Sun Behavioral Health

“Special Medical Record Requirements CFR(s): Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals The medical records maintained by a psychiatric hospital must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution. This Condition is not met as evidenced by: 53190 Based on record review, review of the facility’s incident report, review of the facility’s documents and policies, and interviews, the facility failed to ensure the clinical record provided a complete and accurate functional representation of the patient to indicate the facility was aware of the patient’s status, with appropriate interventions in place, and the outcome of the interventions for 1 of 16 sampled patients, Patient (P) 5, who experienced harm on 03/09/2026 when she was discovered by staff at 7:30 PM, unresponsive on the bathroom floor with scrubs tied around her neck. The findings include: Review of P5’s “Face Sheet” revealed the facility admitted P5 on 03/09/2026 with a diagnosis that included major depressive disorder, severe without psychotic features. Review of P5’s “Intake Assessment,” dated 03/09/2026 at 4:32 PM, revealed the patient was identified as high risk for suicide due to a recent plan, ongoing suicidal ideation, and a history of multiple suicide attempts. Further review revealed P5 exhibited additional risk factors, including impulsivity and feelings of hopelessness. Continued review revealed the Intake Nurse, Registered Nurse (RN) 6, initialed and electronically signed documentation indicating she consulted with Psychiatrist 1 and notified him that P5 screened as high risk for suicide. Documentation further indicated this was addressed by Psychiatrist 1 in the admission orders. Review of the “Accountability Flow Sheet,” dated 03/09/2026 revealed Mental Health Technician (MHT) 7 documented Q15 minute safety checks at regular intervals from 5:30 PM through 7:15 PM. However, review of camera footage on 04/08/2026 dated 03/09/2026 revealed that MHT7 remained seated at the nurse’s station and did not get up during this time. Review of the facility’s document “Timeline” revealed P5 arrived in the unit at approximately 5:15 PM on 03/09/2026. At 5:30 PM, Mental Health Technician (MHT) 7 documented a Q15 safety check. At 5:32 PM, RN12 escorted P5 to her room. At 5:50 PM, Pediatrician 1 checked on P5. RN12 entered P5’s room again at 6:22 PM and 6:43 PM. The oncoming MHT4 initiated Q15 safety checks at 7:30 PM, at which time P5 was found unresponsive on the bathroom floor with scrubs tied around her neck. Review of the facility’s incident report “[Facility State] Investigation Report,” for P5, with the date of investigation 03/10/2026, revealed P5 was admitted via transfer on 03/09/2026 as a voluntary admission for active suicidal ideation and inability to remain safe in the home environment. The investigation revealed the intake assessment identified P5 as high risk on the Columbia-Suicide Severity Rating Scale) C-SSRS and documented the provider had been contacted; however, the investigation confirmed, and the intake nurse verbally confirmed that no physician orders were obtained, and the provider had not been contacted. The investigation further revealed the unit nurse completed the nursing assessment and frequent screener, also identifying P5 as high risk, yet placed the patient on low precautions without notifying a provider or obtaining physician orders. Staffing schedules reviewed during the investigation identified P5 was assigned to Mental Health Technician (MHT) 7 who was noted to have failed to complete accurate observation rounds. Facility camera review revealed MHT7 monitored P5 only from the nursing station rather than completing required rounds. The report stated at Further review of the investigation report revealed RN6, the Intake Nurse and MHT7 were terminated, while the unit nurse received a “teachable moment.” In a joint interview on 04/06/2026 at 1:18 PM with the Director of Quality, Performance Improvement & Risk Management and the Chief Nursing Officer (CNO), both stated MHT7 on 03/09/2026 falsified required Q15-minute safety checks, as evidenced by video surveillance footage. They stated, “What occurred is against everything we stand for. It was a series of unfortunate events that led to a patient self -harming incident.” In an additional interview on 04/07/2026 at 9:33 AM with the Director of Quality, Performance Improvement, and Risk Management, she stated it was her expectation that staff followed physician orders; however, the nurse did not contact the physician to obtain orders for P5. She further stated Psychiatrist 1 reported, had any orders been provided, the recommendation would have been to place the patient on 1:1 observation. In an interview on 04/07/2026 at 11:00 AM with Psychiatrist 1, he stated he was first notified of the incident at approximately 8:00 PM on 03/09/2026 by the House Supervisor. He further stated he was not present at the facility, as he had left for the day and was not on call. He stated he was unaware the patient had arrived at the facility and felt “blindsided.” He further stated once the patient arrived in intake, staff was expected to contact the physician for orders; however, staff did not call to obtain orders upon the P5’s arrival. He stated he did not personally evaluate the patient and was not notified of the patient’s arrival. He stated protocol was not followed and emphasized the importance of adhering to protocol to ensure patient and staff safety. He stated, based on the information known after the fact, he would have recommended the patient be placed on 1:1 observation. Refer to Standard A-1621 and A-1650”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 53190 Based on interview, record review, and review of the facility’s documentation and policies, the facility failed to follow its own intake process and ensure nursing staff obtained physician orders on admission for 1 of 16 sampled patients, Patient (P) 5. On 03/09/2026, P5, an adolescent patient who screened as high risk on the Columbia-Suicide Severity Rating Scale (C-SSRS) was admitted. However, Psychiatrist 1 was never notified of the patient’s arrival, and verbal orders were entered under his name without direct communication. The facility’s failure to obtain verbal orders from Psychiatrist 1 for P5 resulted in the patient not being placed on an appropriate level of observation, placing P5 at risk for inadequate supervision and delayed intervention. The findings include: Review of facility’s policy titled, “Admission of Patient to Unit,” dated 09/2025 stated, “The purpose of the policy is to ensure a safe and appropriate admission process. When criteria for admission are met and a provider order is given to a nurse (RN [Registered Nurse] or LPN/LVN [Licensed Practical Nurse/Licensed Vocational Nurse]) the patient will be admitted to the hospital. The on-call provider will be notified of the potential admission by the Intake Department. The Intake Coordinator will provide the on-call provider with the clinical information obtained during the intake assessment. The on-call provider will determine the level of care that the patient requires based on the assessment. This determination will be communicated to the intake coordinator, who will either proceed with admission or a referral to the appropriate outpatient level of care. The admitting provider will provide admission orders to a nurse. The intake nurse (or unit nurse) will obtain admission orders.” Review of the facility’s policy titled, “Level of Observation and Precaution Levels,” dated 09/2025, stated “1. The physician shall order one of three levels of observation at time of admission and may change the level of observation if the patient’s condition warrants a change. 2. The physician will order a specific safety precaution for: Suicide, Assault/Aggressive, elopement, unit restrictions, sexual acting out. Patients are assessed upon admission in intake for their risk for suicide. The CSSR-S tool is utilized. Depending on the score of the CSSR-S a patient may respond to questions that may be indicative of a low, moderate, or high risk. Patients who are moderate or high risk may require a 1:1 level observation based on the full assessment. Patients who score moderate or high alert will be further evaluated for the need for CVO (constant visual observation) or 1:1 level of observation.” Review of the Intake Coordinator job description, dated 04/2019, stated, “Position Summary: Upon assessment of the patient, coordinated with the physician to ensure appropriate treatment is provided either at the hospital or another appropriate provider in the community.” Review of P5’s “Face Sheet” revealed the facility admitted P5 on 03/09/2026 with a diagnosis that included major depressive disorder, severe without psychotic features. Review of P5’s History and Physical (H&P), dated 03/09/2026, revealed a psychiatric history significant for major depressive disorder, post-traumatic stress disorder (PTSD), anxiety, and chronic suicidal ideation. The patient presented following disclosure of active suicidal ideation with a plan. The H&P stated P5 had been discharged on 03/07/2026 from another facility where she was hospitalized for three weeks for suicidal ideation. Upon returning home following discharge, P5 informed her family member she continued to have suicidal intent. P5 described her plan to her family member, who immediately called emergency medical services (EMS). P5 reported a two-year history of severe depression. Further review revealed P5 stated she continued to have suicidal thoughts and did not believe she could remain safe in the home environment. Review of P5’s “Columbia-Suicide Severity Rating Scale [C-SSRS]” completed at admission, dated 03/09/2026, indicated the patient was assessed as high risk for suicide by responding with a “Yes” that in the past three months she had “done anything, started to do anything, or prepared to do anything to end your life.” Review of P5’s “Intake Assessment,” dated 03/09/2026 at 4:32 PM, revealed the patient was identified as high risk for suicide due to a recent plan, ongoing suicidal ideation, and a history of multiple suicide attempts. Further review revealed P5 exhibited additional risk factors, including impulsivity and feelings of hopelessness. Continued review revealed the intake nurse, Registered Nurse (RN) 6, initialed and electronically signed the documentation indicating she consulted with Psychiatrist 1 and notified him that P5 screened as high risk for suicide. Documentation further indicated this was addressed by Psychiatrist 1 in the admission orders. Review of the facility’s incident report “[Facility State] Investigation Report,” for P5, with the date of investigation 03/10/2026, revealed P5 was admitted via transfer on 03/09/2026 as a voluntary admission for active suicidal ideation and inability to remain safe in the home environment. The investigation revealed the intake assessment identified P5 as high risk on the CSSR and documented the provider had been contacted; however, the investigation confirmed, and the intake nurse verbally confirmed that no physician orders were obtained, and the provider had not been contacted. The investigation further revealed the unit nurse completed the nursing assessment and frequent screener, also identifying P5 as high risk, yet placed the patient on low precautions without notifying a provider or obtaining physician orders. Further review of the investigation report revealed RN6, the Intake Nurse was terminated, while the unit nurse received a “teachable moment.” In an interview on 04/08/2026 at 8:36 AM with RN6, she stated “Yes, on 03/09/2026 I entered orders during the intake process for a pre-admitted patient. My understanding is that the physician had already been contacted by off-site staff regarding the admission. I don’t recall having direct communication with the physician.” In an interview with RN9, the Adolescent Unit Manager, on 04/07/2026 at 3:34 PM, she stated it was the responsibility of the intake nurse to contact the physician to obtain orders and to assist in facilitating and determining the appropriate level of observation for each patient. She stated it was never acceptable to enter orders without direct communication with the physician. RN9 further stated it was essential to contact the physician for every patient, as each individual had unique needs requiring varying levels of care. She stated adherence to this process was critical to ensure the safety of both patients and staff. In an interview with the Intake Manager on 04/07/2026 at 1:38 PM, she stated there was currently no mechanism in place to verify that physician orders were obtained at the time of admission. She further stated the facility did not monitor or audit whether physicians were contacted upon admission, indicating there was no established process to track this practice. The Intake Manager stated physicians were expected to notify staff if they had not been contacted regarding orders or if an incorrect dose had been entered. She stated it was the facility’s expectation that nursing staff entered physician orders only after direct communication with the physician. In an interview with Psychiatrist 1 on 04/07/2026 at 11:00 AM, he stated he was first notified of the incident at approximately 8:00 PM by the House Supervisor. He further stated he was not present at the facility, as he had left for the day and was not on call. He stated he was unaware the patient had arrived at the facility and felt “blindsided.” He stated the intake and admission process consisted of receiving a brief report and admission criteria from the transferring facility. He further stated once the patient arrived in intake, staff was expected to contact the physician for orders; however, staff did not call to obtain orders upon P5’s arrival. He stated he did not personally evaluate the patient and was not notified of the patient’s arrival. He stated protocol was not followed and emphasized the importance of adhering to protocol to ensure patient and staff safety. He stated, based on the information known after the fact, he would have recommended the patient be placed on 1:1 observation. In an interview with the Director of Quality, Performance Improvement, and Risk Management, and the Chief Nursing Officer (CNO) on 04/06/2026 at 1:18 PM, both stated RN6 falsified documentation by entering provider orders that were not given to her by a provider. The CNO stated, while the provider had accepted the admission, no orders had been issued for P5 at the time, or at any point, when RN6 entered the orders into the medical record. In an additional interview with the Director of Quality, Performance Improvement, and Risk Management on 04/07/2026 at 9:33 AM, she stated it was her expectation that staff followed physician orders; however, RN6 did not contact the physician to obtain orders. She further stated Psychiatrist 1 stated, had any orders been provided, the recommendation would have been to place the patient on 1:1 observation. In an additional interview with the CNO on 04/08/2026 at 11:23 AM, she stated it was her expectation that nursing staff contact the physician during the intake process to determine the appropriate level of observation based on the patient’s condition and required precautions. The CNO further stated the initial level of observation was determined upon admission through the intake process and direct communication with the physician. In an interview with the Chief Executive Officer (CEO) on 04/09/2026 at 2:24 PM, he stated, based on his understanding of the incident, Psychiatrist 1 accepted the transfer but was not notified of P5’s arrival and did not provide any orders. He stated it was his expectation intake nurses did not enter orders without first contacting the physician.”

“Assessment - Diagnostic Data CFR(s): Standard: Development of Assessment/Diagnostic Data Medical records must stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the patient is hospitalized. This Standard is not met as evidenced by: 53190 Based on record review, review of the facility’s incident report, review of the facility’s policies, and interview, the facility failed to ensure a physician was involved in the admission process and appropriate physician orders were obtained for 1 of 16 sampled patients, Patient (P) 5. The facility failed to implement a process to verify physicians were contacted at the time of admission and orders were obtained prior to nursing staff entering them into the medical record. Interviews revealed nursing staff entered provider orders without physician consultation, placing P5 at risk for inappropriate treatment, delayed care, and potential harm. The facility’s incident report revealed on 03/09/2026, at approximately 7:31 PM, staff responded to a call for help and found P5 unresponsive and on the bathroom floor with paper scrubs tied around her neck. The scrubs were removed, and emergency measures were initiated. The patient began breathing and coughing, her airway was maintained, and by 7:41 PM the patient was alert; oriented to person, place, time, and situation/event; and able to answer questions. The findings include: Review of the facility’s policy titled, “Level of Observation and Precaution Levels,” dated 09/2025 stated, “1. The physician shall order one of three levels of observation at time of admission and may change the level of observation if the patient’s condition warrants a change. The level of observation is to be documented on the close 15-minute observation sheet daily or when any changes are made. 2. The physician will order a specific safety precaution for: Suicide, Assault/Aggressive, elopement, unit restrictions, sexual acting out. Q [every] 15-minute Observations: Minimum level of observation for all patients. Patients who score low risk of suicide upon admission will be placed on this level of observation. Staff will observe patients and document the patient observation record every 15 minutes. Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress. Staff will be vigilant for potential risk factors identified for specific patients given their level or precautions. Patients are assessed upon admission in intake for their risk of suicide. The CSSR-S [Columbia-Suicide Severity Rating Scale] tool is utilized. Depending on the score of the CSSR-S a patient may respond to questions that may be indicative of a low, moderate, or high risk. Patients who are moderate or high risk may require a 1:1 level observation based on the full assessment. Patients who score moderate or high alert will be further evaluated for the need for CVO [constant visual observation] or 1:1 level of observation.” Review of the facility’s policy titled, “Suicide Prevention Program/Assessment & Reassessment for Suicidal/Self-harm Ideation,” dated 06/2025, stated, “To ensure patients who are at risk for suicide are safe while in the care of [name of facility]. This program includes assessments of safety/environment, patient assessment of suicide risk and intervention to prevent injury and maintain a therapeutic relationship with all patients admitted to [name of facility] (also called the hospital), everyone admitted to the hospital will be assessed and re-assessed for risk of suicide/self-harm.” Review of the facility’s policy titled, “Admission of Patient to Unit,” dated 09/2025, stated, “When criteria for admission are met and a provider order is given to a nurse (Registered Nurse [RN] or Licensed Practical Nurse/Licensed Vocational Nurse [LPN/LVN]) the patient will be admitted to the hospital. The on-call provider will be notified of the potential admission by the Intake Department. The Intake Coordinator will provide the on-call provider with the clinical information obtained during the intake assessment. The on-call provider will determine the level of care that the patient requires based on the assessment. This determination will be communicated to the intake coordinator, who will either proceed with admission or a referral to the appropriate outpatient level of care. The admitting provider will provide admission orders to a nurse. The intake nurse (or unit nurse) will obtain admission orders.” Review of P5’s “Face Sheet” revealed the facility admitted P5 on 03/09/2026 with a diagnosis that included major depressive disorder, severe without psychotic features. Review of P5’s History and Physical (H&P), dated 03/09/2026, revealed a psychiatric history significant for major depressive disorder, post-traumatic stress disorder (PTSD), anxiety, and chronic suicidal ideation. The patient presented following disclosure of active suicidal ideation with a plan. The H&P stated P5 had been discharged on 03/07/2026 from another facility where she was hospitalized for three weeks for suicidal ideation. Upon returning home following discharge, P5 informed her family member she continued to have suicidal intent. P5 described her plan to her family member, who immediately called emergency medical services (EMS). P5 reported a two-year history of severe depression. Further review revealed P5 stated she continued to have suicidal thoughts and did not believe she could remain safe in the home environment. Review of P5’s “Columbia-Suicide Severity Rating Scale [C-SSRS]” completed at admission, dated 03/09/2026, indicated the patient was assessed as high risk for suicide by responding with a “Yes” that in the past three months she had “done anything, started to do anything, or prepared to do anything to end your life.” Review of P5’s “Intake Assessment,” dated 03/09/2026 at 4:32 PM, revealed the patient was identified as high risk for suicide due to a recent plan, ongoing suicidal ideation, and a history of multiple suicide attempts. Further review revealed P5 exhibited additional risk factors, including impulsivity and feelings of hopelessness. Continued review revealed the Intake Nurse, Registered Nurse (RN) 6, initialed and electronically signed the documentation indicating she consulted with Psychiatrist 1 and notified him that P5 screened as high risk for suicide. Documentation further indicated this was addressed by Psychiatrist 1 in the admission orders. Review of the facility’s incident report “[Facility State] Investigation Report,” for P5, with the date of investigation 03/10/2026, revealed P5 was admitted via transfer on 03/09/2026 as a voluntary admission for active suicidal ideation and inability to remain safe in the home environment. The investigation revealed the intake assessment identified P5 as high risk on the CSSR and documented the provider had been contacted; however, the investigation confirmed, and the intake nurse verbally confirmed that no physician orders were obtained, and the provider had not been contacted. The investigation further revealed the unit nurse completed the nursing assessment and frequent screener, also identifying P5 as high risk, yet placed the patient on low precautions without notifying a provider or obtaining physician orders. The facility’s incident report revealed on 03/09/2026, at approximately 7:31 PM, staff responded to a call for help and found P5 unresponsive and on the bathroom floor with paper scrubs tied around her neck. The scrubs were removed, and emergency measures were initiated. The patient began breathing and coughing, her airway was maintained, and by 7:41 PM the patient was alert; oriented to person, place, time, and situation/event; and able to answer questions. Further review of the investigation report revealed RN6, the Intake Nurse was terminated, while the unit nurse received a “teachable moment.” In an interview on 04/08/2026 at 8:36 AM with RN6, she stated “Yes, on 03/09/2026 I entered orders during the intake process for a pre-admitted patient. My understanding is that the physician had already been contacted by off-site staff regarding the admission. I don’t recall having direct communication with the physician.” In an interview on 04/09/2026 at 2:10 PM with RN12, she stated on 03/09/2026 she received report from the Intake Nurse for P5. She stated, upon review of P5’s medical record, P5 was identified as suicidal and had disclosed to her family member that she had a plan. However, upon arrival to the unit, P5 informed RN12 that she did not have a plan. RN12 stated she maintained the patient as high risk but did not contact the physician or question the ordered level of observation, which remained at the standard every 15-minute (Q15) safety checks. RN12 stated, despite P5’s recent report of suicidal ideation with intent to self-harm during intake, she did not reassess or escalate the level of observation. She stated it was the expectation that the level of observation be questioned and clarified with the physician when a patient was actively experiencing suicidal ideation, particularly when the ordered observation level was less restrictive than what was required by facility policy to ensure patient safety. In an interview on 04/07/2026 at 3:34 PM with RN9, the Adolescent Unit Manager, she stated it was the responsibility of the Intake Nurse to contact the physician to obtain orders and to assist in facilitating and determining the appropriate level of observation for each patient. She stated it was never acceptable to enter orders without direct communication with the physician. RN9 further stated it was essential to contact the physician for every patient, as each individual had unique needs requiring varying levels of care, and adherence to this process was critical to ensure the safety of both patients and staff. In an interview on 04/07/2026 at 1:38 PM with the Intake Manager, she stated there was currently no mechanism in place to verify that physician orders are obtained at the time of admission. She further stated the facility did not monitor or audit whether physicians were contacted upon admission, indicating there was no established process to track this practice. The Intake Manager stated physicians were expected to notify staff if they had not been contacted regarding orders or if an incorrect dose of medication had been entered. She stated it was the facility’s expectation that nursing staff entered physician orders only after direct communication with the physician. In an interview on 04/07/2026 at 11:00 AM with Psychiatrist 1, he stated he was first notified of the incident at approximately 8:00 PM on 03/09/2026 by the House Supervisor. He further stated he was not present at the facility, as he had left for the day and was not on call. He stated he was unaware the patient had arrived at the facility and felt “blindsided.” He stated the intake and admission process consisted of receiving a brief report and admission criteria from the transferring facility. He further stated that once the patient arrived in intake, staff was expected to contact the physician for orders; however, staff did not call to obtain orders upon P5’s arrival. He stated he did not personally evaluate the patient and was not notified of the patient’s arrival. He stated protocol was not followed and emphasized the importance of adhering to protocol to ensure patient and staff safety. He stated, based on the information known after the fact, he would have recommended the patient be placed on 1:1 observation. In an interview on 04/06/2026 at 1:18 PM with the Director of Quality, Performance Improvement, and Risk Management, and the Chief Nursing Officer (CNO), both stated RN6 falsified documentation by entering provider orders that were not given to her. They stated P5 was admitted via transfer and was also positive for influenza. The CNO stated, while the provider had accepted the admission, no orders had been issued for P5 at the time, or at any point, when RN6 entered the orders into the medical record. In an additional interview on 04/07/2026 at 9:33 AM with the Director of Quality, Performance Improvement, and Risk Management, she stated it was her expectation that staff followed physician orders; however, the nurse did not contact the physician to obtain orders for P5. She further stated Psychiatrist 1 stated, had any orders been provided, the recommendation would have been to place the patient on 1:1 observation. In an additional interview on 04/08/2026 at 11:23 AM with the CNO, she stated it was the expectation that nursing staff contacted the physician during the intake process to determine the appropriate level of observation based on the patient’s condition and required precautions. The CNO stated patients identified as higher risk for self-harm should be placed on an increased level of observation to ensure their safety. The CNO further stated the initial level of observation was determined upon admission through the intake process and direct communication with the physician. She stated an assessment was completed each shift to evaluate and adjust the level of observation as needed. In an interview on 04/09/2026 at 2:24 PM with the Chief Executive Officer (CEO), he stated, based on his understanding of the incident, Psychiatrist 1 accepted the transfer but was not notified of P5’s arrival and did not provide any orders. He stated it was his expectation intake nurses did not enter orders without first contacting the physician. He further stated unit nurses were expected to question and clarify orders when there were concerns to meet the patient’s clinical needs.”

“Document Therapeutic Efforts CFR(s): The treatment received by the patient must be documented in such a way to assure that all active therapeutic efforts are included. This Standard is not met as evidenced by: 53190 Based on record review, review of the facility’s incident report, review of the facility’s documents and policies, and interviews, the facility failed to ensure the psychiatric evaluation informed appropriate levels of observation, including the complete and consistent performance of ordered every 15-minute (Q15) safety checks for a patient identified as high risk for self-harm, for 1 of 16 sampled patients, Patient (P) 5. The facility’s incident report revealed on 03/09/2026, at approximately 7:31 PM, staff responded to a call for help and found P5 unresponsive and on the bathroom floor with paper scrubs tied around her neck. The scrubs were removed, and emergency measures were initiated. The patient began breathing and coughing, her airway was maintained, and by 7:41 PM the patient was alert; oriented to person, place, time, and situation/event; and able to answer questions. The findings include: Review of the facility’s policy titled, “Level of Observation and Precaution Levels,” dated 09/2025 stated, “1. The physician shall order one of three levels of observation at time of admission and may change the level of observation if the patient’s condition warrants a change. The level of observation is to be documented on the close 15-minute observation sheet daily or when any changes are made. 2. The physician will order a specific safety precaution for: Suicide, Assault/Aggressive, elopement, unit restrictions, sexual acting out. Q [every] 15-minute Observations: Minimum level of observation for all patients. Patients who score low risk of suicide upon admission will be placed on this level of observation. Staff will observe patients and document the patient observation record every 15 minutes. Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress. Staff will be vigilant for potential risk factors identified for specific patients given their level or precautions. Patients are assessed upon admission in intake for their risk of suicide. The CSSR-S [Columbia-Suicide Severity Rating Scale] tool is utilized. Depending on the score of the CSSR-S a patient may respond to questions that may be indicative of a low, moderate, or high risk. Patients who are moderate or high risk may require a 1:1 level observation based on the full assessment. Patients who score moderate or high alert will be further evaluated for the need for CVO [constant visual observation] or 1:1 level of observation.” Review of the facility’s policy titled, “Suicide Prevention Program/Assessment & Reassessment for Suicidal/Self-harm Ideation,” dated 06/2025, stated, “To ensure patients who are at risk for suicide are safe while in the care of [name of facility]. This program includes assessments of safety/environment, patient assessment of suicide risk and intervention to prevent injury and maintain a therapeutic relationship with all patients admitted to [name of facility] (also called the hospital), everyone admitted to the hospital will be assessed and re-assessed for risk of suicide/self-harm.” Review of the facility’s policy titled, “Admission of Patient to Unit,” dated 09/2025, stated, “When criteria for admission are met and a provider order is given to a nurse (RN or LPN/LVN) the patient will be admitted to the hospital. The on-call provider will be notified of the potential admission by the Intake Department. The Intake Coordinator will provide the on-call provider with the clinical information obtained during the intake assessment. The on-call provider will determine the level of care that the patient requires based on the assessment. This determination will be communicated to the intake coordinator, who will either proceed with admission or a referral to the appropriate outpatient level of care. The admitting provider will provide admission orders to a nurse. The intake nurse (or unit nurse) will obtain admission orders.” Review of P5’s “Face Sheet” revealed the facility admitted P5 on 03/09/2026 with a diagnosis that included major depressive disorder, severe without psychotic features. Review of P5’s History and Physical (H&P), dated 03/09/2026, revealed a psychiatric history significant for major depressive disorder, post-traumatic stress disorder (PTSD), anxiety, and chronic suicidal ideation. The patient presented following disclosure of active suicidal ideation with a plan. The H&P stated P5 had been discharged on 03/07/2026 from another facility where she was hospitalized for three weeks for suicidal ideation. Upon returning home following discharge, P5 informed her family member she continued to have suicidal intent. P5 described her plan to her family member, who immediately called emergency medical services (EMS). P5 reported a two-year history of severe depression. Further review revealed P5 stated she continued to have suicidal thoughts and did not believe she could remain safe in the home environment. Review of P5’s Columbia-Suicide Severity Rating Scale (C-SSRS) completed at admission, dated 03/09/2026, indicated the patient was assessed as high risk for suicide by responding with a “Yes” that in the past three months she had “done anything, started to do anything, or prepared to do anything to end your life.” Review of P5’s “Intake Assessment,” dated 03/09/2026 at 4:32 PM, revealed the patient was identified as high risk for suicide due to a recent plan, ongoing suicidal ideation, and a history of multiple suicide attempts. Further review revealed P5 exhibited additional risk factors, including impulsivity and feelings of hopelessness. Continued review revealed the Intake Nurse, Registered Nurse (RN) 6, initialed and electronically signed the documentation indicating she consulted with Psychiatrist 1 and notified him that P5 screened as high risk for suicide. Documentation further indicated this was addressed by Psychiatrist 1 in the admission orders. Review of the facility’s incident report “[Facility State] Investigation Report,” for P5, with the date of investigation 03/10/2026, revealed P5 was admitted via transfer on 03/09/2026 as a voluntary admission for active suicidal ideation and inability to remain safe in the home environment. The investigation revealed the intake assessment identified P5 as high risk on the CSSR and documented the provider had been contacted; however, the investigation confirmed, and the intake nurse verbally confirmed that no physician orders were obtained, and the provider had not been contacted. The investigation further revealed the unit nurse completed the nursing assessment and frequent screener, also identifying P5 as high risk, yet placed the patient on low precautions without notifying a provider or obtaining physician orders. Staffing schedules reviewed during the investigation identified P5 was assigned to Mental Health Technician (MHT) 7 who was noted to have failed to complete accurate observation rounds. Facility camera review revealed MHT7 monitored P5 only from the nursing station rather than completing required rounds. Further review of the investigation report revealed RN6, the Intake Nurse and MHT7 were terminated, while the unit nurse received a “teachable moment.” Review of the facility’s document “Timeline” revealed P5 arrived in the unit at approximately 5:15 PM on 03/09/2026. At 5:30 PM, Mental Health Technician (MHT) 7 documented a Q15 safety check. At 5:32 PM, RN12 escorted P5 to her room. At 5:50 PM, Pediatrician 1 checked on P5. RN12 entered P5’s room again at 6:22 PM and 6:43 PM. The oncoming MHT4 initiated Q15 safety checks at 7:30 PM, at which time P5 was found unresponsive on the bathroom floor with scrubs tied around her neck. Review of the facility’s document “Accountability Flow Sheet” dated 03/09/2026, revealed MHT7 documented Q15 minute safety checks at regular intervals from 5:30 PM through 7:15 PM. However, review of camera footage, dated 03/09/2026, revealed MHT7 remained seated at the nurse’s station and did not get up during this time. In an interview on 04/09/2026 at 1:27 PM with MHT9, she stated on 03/09/2026 she did not observe MHT7 physically complete any Q15 minute safety checks on P5 but witnessed MHT7 enter the safety checks into the computer’s documentation system, indicating the safety checks were falsely documented. MHT9 stated Q15 minute safety checks required staff to physically observe the patient at the ordered intervals, with documentation completed in real time. In an interview on 04/09/2026 at 1:43 PM with MHT10, she stated she was present at the nurse’s station and observed MHT7 documenting Q15 minute safety checks from the nurse’s station. MHT10 stated Q15 minute safety checks required staff to physically observe the patient at the ordered intervals, with documentation completed in real time. In an interview on 04/08/2026 at 9:28 AM with MHT4, she stated shift reports were given between 7:00 PM and 7:15 PM, and the off-going shift was expected to round on the patients with the on-coming shift at 7:15 PM. MHT4 further stated on 03/09/2026, MHT7, the off-going MHT, and herself did not round together. MHT4 stated she initiated her first safety rounds at approximately 7:30 PM, at which time she found P5 unresponsive on the bathroom floor. She stated the patient’s face was blue/purple in color with scrubs tightly tied around her neck, requiring scissors to remove them. MHT4 further stated Q15 minute safety checks required staff to physically observe the patient at the ordered intervals, with documentation completed in real time. In an interview on 04/10/2026 at 5:41 PM with Registered Nurse (RN) 16, she stated she recalled the incident that occurred on 03/09/2026, and she had previously completed a witness statement with nothing further to add. Review of RN16’s “Witness Statement” revealed a code Medical Response Team (MRT) was called, and RN16 ran to P5’s room where she observed MHT4 sitting on the floor next to the patient. The statement indicated P5 was not breathing and had no pulse. Per the statement, RN16 initiated Cardiopulmonary Resuscitation (CPR) and delivered approximately five chest compressions, and P5 subsequently took a large breath and began coughing. In an interview on 04/07/2026 at 11:00 AM with Psychiatrist 1, he stated he was first notified of the incident at approximately 8:00 PM on 03/09/2026 by the House Supervisor. He further stated he was not present at the facility, as he had left for the day and was not on call. He stated he was unaware the patient had arrived at the facility and felt “blindsided.” He stated the intake and admission process consisted of receiving a brief report and admission criteria from the transferring facility. He further stated once the patient arrived in intake, staff were expected to contact the physician for orders; however, staff did not call to obtain orders upon P5’s arrival. He stated he did not personally evaluate the patient and was not notified of the patient’s arrival. He stated protocol was not followed and emphasized the importance of adhering to protocol to ensure patient and staff safety. He stated, based on the information known after the fact, he would have recommended the patient be placed on 1:1 observation. In a joint interview on 04/06/2026 at 1:18 PM with the Director of Quality, Performance Improvement & Risk Management and the Chief Nursing Officer (CNO), both stated MHT7 on 03/09/2026 falsified required Q15-minute safety checks, as evidenced by video surveillance footage. They stated, “What occurred is against everything we stand for. It was a series of unfortunate events that led to a patient self-harming incident.” In an additional interview on 04/08/2026 at approximately 3:00 PM with the Director of Quality, Performance Improvement & Risk Management, she stated MHT7 “just did not do her job.” In an additional interview on 04/08/2026 at 11:23 AM with the CNO, she stated it was the expectation that nursing staff contacted the physician during the intake process to determine the appropriate level of observation based on the patient’s condition and required precautions. The CNO stated patients identified as higher risk for self-harm should be placed on an increased level of observation to ensure their safety. In an interview on 04/09/2026 at 2:24 PM with the Chief Executive Officer (CEO), he stated, “I know that it does happen, that MHTs falsely document Q15 minute safety checks, and they are to receive disciplinary action.” The CEO further stated it was his expectation that physician orders were followed, and documentation accurately reflected the appropriate level of observation for each patient.”

“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: 29137 Based on interview, record review, review of the facility’s risk management investigation, and review of the facility’s policies, the facility failed to ensure patients were free from abuse for 1 of 29 sampled patients, Patient (P) 27. In addition, the facility failed to ensure complete abuse investigations were completed for 2 of 29 sampled patients, P1 and P2. The findings include: Review of the facility’s policy titled, “Abuse and Neglect Reporting,” revised 03/2024, revealed patients had the right to be free from physical, mental, verbal, and sexual abuse, neglect, and exploitation. Per the policy, all allegations, observations, or suspected cases of abuse, neglect, or exploitation that occurred in the hospital would be investigated by the hospital. Further review revealed cases of suspected sexual assault, physical abuse, or neglect would be given priority and would be investigated thoroughly. Continued review revealed in instances of investigations concerning a staff member’s behavior, the involved staff member would be immediately suspended. Additionally, any allegation of suspected or alleged abuse or neglect against a staff member would require the staff member be immediately suspended while the allegation was investigated, and the employee would not be permitted to work until the investigation was completed. Review of the facility’s policy titled, “Patient Rights and Responsibilities,” PolicyStat ID 14085180, revised 01/2018, revealed the patient had the right to be free of abuse, neglect, or exploitation; and to be treated in a safe treatment environment, with respect for personal dignity, autonomy, and privacy, in accordance with existing federal, state, and local laws and regulations. Additional review revealed the patient had the right to reasonable protection from physical, sexual, or emotional abuse or harassment. 1. Review of P26’s “Face Sheet” revealed he/she was admitted on 06/03/2023 with a primary diagnosis of unspecified mood (affect) disorder. Review of P27’s “Face Sheet” revealed he/she was admitted on 06/06/2023 with a primary diagnosis of major depressive disorder, recurrent severe without psychotic features. Review of the facility’s risk management “Investigation,” undated, revealed on 06/07/2023, at approximately 7:57 PM, P26 physically attacked P27, picking him/her up without provocation in the common area of the Boy’s Compass Unit (BCU). Per the investigation, P26 slammed P27 to the floor, and when P27 got up, P26 then punched him/her in the jaw. Continued review of the investigation revealed P26 was moved to a secure locked area, and P27 was assessed for injuries. Further review revealed during P27’s ongoing assessment, it was reported P27 suffered seizure-like activity and was transported to a local hospital. Additional facility investigation review revealed notifications were made and orders were obtained for both patients. Continued review of the facility’s risk management “Investigation,” undated, revealed a video was available from the incident involving P26 and P27. The facility provided the State Survey Agency (SSA) Surveyor with a copy of the video. Review of the facility’s provided video of the incident between P26 and P27 on 06/07/2023, revealed at 7:54:00 PM, P26 was observed to be standing in the center of the BCU common area. At 7:56:05 PM, P26 entered the frame from the left side medication (med) room area. Observations of this area revealed it was a very small area with a chair and was out of the frame for the video. Between 7:56:12 PM to 7:56:36 PM, P26 walked to the front of the nurse’s station without acknowledging P27. P26 then walked back out of the frame to the med room area. From 7:56:51 PM to 7:56:58 PM, P26 returned to the video frame and walked toward the center of the BCU common area. P27 was still standing in the center of the area. Three unidentifiable staff members were within approximately five feet of both patients. Continued review of the facility’s provided video of the incident between P26 and P27 on 06/07/2023, revealed at 7:57:03 PM, P26 walked to approximately three feet behind P27. At 7:57:06 PM, P26 walked up and back a couple of steps from behind P27. At 7:57:10 PM to 7:57:12 PM, P26 took P27 down to the floor by grabbing his/her legs. At 7:57:13 PM to 7:57:15 PM, P26 ran away from the area to the TV area of the BCU with staff following. P27 picked himself/herself up from the floor. Between 7:57:15 PM and 7:57:22 PM, P26 ripped off his/her shirt, advanced to P27, and delivered a right upper cut punch to P27’s left jaw. Staff was immediately at P27’s side. Continued review of the facility’s provided video of the incident between P26 and P27 on 06/07/2023, revealed at 7:57:26 PM to 7:57:59 PM, P26 walked away from P27 out of the frame and returned to the frame with staff at hand. P26 then walked to the nurse’s station window with two staff at P26’s side. At 7:58:07 PM, P26 remained at the window and staff walked away. Between 7:59:12 PM and 7:59:47 PM, Registered Nurse (RN) 3 motioned for P27 to follow him, and they left the frame and then returned to the frame. At 7:59:57 PM, P27 walked out of the frame to the med room window. Continued review of the facility’s provided video of the incident between P26 and P27 on 06/07/2023, revealed at 8:08:25 PM, P27 came back into the frame and went to the nurse’s station window with RN3 at his/her side; P27 was led to a chair with nursing staff at hand. At 8:09:41 PM to 8:15:40 PM, staff fixed an ice pack for P27’s jaw. At 8:16:40 PM, staff took P27’s blood pressure (b/p), which was 166/99, and heart rate, which was 125 beats per minute (bpm). At 8:20:08 PM, P27 leaned to the left side and fell from the chair, striking his/her head. Staff was approximately three to four feet from P27 and advanced to assist P27. At 8:20:10 PM, numerous staff attended to P27; turned him/her to the left side; and brought the emergency cart containing items such as oxygen and a mask, defibrillator, glucose monitor, and vital sign machine. At 8:20:15 PM staff surrounded P27, preventing P27’s reported seizure activity from being seen. Between 8:22:15 PM to 8:38:30 PM, emergency medical services (EMS) and a police escort arrived and assessed, evaluated, and departed with P27. Review of RN3’s “Progress Note,” dated 06/07/2023 at 11:30 PM, revealed P26 assaulted P27, and they were separated with P26 placed in a secure, locked area. Per the note, P27 walked around the BCU common area and told RN3 how mad and agitated he/she was about the incident. The note revealed P27 was given medication for agitation and shoulder and jaw pain, which was described as 9/10 on the pain scale. The note stated while RN3 was on the phone with the Physician (PHYS) 2, P27 fell out of the chair and had seizure activity that lasted approximately a minute. Further review of RN3’s progress note revealed that at 8:26 PM (after seizure activity), P27 had a b/p of 145/87, oxygen saturation of 99 percent, heart rate of 77 bpm, and respirations of 18 per minute. The note stated P27 was alert and oriented to self but not time or place, and both pupils were sluggish and dilated to 4+ (normal). While interviewing RN3 on 05/15/2024 at 9:23 AM, he stated that after the incident, P26 was taken to a secure, locked area with a staff member present at all times, and P27 was assessed and treated at the time for reported shoulder and jaw pain. He stated, as P27 was moving around the environment, prior to the reported seizure activity, he was constantly being assessed for level of consciousness, mental status, and motor/verbal responses. He also stated that P26 had not displayed aggressive behaviors since admission (06/03/2023). During an interview with the House Supervisor on 05/13/2024 at 3:19 PM, she stated she was the House Supervisor the evening of 06/07/2023 and had been notified about the incident between P26 and P27, but it was over by the time she arrived to the BCU. She further stated she remained on the BCU to assist as needed. The House Supervisor stated the environment was under control, and P27 had been assessed and treated for pain prior to the reported seizure activity. She stated re-assessment of P27 occurred after the reported seizure activity and prior to P27 being sent out for further evaluation and treatment. During an interview with PHYS2, a medical physician, on 05/14/2024 at 8:52 AM, he stated he had been notified of P27’s initial injuries and was still on the phone with RN3 when she reported P27 was exhibiting seizure like activity. He stated he gave the order for P27 to be sent out for further evaluation and treatment. While interviewing PHYS1, a psychiatric physician, on 05/14/2024 at 3:20 PM, he stated P26 had not exhibited aggressive behaviors since admission. However, he stated P26’s anger and aggressiveness was due to choices, and there was no medication that would help. While interviewing the Chief Nursing Officer (CNO) on 05/14/2024 at 10:07 AM, she stated she had reviewed the incident and felt P27 was assessed and treated appropriately. The CNO also stated she felt patient safety had been provided with P26 placed in a secure, locked area with a staff member present at all times. 47852 During an interview with the Director of Quality, Performance Improvement, and Risk Management (RM) 1 on 05/03/2024 at 9:30 AM, she stated videos for the alleged incidents with P1 and P2 had been requested by the Department of Community Based Services Social Worker (SSA) 1, and the facility did not realize they needed to keep them after that, and they were erased. She stated the facility usually kept the videos for about 30 days unless they were made aware of an incident, and they specifically saved the videos. She stated, since neither P1’s or P2’s allegations were made during their hospitalizations, and a specific date was not specified in the allegations, the facility did not save the videos. She stated cameras were in the hallways and common areas but not the patient rooms or bathrooms. 2. Review of P1’s “Face Sheet” revealed the facility admitted the patient on 02/03/2024 with diagnoses of major depressive disorder (MDD), recurrent, severe, without psychotic features. Further review revealed P1 was discharged from the facility on 02/13/2024. Review of P1’s “Physician’s Orders,” dated 02/04/2024, revealed an order for one-on-one observation, from 02/04/2024 to 02/09/2024, and an order for Close Visual Observation (CVO), dated 02/09/2024, now until discharge on 02/13/2024. Review of the facility’s risk management “Investigation,” dated 02/20/2024, revealed P1 alleged Mental Health Technician (MHT) 1 raped him/her during the patient’s one-on-one assignment sometime during P1’s hospitalization between 02/03/2024 and 02/13/2024. Further review revealed the complaint was received by SSA1 on 02/20/2024. Continued review revealed SSA1 investigated the allegation with the facility’s staff present. Additionally, the facility investigation revealed SSA1 unsubstantiated the allegation. However, there was no documentation of the facility’s findings. The investigation did state the facility was unaware of the patient’s allegation while the patient was hospitalized at the facility. Review of the facility’s February 2024 staffing schedules revealed MHT1 was scheduled to work on P1’s unit on 02/03/2024 and 02/04/2024. Review of P1’s “Supervision” sheets revealed MHT1 signed as supervising the patient on 02/04/2024 in the patient’s room from 11:00 AM until 12:45 PM. Further review revealed MHT1 signed as supervising P1 in the patient’s room on 02/07/2024 from 2:00 PM to 3:30 PM. During an interview with RM1 on 05/01/2024 at 12:45 PM, she stated she was unaware of P1’s allegation of rape until notified by SSA1 on 02/20/2024. She further stated SSA1 investigated the allegation and completed a documentation review and interviews and concluded MHT1 did not work with P1 directly, and SSA1 unsubstantiated the allegation. She stated the facility did not complete a separate investigation and did their investigation along with SSA1. Additionally, she stated the staffing sheets reviewed by SSA1 showed MHT1 did not work on P1’s unit. She stated MHT1 had stated he never worked on P1’s unit; therefore, MHT1 was not suspended. During an additional interview with RM1 on 05/01/2024 at 1:50 PM, she stated upon review of the February 2024 staffing sheets this afternoon, she discovered MHT1 did work directly with P1 on a one-on-one basis, and MHT1 was immediately suspended for “lying regarding his observation with P1.” She further stated SSA1 had only asked for night shift schedules during her investigation, and no one had looked at day shift scheduling for February 2024. During an interview with SSA1 on 05/01/2024 at 3:48 PM, she stated she did initiate an investigation for MHT1 regarding P1’s allegations on 02/18/2024 and completed the investigation on 03/27/2024. 3. Review of P2’s “Face Sheet” revealed the facility admitted the patient on 02/06/2024 with diagnoses of major depressive disorder (MDD), recurrent, severe, without psychotic features and post-traumatic stress disorder. Further review revealed Patient 2 was discharged from the facility on 02/14/2024. Review of P2’s “Physician’s Orders” revealed P2 had no orders for one-on-one observation or CVO during his/her hospitalization. Review of the facility’s risk management “Investigation,” dated 04/24/2024, revealed P2 alleged MHT1 raped him/her during the patient’s one-on-one assignment sometime during P2’s hospitalization between 02/06/2024 and 02/14/2024. Further review revealed the complaint was received by SSA1. Continued review revealed SSA1 investigated the incident with facility staff present. Additionally, there was no documentation of the facility’s findings. The investigation included an interview in which MHT1 told SSA1 he never worked on P2’s unit. Review of P2’s “Supervision” sheets revealed MHT1 signed as supervising P2 on 02/07/2024 in the day room from 4:30 PM until 4:45 PM and at 6:15 PM. Further review revealed MHT1 supervised P2 on 02/07/2024 in a group session from 7:00 PM to 7:15 PM. During an interview with RM1 on 05/01/2024 at 12:45 PM, she stated she was unaware of P2’s allegation of rape until notified by SSA1 on 04/24/2024. She further stated SSA1 conducted an investigation and completed documentation review and interviews and concluded MHT1 did not work with P2 directly, and SSA1 unsubstantiated the allegation. She stated the facility did not complete a separate investigation and did their investigation along with SSA1. Additionally, she stated the staffing sheets reviewed by SSA1 showed MHT1 did not work on P2’s unit. She stated MHT1 had stated he never worked on P2’s unit; therefore, MHT1 was not suspended. During an interview with RM1 on 05/01/2024 at 1:50 PM, she stated upon review of the February 2024 staffing sheets this afternoon, she discovered MHT1 did work directly with P2, and MHT1 was immediately suspended for “lying regarding his observation with P2.” She further stated SSA1 had only asked for night shift schedules during her investigation, and no one had looked at day shift scheduling for February 2024. During a continued interview with SSA1 on 05/01/2024 at 3:48 PM, she stated she did initiate an investigation for MHT1 regarding P2’s allegations on 04/24/2024 and had not completed her investigation. During an additional interview with RM1 on 05/03/2024 at 9:30 AM, she stated MHT1 had been interviewed and suspended, and staff had been provided abuse education. During an interview with MHT1 on 05/10/2024 at 9:37 AM, he stated his job duties included providing direct care to patients on his unit. He further stated he primarily worked the adolescent boys units but occasionally was pulled to other units if extra staff was needed or to give other staff breaks. He stated he remembered P1 and might have provided increased supervision for him/her during visitation hours when extra staff was required or to provide breaks for other staff. Additionally, he stated he did not remember P2. During an interview with RN1 on 05/07/2024 at 1:54 PM, she stated she had annual abuse training. She further stated if an abuse allegation was made against a staff member, the staff member would be suspended pending the investigation. During an interview with MHT2 on 05/08/2024 at 10:43 AM, she stated she had annual abuse training. She further stated if she was made aware of an abuse allegation against a staff member, she would report it to the Charge Nurse (CN) and send an email to the Unit Manager, as well as make a note of the allegation in the patient’s chart. During an interview with RN2 on 05/08/2024 at 11:24 AM, she stated she remembered P1 had Covid while in the facility and was isolated to his/her room. She further stated the facility tried to schedule same sex staff to stay with patients on increased supervision levels, but it was not always possible. She stated she did not remember any allegations made by P1 or P2 while they were hospitalized in the facility. She stated she had abuse training annually, and if an abuse allegation was made, she would notify the Unit Manager and House Supervisor, separate the staff member from the patient, then complete an incident report and call the patient’s guardian. During an interview with PHYS1 on 05/09/2024, he stated he took care of P1 and P2 while they were hospitalized, but he did not remember them making any accusations while they were in the facility. During an interview with Licensed Professional Clinical Counselor (LPCC) 2 on 05/09/2024 at 12:32 PM, she stated she currently worked with P1 on an outpatient basis at the facility since 04/16/2024. She further stated P1 “brought up” the allegation against MHT1 during his/her outpatient stay and expressed concern over the possibility of seeing MHT1 while in the facility. She stated P1 had told her MHT1 had sexually assaulted him/her while being an inpatient, but he/she did not offer specifics. Additionally, she stated it was her opinion P1 had been questioned by multiple people regarding the allegation and would respond negatively in treatment if he/she was questioned by this State Survey Agency Surveyor. During an interview with the Chief Operating Officer (CEO) on 05/15/2024 at 10:26 AM, he stated his expectation was for staff to follow the facility’s policies.”