the facility premises. 9. Staff P1 (Director Quality & Compliance) on 12/20/2024 at approximately 3:50 pm, confirmed no staff education is documented on the Root Cause Analysis and staff education is not on the schedule currently.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 26641 Based on document review, the facility failed to ensure adequate staffing per policy for 1 patient care unit (Unit 200). Findings include: 1. The facility policy titled, “Clinical Staff (Nurse) Staffing Plan”, PolicyStat ID (none on policy), revised 9/2024, indicated: A. On page 1 of 6, under Purpose section, This policy is to establish guidelines for providing sufficient numbers and mix of staff necessary to provide multi-disciplinary patient care that is consistent with the assessed needs of the population served ... B. On page 4 of 6, under Staffing Plan section, point B. Clinical staff members include Registered Nurses (RNs), Licensed Practical Nurses (LPNs) ...Behavioral Health Techs (BHAs) ...There must be at least one (1) RN on every unit at all times. There must be at least two (2) total clinical staff members assigned to every unit at all times ...B. For each patient placed on 1:1 level of observation, one additional staff will be added to the unit staffing. 2. Review of Staffing Grid & Staffing Pattern Worksheet (midnight census) on 12/20/2024 at approximately 3:30 pm, indicated for Unit 200: A. On 11/24/2024: a. During 7:00 am to 3:30 pm for patient census of 25, required number of staff equals 6: 1 Registered Nurse (RN), 1 LPN (Licensed Practical Nurse)/RN, and 4 Behavioral Health Associate (BHA) plus 2 for two 1:1 patients, which equals 8; staffed with 1 RN, 1 LPN and 5 BHAs, which equals 7; lacked 1 extra staff member due to 2 patients on 1:1 observation. b. During 3:00 pm to 11:30 pm for patient census of 25, required number of staff equals 6: 1 RN, 1 LPN/RN, 4 BHAs plus 2 for two 1:1 patients, which equals 8; staffed with 1 RN, 1 LPN and 5 BHAs, which equals 7; lacked 1 extra staff member due to 2 patients on 1:1 observation. c. During 11 pm to 7:30 am for patient census of 25, required number of equals 3: 1 RN, 1 LPN/RN, 1 BHA plus 2 for two 1:1 patients, which equals 5; staffed with 2 RNs and 2 BHAs, which equals 4; lacked 1 extra staff member due to 2 patients on 1:1 observation. B. On 11/25/2024: a. During 7:00 am to 3:30 pm for patient census of 25, required number of staff equals 6: 1 RN, 1 LPN/RN, and 4 BHA plus 2 for two 1:1 patients, which equals 8; staffed with 2 RNs and 4 BHAs, which equals 6; lacked 2 extra staff members due to 2 patients on 1:1 observation. b. During 3:00 pm to 11:30 pm for patient census of 25, required number of staff equals 6: 1 RN, 1 LPN/RN, 4 BHAs plus 2 for two 1:1 patients, which equals 8; staffed with 2 RNs and 5 BHAs, which equals 7; lacked 1 extra staff member due to 2 patients on 1:1 observation. C. On 11/26/2024: a. During 7:00 am to 3:30 pm for patient census of 25, required number of staff equals 6: 1 RN, 1 LPN/RN, and 4 BHA plus 2 for two 1:1 patients, which equals 8; staffed with 2 RNs and 4 BHAs, which equals 6; lacked 2 extra staff members due to 2 patients on 1:1 observation. b. During 3:00 pm to 11:30 pm for patient census of 25, required number of staff equals 6: 1 RN, 1 LPN/RN, 4 BHAs plus 2 for two 1:1 patients, which equals 8; staffed with 2 RNs and 5 BHAs, which equals 7; lacked 1 extra staff member due to 2 patients on 1:1 observation. D. On 11/27/2024: During 3:00 pm to 11:30 pm for patient census of 22, required number of staff equals 5: 1 RN, 1 LPN/RN, 3 BHAs plus 2 for two 1:1 patients, which equals 7; staffed with 2 RNs and 3 BHAs, which equals 5; lacked 2 extra staff members due to 2 patients on 1:1 observation. E. On 11/28/2024: a. During 7:00 am to 3:30 pm for patient census of 25, required number of staff equals 6: 1 RN, 1 LPN/RN, and 4 BHA plus 1 for one 1:1 patient, which equals 7; staffed with 2 RNs and 4 BHAs, which equals 6; lacked 1 extra staff member due to 1 patient on 1:1 observation. b. During 3:00 pm to 11:30 pm for patient census of 25, required number of staff equals 6: 1 RN, 1 LPN/RN, 4 BHAs plus 1 for one 1:1 patient, which equals 7; staffed with 2 RNs and 3 BHAs, which equals 5; lacked 2 extra staff members due to 1 patient on 1:1 observation. F. On 12/3/2024: a. During 7:00 am to 3:30 pm for patient census of 23, required number of staff equals 6: 1 RN, 1 LPN/RN, and 4 BHAs plus 1 for one 1:1 patient, which equals 7; staffed with 2 RNs and 3 BHAs, which equals 5; lacked 2 extra staff members due to 1 patient on 1:1 observation. b. During 3:00 pm to 11:30 pm for patient census of 23, required number of staff equals 6: 1 RN, 1 LPN/RN, 4 BHAs plus 1 for one 1:1 patient, which equals 7; staffed with 1 RN and 3 BHAs, which equals 4; lacked 3 extra staff members due to 1 patient on 1:1 observation. 3. During interview with P3 (Chief Executive Officer) on 12/20/2024 at approximately 3:50 pm, he/she stated the facility Staffing Grid was followed for staffing on Unit 200 and that the [IDOH, Indiana Department of Health] Staffing Pattern Worksheet for 11/24/2024 through 12/7/2024 showed the unit was staffed appropriately according to the grid, the patient census on the unit, and the number of patients on 1:1 observation. However, based on review of staffing documents by this surveyor and the interview with P3, the information for staffing did not appear to be congruent.”

“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: 26641 Based on document review and interview, nursing services failed to supervise and evaluate patient care related to failure to ensure accurate Incident Report (IR) documentation for 16 (#616, #966, #969, #970, #971, #982, #983, #984, #985, #986, #990, #991, #992, #997, #998 and #1004) Incident Reports reviewed. Findings include: 1. Facility policy titled, “Incident Reports”, PolicyStat ID 13033981, revised 1/2023, indicated: A. In the Purpose section, All incident reports must be complete using the hospital’s designated Incident Reporting System, Wellsky. B. In the Completing an Incident Report section, point D ...the Incident Report will be reviewed and acknowledged by the Director of Nursing or designee and Risk Manager or designee. 2. Review of Incident Reports on 12/19/2024 at approximately 11:47 am and on 12/20/2024 at approximately 1:00pm, indicated: A. IR’s #616, #966, #969, #970, #971, #982, #983, #984, #985, #986, #990, #991, #992, #997, #998 and #1004 lacked documentation of review by CEO/DON (Chief Executive Officer/Director of Nursing) and Risk Manager. The section titled Reviewed was documented as N (equals No. B. IR’s #969, #970, #982, #992, #997 and #998 lacked check mark for Medications Ordered when medications were either ordered and/or administered to patient as described in narrative section. C. IR #983 had a check mark in No Injury, but description of incident stated injury to patient’s left ring finger. D. IR #984 lacked a check mark for No Injury when description of incident stated no injury. E. IR #987 and #998 lacked a check mark in the Injury section, for the type of injury, after the description of incident stated patient had been thrown to the ground, kicked in the face, and punched multiple times. 3. Interview with P1 (Director Quality & Compliance) and P4 (Quality Coordinator) on 12/19/2024 at approximately 2:06 pm (both interviewed at same time while reviewing IRs). IR’s should be reviewed by CEO/DON and Risk Manager. There is an area for this on the IR form. After being reviewed by these parties, the IR automatically closes out. These have not been being marked as reviewed and/or closed due to not having a DON or QA (Quality Assessment) Director since September and October, respectively. The forms are expected to be reviewed daily the day after the incident.”

“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: 32952 Based on document review and interview, the facility failed to ensure assistance with showers/bathing for 1 of 10 medical records reviewed. (Patient #1) Findings include; 1. Facility policy titled “Patient Personal Care”, PolicyStat ID: 12197137, approved 8/2022 indicated the following: “PROCEDURE: Definition CMS defines ADLs as activities related to personal care, which includes the following: Bathing/showering; Dressing; Getting out in and out of bed/chair; Walking; Using the toilet; Eating. Education: All patients will be provided education upon admission regarding the process for ADLs, including but not limited to: Unit routine for bathing/showering, toileting, meals, etc. Bathing/showers will be offered daily.” 2. Review of Patient #1’s medical record indicated the following: (A) The patient was admitted on 7/14/24 at 3:00 p.m. and was discharged to Facility #2 (acute care facility) on 7/30/24. (B) The patient’s medical record lacked documentation of showers/baths and/or refusals for the following dates: 7/14/24, 7/15/24, 7/16/24, 7/19/24, 7/20/24, 7/21/24, 7/22/24, 7/23/24, 7/24/24 and 7/25/24. A total of 10 out of 17 days. 3. During an interview with A5 (Director of Nursing) on 8/2/24 at 2:00 p.m., A5 verified the lack of documentation in Patient #1’s medical record for showers/baths and/or refusals for 10 of 17 days reviewed.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 44532 Based on document review and interview, the facility failed to communicate patient’s plan of care and failed to have authorization for treatment completed on 1 out of 10 (P7) medical records reviewed. Findings Include: 1. Facility policy titled, “Patient Rights and Responsibilities” PolicyStat ID 13517670, last approved 04/2023, indicated family and/or agent, when appropriate, be informed of your care including unanticipated outcomes in order to participate in current and future decisions affecting the patient’s care and to participate in the development and implementation of your plan of care. 2. Review of P7’s medical record lacked documentation of notification to patient’s family of the plan of care as follows: a. P7 initial treatment care plan/treatment plan, no contact was made to POA through out P7 stay with progress updates. 3. Interview with A5 (Licensed Clinical Social Worker, Director of Clinical Services) on 06/11/2024 at approximately 1455 hours confirmed P7 medical record lacked documentation of notification to patient’s family of initial care plan/treatment plan.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 44532 Based on document review and interview, the facility failed to have authorization for treatment completed on 1 out of 10 (P7) medical records reviewed. Findings Include: 1. Facility policy titled, “Admission of Patients (IN)”, PolicyStat ID 12508272, Patients or their designees (POA/Guardian) must sign a voluntary consent and authorization for treatment during the admission process. This policy was last revised in 12/2021. 2. Review of P7’s MR indicated that the authorization for treatment had not been completed by P7 or the POA. 3. Interview with A3 (Director of Nursing) on 06/11/2024 at 1500 hours confirmed that the authorization for treatment had not been completed by P7 or the POA for this hospital stat at F1.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 35731 Based on document review and interview the hospital failed to ensure a patient’s verbal/written grievance was submitted for investigation in one (1) instance (Patient # 7), and failed to thoroughly investigate a written grievance in one (1) instance. (Patient # 10) Findings include: 1. The hospital policy titled, Patient Grievance Procedure, PolicyStat ID 13517667, indicated a patient grievance was a written or verbal complaint by a patient, regarding the patient’s care, and/or abuse/neglect. All complaints/grievances may be submitted verbally, in writing to a member of the hospital personnel, by a staff member to whom the complaint/grievance was reported. All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance, would be considered a grievance that required immediate redress. This policy was last revised in 01/2020. 2. The hospital policy titled, Patient Rights and Responsibilities, PolicyStat ID 13517670, indicated every person who enters the hospital for care, had rights. The rights included that all grievances would be addressed in a timely manner. The patient would receive care in a safe setting, free from verbal abuse and/or harassment. This policy was last revised in 09/2021. 3. Grievance form dated 01/23/2024 indicated that a inpatient, at the hospital, filled out a grievance form related to a staff member P # 5 (Behavioral Health Assistant) had verbally abused patient # 10. The documentation indicated staff and staff member P # 5 stated it didn’t happen. Administrative staff member A # 2 (Registered Nurse/Director of Nursing) met with P # 5 for a warning. The grievance lacked documentation related to an investigation (statements/interviews/video detail). 4. Review of patient # 7’s medical record (MR) indicated he/she expressed a grievance to staff member P # 4 (Behavioral Health Assistant) on 02/21/2024. Staff member P # 4 wrote the grievance on the grievance form and placed the form in the patient’s MR. 5. In interview on 03/12/2024 at approximately 1:45 pm with administrative staff member A # 3 (Director Quality Compliance), confirmed patient # 7’s grievance was not investigated and should have been brought to someone’s attention, and no other interviews were conducted and/or the video surveillance system reviewed for the grievance related to patient # 10. 6. In interview on 03/12/2024 at approximately 4:00 pm with administrative staff member A # 2, confirmed that A # 3 should have conducted interviews and watched the video surveillance related to the grievance for patient # 10 dated 01/23/2024.”

“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: 35731 Based on document review and interview, the facility failed to keep a patient free from abuse/neglect in one (1) instance. (Patient # 10) Findings include: 1. The hospital policy titled, Patient Abuse and Neglect, PolicyStat ID 13034136, indicated abuse was any willful, negligent treatment in a mental health facility. This policy was last revised in 01/2023. 2. The hospital policy titled, Patient Rights and Responsibilities, PolicyStat ID 13517670, indicated every person who enters the hospital for care, had rights. The rights included that all grievances would be addressed in a timely manner. Receive care in a safe setting, free from verbal or physical abuse or harassment. Be free from restraints and seclusion of any form used as a means of coercion, discipline, convenience or retaliation by staff. This policy was last revised in 09/2021. 3. The hospital policy titled, Restraint or Seclusion Use, PolicyStat ID 13483128, indicated monitoring the physical and psychological well-being of the patient who is restrained or secluded, included but not limited to respiratory and circulatory status, skin integrity, vital signs, and the need for personal comfort measures including hydration, feeding and toileting. This policy was last revised in 02/2024. 4. Critical Incident Report (CIR) dated 01/25/2024 was reviewed. Staff reported that patient # 10 had been put in seclusion on 01/18/2024 without a physician order. The investigation found that on 01/18/2024 patient # 10 was placed in seclusion at 10:02 pm by staff members P # 1 (Behavioral Health Assistant-BHA) and P # 2 (Registered Nurse-RN), and was not released until 01/19/2024 at 6:52 am. The patient was in seclusion for 8 hours 50 minutes. The investigation documentation lacked any follow-up education with staff related to abuse/neglect/documentation/patient rights. 5. Patient # 10’s medical record (MR) indicated the following: a. History & Physical indicated the patient was a 70 year/old (y/o) admitted on 12/23/2023 with a diagnosis of dementia, inappropriately sexual behaviors, suicide ideation, and delusions. b. Patient Safety Observation Rounds dated 01/18/2024 by P # 1 (Behavioral Health Assistant-BHA), indicated the patient was in the milieu from 7:15 pm until 9:15 pm then the patient went to their room from 9:30 pm until 6:15 am on 01/19/2024. c. The MR lacked a physician order for seclusion dated 01/18/2024 and/or 01/19/2024. d. The MR lacked documentation related to monitoring the physical and psychological well-being of the patient who was in seclusion. 6. In interview on 03/13/2024 at approximately 2:00 pm with A # 3 (Director Quality Compliance), confirmed the video was reviewed for 01/18/2024 when the patient was in seclusion. The door was shut and locked the entire time. 7. In interview on 03/14/2024 at approximately 1:45 pm with A # 4 (Human Resource Director), confirmed no additional staff education had been conducted by A # 2 (Registered Nurse/Director of Nursing).”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 35731 Based on document review and interview, the facility failed to ensure the registered nurse obtained an order for seclusion in one (1) instance. (Patient # 10) Findings include: 1. The hospital policy titled, Restraint or Seclusion Use, PolicyStat ID 13483128, indicated restraint/seclusion may only be utilized upon the written or telephone order of a Licensed Independent Practitioner, Nurse Practitioner, or Physician’s Assistant. This policy was last revised in 02/2024. 2. Critical Incident Report (CIR) indicated on 01/25/2024 staff reported that patient # 10 had been put in seclusion on 01/18/2024 without a physician order. The investigation found that on 01/18/2024 patient # 10 was placed in seclusion at 10:02 pm by staff members P # 1 and P # 2, and not released until 01/19/2024 at 6:52 am. The patient was in seclusion for 8 hours 50 minutes. 3. 2. Patient # 10’s medical record (MR) indicated the following: a. History & Physical indicated the patient was a 70 year/old (y/o) admitted on 12/23/2023 with a diagnosis of dementia, inappropriately sexual behaviors, suicide ideation, and delusions. b. The MR lacked a physician order for seclusion dated 01/18/2024. 4. In interview on 03/13/2024 at approximately 2:00 pm with A # 3, confirmed the video was reviewed for 01/18/2024 when the patient was in seclusion. The door was shut and locked the entire time. 5. In interview on 03/13/2024 at approximately 1:30 pm with administrative staff member A # 4 (Human Resource Director-HRD), confirmed P # 2 (Registered Nurse) did not obtain a physician order for seclusion.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 35731 Based on document review and interview the Director of Nursing (DON) failed to ensure an adequate number of personnel were available to provide patient care in three (3) instances. (01/14/2024, 01/19/2024 & 01/20/2024) Findings include: 1. The hospital policy titled, Clinical Staff (Nurse) Staffing Plan, PolicyStat ID 12279065, indicated the DON was accountable to ensure a sufficient number of staff were on duty at all times. Day shift should have one (1) clinical staff member for every five (5) patients. This policy was last revised in 08/2022. 2. Review of the DON job description dated 06/ 19/1023, indicated the DON was responsible for appropriate staffing levels. 3. Review of the Staffing Pattern Worksheet for the 200 unit, dated 01/14/2024 - 01/27/2024, indicated the unit was short staffed on the day shift on the following dates: a. 01/14/2024 - the unit census was 26 patients - they should have had five (5) clinical staff members and they were only staffed with four (4). b. 01/19/2024 - the unit census was 25 patients - they should have had five (5) clinical staff members and they were only staffed with four (4). c. 01/20/2024 - the unit census was 26 patients - they should have had five (5) clinical staff members and they were only staffed with four (4). 4. In interview on 03/12/2024 at approximately 4:00 pm with administrative staff member A # 2 (Registered Nurse/DON), confirmed the hospital uses patient acuity and the staffing matrix to staff the units.”

“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: 35731 Based on document review and interview the hospital failed to ensure a policy was followed related to Restraint or Seclusion use in two (2) of eleven (11) medical records reviewed. (Patient # 7 & Patient # 10) Findings include: 1. The hospital policy titled, Restraint or Seclusion Use, PolicyStat ID 13483128, indicated a face-to-face assessment should be completed within one (1) hour of seclusion. All nursing assessments should be documented using the restraint/seclusion packet, and all documentation should include date, time and staff signature/initials. The nurse present at the episode would arrange a patient debriefing. All debriefing forms should be forwarded to the Director of Nursing (DON). 2. The Restraint/Seclusion Packet for Patient # 7’s MR indicated the following: a. An order dated 02/13/2024 at 7:40 pm, indicated the MR lacked debriefing documentation, staff signature, date, and time. b. An order dated 02/15/2024 at 12:30 pm, indicated the MR lacked debriefing documentation, staff signature, date, and time. 3. The Restraint/Seclusion Packet for Patient # 10’s MR indicated the following: a. An order dated 01/01/2024 at 2:00 pm, indicated the MR lacked debriefing documentation, staff signature, date, and time. b. An order dated 01/17/2024 at 8:45 pm, indicated the MR lacked debriefing documentation, staff signature, date, and time. c. An order dated 01/20/2024 at 11:10 pm, indicated the lacked debriefing documentation, staff signature, date, and time. d. All debriefing forms were still in the chart and not forwarded to the DON for review. 4. In interview on 03/12/2024 at approximately 1:45 pm with administrative staff member A # 3 (Director Quality Compliance), confirmed staff should follow the hospital’s policies and procedures.”

“Director of Nursing Qualifications CFR(s): The director of psychiatric nursing services must be a registered nurse who has a master’s degree in psychiatric or mental health nursing or its equivalent from a school of nursing accredited by the National League for Nursing, or be qualified by education and experience in the care of the mentally ill. This Standard is not met as evidenced by: 35731 Based on document review and interview the facility failed to ensure an employee was qualified by education/experience in one (1) instance. (A # 2 - Director of Nursing-DON) Findings include: 1. Review of Director of Nursing (DON) job description, indicated the educational requirements to be a Master’s Degree in Psychiatric or Mental Health Nursing, or its equivalent education in acute care behavioral health. Job description was signed by A # 2 (DON) on 06/19/2023. 2. Review of the personnel file for A # 2, indicated he/she lacked the required education/documentation (Master’s Degree in Psychiatric or Mental Health Nursing). 2. In interview on 03/13/2024 at approximately 1:30 pm with administrative staff member A # 4 (Human Resource Director-HRD), confirmed A # 2’s personnel file had an Associates Degree in Nursing. The file lacked any documentation related to a Master’s Degree and/or experience in mental health nursing.”

“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: 14445 Based on document review and interview, the Registered Nurse failed to follow the P&P (Policy & Procedure) related to Patient Personal Care for bathing offered daily for 4 of 10 Medical Records (MR’s) reviewed. (Patients # 7, # 8, # 9 & # 10). Findings include: 1. Review of established hospital policy titled: “Patient Personal Care”, indicated on page 1, under Education, 2nd point; “Bathing/showers will be offered daily”, and under General Care, 1st point; “All patients shall be encouraged or assisted in grooming daily or more often as needed”. Last revised 1/2020. 2. Review of Patient # 8 MR, indicated the following: A. Patient admitted to APH # 40 (Acute Psychiatric Hospital) on 12/29/2023. B. Patient discharged/transferred to AH # 60 (Acute Care Hospital) on 1/18/2024. C. MR lacked documentation in daily flowsheets and/or daily notes for ADL’s (activities of daily living) - hygiene care/bathing, offered or completed or refused, for the following days: 12/30/2023, 12/31/2023, 1/2/2024, 1/3/2024, 1/4/2024, 1/6/2024, 1/9/2024, 1/12/2024, 1/13/2024 and 1/16/2024. 3. Review of Patient # 7 MR, indicated the following: A. Patient admitted to APH # 40 on 10/28/2023. B. Patient discharged on 12/7//2023. C. MR lacked documentation in daily flowsheets and/or daily notes for hygiene care/bathing, offered or completed or refused, for the following days: 10/29/2023, 10/30/2023, 10/31/2023, 11/1/2023, 11/3/2023, 11/4/2023, 11/6/2023, 11/10/2023, 11/13/2023, 11/15/2023, 11/17/2023, 11/18/2023, 11/19/2023, 11/20/2023, 11/21/2023, 11/24/2023, 11/27/2023, 11/28/2023, 11/30/2023, 12/1/2023, 12/2/2023, 12/4/2023, 12/5/2023 and 12/6/2023. 4. Review of Patient # 9 MR, indicated the following: A. Patient admitted to APH # 40 on 12/14/2023. B. Patient discharged on 12/22/2023. C. MR lacked documentation in daily flowsheets and/or daily notes for hygiene care/bathing, offered or completed or refused, for the following days: 12/15/2023, 12/17/2023, 12/19/2023 and 12/21/2023. 5. Review of Patient # 10 MR, indicated the following: A. Patient admitted to APH # 40 on 12/19/2023. B. Patient discharged on 12/26/2023. C. MR lacked documentation in daily flowsheets and/or daily notes for hygiene care/bathing, offered or completed or refused, for the following days: 12/21/2023, 12/22/2023, 12/24/2023 and 12/25/2023. 6. In interview on 1/29/2024 at approximately 2:50 pm, with A # 2 (LPN {Licensed Practical Nurse} - Nursing), confirmed that staff should be documenting hygiene completed or hygiene refusals on flowsheets. 7. In interview on 1/30/2024 at approximately at approximately 10:43 am, with NS # 25 (Behavioral Health Associate - staff), confirmed that Aides/staff responsible for documenting for bathing, hygiene. 8. In interview on 1/30/2024 at approximately 10:00 am, with A # 3 (Director Quality Control), confirmed that the MR lacking some entries for daily hygiene.”

“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: 35731 Based on document review and interview the registered nurse failed to ensure daily ADL’s were documented in one (1) of ten (10) medical record’s (MR’s) reviewed. (Patient # 10) Findings include: 1. The hospital policy titled, Patient Personal Care, PolicyStat ID 12197137, indicated all patients should be encouraged or assisted in grooming daily or more often as needed. Oral care would be encouraged. This policy was last revised in 01/2020. 2. Review of patient # 10’s MR indicated the Patient Safety Observation Rounds lacked documentation of ADL’s (Activity Daily Living-bathing/showering, oral care) offered and/or refused on for the following dates: 11/30/2023, 11/29/2023, 11/27/2023, 11/26/2023, 11/25/2023, 11/23/2023, 11/22/2023, 11/19/2023, and 11/18/2023. 3. In interview on 01/22/2024 with staff member S # 4 (Behavioral Health Assistant), confirmed the patient should be offered a bath/shower daily and it should be documented on the Patient Safety Observation Rounds sheet.”