Oceans Behavioral Hospital of Baton Rouge

“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: 52121 Based on record review and interviews, the hospital failed to provide care in a safe setting by failing to ensure staff properly secured a staff break room door on a psychiatric unit. This deficient practice had the potential to impact all patients on the psychiatric unit. Findings: Review of Patient #3’s Clinical Record revealed he was admitted to the hospital on 06/16/2026 with a diagnosis of schizoaffective disorder, bipolar type. Review of the hospital’s finalized Self-Report to the Louisiana Department of Health, dated 06/26/2026, revealed Patient #3 gained access to the restricted staff break room on 06/17/2026, successfully kept staff from entering for a period of time, and hit a staff member with a coffee pot once staff was able to make entry. When Patient #3 emerged from the staff break room, he caused further damage by discharging the contents of a fire extinguisher around the unit. Review of the hospital’s Intensive Analysis form, dated 06/22/2026 for the 06/17/2026 event, involving Patient #3 revealed, in part: Event Description: ... Behavioral Health Technician (BHT) noted exiting the break room. BHT did not own the door. Shortly after, staff noted Patient #3 pushing the door open and entering the break room. Root Cause Analysis findings included: The intended process was that staff ensure all employee-only areas, including break rooms, remain locked and secure from patient access. The patient was able to enter the employee break room without staff intervention. Controllable environmental factor: Staff failed to ensure the employee break room remained locked and secure from patient access. Review of the hospital’s Maintenance Daily Rounds sheet, dated 06/15/2026 to 06/19/2026, revealed, in part: Facility: Baton Rouge South “06/19/2026 Door was adjusted to close harder and faster. Used Allen wrench on the adjustment screws.” An interview was conducted on 07/28/2026 at 9:30 a.m. with S4NS. She stated that prior to the incident on 06/17/2026 unit staff were aware they had to physically pull the break room door shut for the lock to engage. An interview was conducted on 07/28/2026 at 2:22 p.m. with S5NS. She stated she had been employed at the hospital approximately three months and the break room door would never fully close on its own until the maintenance fix on 06/19/2026. She stated that prior to the maintenance fix staff had to pull the break room door and make sure they heard a click sound to know it locked. An interview was conducted on 07/28/2026 at 12:30 p.m. with S2DON. She confirmed staff failed to secure the break room door on 06/17/2026 which resulted in an adverse event.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 52121 Based on record review and interview, the hospital failed to implement and document hospital-wide staff education on topics identified through its intensive analysis following a serious adverse event where a patient accessed a restricted staff break room. Findings: Review of Patient #3’s Clinical Record revealed he was admitted to the hospital on 06/16/2026 with a diagnosis of schizoaffective disorder, bipolar type. Review of the hospital’s finalized Self-Report to the Louisiana Department of Health, dated 06/26/2026, revealed Patient #3 gained access to the restricted staff break room on 06/17/2026, successfully kept staff from entering for a period of time, and hit a staff member with a coffee pot once staff was able to make entry. When Patient #3 emerged from the staff break room, he caused further damage by discharging the contents of a fire extinguisher around the unit. Review of the hospital’s Intensive Analysis form, dated 06/22/2026 for the 06/17/2026 event, involving Patient #3 revealed, in part, the following corrective actions and measures of success: Corrective Actions: Enhanced staff education Measure of Success: Complete the following Relias classes: A. Own the Door B. Preventing/De-Escalating Crisis Situations C. Handling of Aggressive Behaviors An interview was conducted on 07/28/2026 at 12:30 p.m. with S2DON. She stated the six employees involved in the incident had either been retrained on the topics above or had been terminated. S2DON confirmed that the three Relias classes were not assigned to all staff following the incident. S2DON further confirmed there was no documentation to show all hospital staff had been retrained or in-serviced on the three topics identified in the Intensive Analysis.”

“Personnel - Discharge Planning CFR(s): [The hospital must employ or undertake to provide adequate numbers of qualified professional, technical, and consultative personnel to:] Engage in discharge planning; This Standard is not met as evidenced by: 48537 Based on record review, interviews and hospital policy review, the hospital failed to ensure all discharge materials including transition record, medications, and instructions were reviewed with the Patient and/or representative of 1 (#2) of 3 patients sampled. Findings: Review of the hospital policy #PC-18 titled “Discharge Planning: Transition Record” last revised on 10/01/2024 revealed in part: “Purpose: To establish guidelines for assisting patients to the appropriate level of psychosocial/physical care, treatment and services for post-treatment placement, follow-up, and/or transfer. Policy: Discharge planning commences upon admission to any program. Tentative discharge plans are established, reviewed, and modified throughout treatment. Procedure: 4. Social Services/Case Management personnel shall: -Notifies patient and family of the date discharge will occur; -When feasible, prior to discharge or transfer to a lower level of care, conducts a discharge conference with patient (family/significant others, as appropriate to: ~Finalize living arrangement and post-treatment care plans to meet ongoing needs for care and services; ~Review patient progress in treatment; ~Discuss patient and family’s expectations of patient’s behavior and participation in recommended therapies post-discharge. 5. The Nurse shall: -Review patient’s medication regimen and educate on medications; -Upon discharge, provide the patient recommendations for anticipated continuing care, treatment, and services and discharge medication interventions. 6. The Treatment Team members will complete a crisis safety plan, if applicable, and document the final discharge plans on the Transition Record. This information shall include at a minimum: -Reason for inpatient admission; -Principal diagnosis at discharge; -Current medication list; - Studies pending at discharge; -Patient self-management instructions; -Contact information for obtaining results of studies pending at discharge, if indicated; -Plan for follow-up care including primary physician, other health care professional, or site designated for follow up, any/all follow-up appointments and aftercare services; -Patient signatures of acceptance/understanding of recommendations and Transition Record being provided.” Review of Patient #2’s medical record revealed she was admitted to the hospital on 09/06/2025 at 2:30 a.m. from an outside emergency room facility on a PEC and subsequently a CEC for psychosis with suicidal and homicidal ideations with hallucinations and delusions. Review of Patient #2’s Consent for Treatment document revealed she herself signed the document and also provided authorization for her daughter in law to be contacted, updated and provided information regarding her care at any point during her hospitalization. Patient #2 did not revoke this authorization at any point during her hospitalization. Review of Patient #2’s Transition Record revealed the following in part: Transition Record: Discharge Date and Time - 09/20/2025 at 10:00 a.m. Discharge Status - Scheduled -Provided education to patient or family member on diagnosis Discharge to - Home Mode of transportation to discharge location - home with family member in private vehicle Follow-Up Appointments: PCP Appointment Scheduled Psychiatry Appointment Scheduled Neurologist Appointment Scheduled Medical: Are there any lab or X-Ray results pending at discharge? “No” - Patient #2 did have a pending potassium lab result at her time of discharge, which was called to her daughter in law, which had resulted after she had been discharged, and the facility instructed the daughter-in-law to bring Patient #2 to the ER or after-hours lab to get her potassium level checked. Discharge Plan Education: Patient Understanding of Discharge Plan- Patient/Family able to verbalize discharge instructions (checked); Patient verbalizes understanding when/how to seek further treatment (checked) Discharge medication reconciliation- Medication reconciliation is completed by provider and copy of medication list with discharge education is given to patient by nursing (checked) Patient Authorization and Signature: The patient has received a copy of the following- Discharge Orders (checked); Crisis Safety Plan (checked); Discharge Medication Reconciliation (checked) Patient Signature: Patient refuses or is unable to sign (checked) Date: 09/18/2025 Time: 3:22 PM Social worker/therapist/case manager signature: S3CM Date: 09/18/2025 Time: 3:22 PM No additional SocialWorker/Therapist/Case Manager or Nurse signature or Patient legal guardian/representative signature is found on the document. Review of Patient #2’s medical record revealed an official discharge date of 09/19/2025 at 11:55 a.m. to home with her daughter in law. Review of Patient #2’s multidisciplinary team notes involving communication with Patient #2’s daughter in law immediately following discharge revealed the following in part: On 09/19/2025 at 4:34 PM - DON spoke with Patient #2’s daughter-in-law, attempted to notify her of medication changes while inpatient. Patient #2’s DIL stated that she did not get a medication list printed. I also notified her of the pt’s high potassium which resulted after her leaving our building and that we recommend getting her to an ER or an after-hours that does labs. Signed at 4:56 PM by S2DON. On 11/24/2025 at 4:10 PM, an interview was conducted with S1VPCS. S1VPCS said the expectation would be if the patient was unable to sign or refused to sign their transition record at discharge and had a representative who the patient had given authorization to be a part of their treatment and discharge planning process, the expectation would be the transition record should be reviewed with the patient’s representative and they would sign on behalf of the patient as having received the information and confirmed understanding. S1VPCS reviewed Patient #2’s transition record and confirmed it revealed documentation on 09/18/2025 at 3:22 p.m. of Patient #2 being unable to or refusing to sign and/or documentation within the transition record or other multidisciplinary notes that the transition guide was reviewed in its entirety with Patient #2’s daughter-in-law prior to Patient #2’s discharge on 09/19/2025.”

“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: 50453 Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation (CoP) for Nursing Services. The deficient practice was evidenced by: 1) failure of the Registered Nurse to document patient observations every 2 hours per hospital policy for 8 (#R23-R30) of 38 (#R1-#R38) Patient Observation Check Sheets reviewed (see findings in A0395); 2) failure of the Registered Nurse to supervise staff to ensure timely observation rounds were performed for 26 (#R2-#R20, #R23-#R30) of 38 (#R1-#R38) Patient Observation Check Sheets reviewed (see findings in A0395); 3) failure of the nursing staff to monitor blood glucose results or document provider notifications for out of range blood glucose results per provider orders in 1 (#1) of 3 (#1-#3) patients reviewed (see findings in A0398); and 4) failure of the nursing staff to administer Patient #1’s medications per physician order (see findings in A0405).”

“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: 50453 Based on record review and interviews, the hospital failed to ensure the patients right to make informed decisions regarding his or her care. This deficient practice was evidenced by failure to notify and allow the patient representative to make decisions related to care after evidence of neglect was identified involving Patient #1. Findings: Review of hospital policy number RTS-01, titled “Patient Rights Louisiana,” last revised 09/01/2025, revealed in part: “PURPOSE: To ensure that all patients are aware of their rights while being treated at this facility and to provide guidance to the program staff regarding the method for ensuring patient rights are respected and the method for restricting a patient’s rights if deemed necessary. PROCEDURE: 4. If the patient is cognitively and/or physically unable to sign and comprehend this information about their rights, the patient’s guardian or a family member will be so informed and will sign them as legally appropriate; or if the patient is disoriented or in a state that impairs cognition at the time of entry, he/she is informed of his/her rights at an appropriate time during care, treatment, and services. Treatment: You have the right be involved in making decisions regarding the nature of care, treatment, and services that you will receive and to make decisions about your care. If you are unable to make decisions about the care, treatment, and services, the rights of involvement of family/surrogate decisions maker instated on the patient’s behalf will be respected in accordance law and regulations. You have the right to have medications prescribed by a practitioner and only administered under their order. You have the right to be informed about the outcomes/unanticipated occurrences in order to participate in current and future healthcare decisions.” Review of Patient #1’s medical record revealed that Patient #1 was admitted with a diagnosis Psychosis, behavioral disturbance, and cognitive disorder. Patient #1 had a history of Dementia, Hypertension, Diabetes Mellitus type 2, Coronary Artery Disease, Hyperlipidemia, and Hypokalemia. Review of Patient #1’s consents revealed that Patient #1 was unable to sign and participate in treatment plan due to cognitive impairment. Review of self-report revealed in part that Patient #1 was involved in an incident of gross neglect related to S10LPN fabricating medical documentation and failing to carry out provider orders. Review of Patient #1’s medical record revealed in part that Patient #1 received the incorrect insulin twice on 07/08/2025. Further review of Patient #1’s medical record revealed that the nurse failed to monitor the patients BG and administer insulin per provider orders. In an interview on 08/06/2025 at 10:40 AM, S2ADM confirmed that the self-report documented that Patient #1’s family was not notified of the alleged neglect. In an interview on 08/07/2025 at 12:17 PM, S1DON confirmed that the family of Patient #1 was not notified of the unanticipated outcomes and occurrences involving Patient #1.”

“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: 50453 Based on observation and interview, the hospital failed to ensure each patient’s right to receive care in a safe setting. The deficient practice is evidenced by: 1) leaving an unlocked medication cart unattended in a patient care area posing a potential risk for injury; and 2) failure to notify the provider of a critical lab result per hospital policy for Patient #1. Findings: 1) Leaving an unlocked medication cart unattended in a patient care area posing a potential risk for injury. During a tour on 08/06/2025, S5LPN was observed with the medication cart in Room #a preparing medications for patient medication pass. There were 8 patients sitting in the Room #a watching the television. S5LPN was observed walking away from the medication cart and entering Room #b to administer medications. Further observation revealed that the medication cart was not locked while it was left unattended which contained medications and needles which patients could access. In an interview on 08/06/2025 at 11:47 AM, S1DON, S3DOQ, and S4ADN confirmed the above mentioned findings. S1DON further confirmed that there were no other staff in Room #a with the 8 patients when S5LPN walked away from the unlocked medication cart. In an interview on 08/06/2025 at 11:50 AM, S5LPN confirmed that she left the medication cart unlocked when she walked away from it. S5LPN further confirmed that she should have locked the cart before leaving it unattended in the patient care area. 2) Failure to notify the provider of a critical lab result per hospital policy for Patient #1. A review of hospital policy number NSG-67, titled “Protocols for Critical Lab Values,” last revised 10/01/2024, revealed in part: “POLICY: All critical laboratory test results require prompt notification to care providers including the read back process when appropriate to ensure patient safety. PROCEDURE: 2. The nursing staff will receive report/notification of all critical labs from lab vendor. 3. The Physician/Non-Physician Practitioner (NPP) will be notified within 30 minutes of the nurse receiving the critical lab value. 8. Critical Lab monitoring and communication is incorporated into the Performance Improvement Program.” Review of Patient #1’s medical record revealed the following nursing notes in part: 07/08/2025 at 11:00 AM- called and notified critical lab (blood sugar) of 409. Documented by S8RN. 07/08/2025 at 12:00 PM- Checked Patient #1’s blood glucose at 11:45 AM, too high to read. 14 units of Humulin R given per Humulin R sliding scale. Notified RN. Documented by S9LPN. 07/08/2025 at 12:09 PM- Notified NP of critical blood glucose lab result from labcorp and recheck of current blood glucose which was too high to read on Accu-check monitor. Per NP check patient blood sugar every 2 hours and give sliding scale insulin. Documented by S8RN. Further review of Patient #1’s medical record failed to reveal that the critical lab result was reported to the provider within 30 minutes per policy. In an interview on 08/07/2025 at 11:21 AM, S1DON confirmed that the nurse did not notify the provider of the critical lab for a glucose of 409 for Patient #1 within 30 minutes per hospital policy.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to measure, analyze and track all adverse patient events. The deficient practice is evidenced by failing to provide documentation of preventative actions that were implemented to educate staff related to insulin administration and following provider orders. Findings: Review of hospital policy number QAPI-004, titled “Incident Reporting,” last revised 08/01/2024, revealed in part: “PURPOSE: To document any potential or adverse incident within the facility or on the facility grounds/property/vehicle, with the facts available at the time, recorded by persons involved, either in the incident or in the discovery of the incident. Information to Provide in the Incident Report: 1. The Incident Report shall be limited to factual statements (who, what, where, and when) related to the patient safety incident and any interventions take to reduce the risk of future incidents and promote safety. Incident Reporting Investigation: 2. Each department Director is responsible for reviewing incidents that occur in their area, investigating and completing follow-up. 4. Assess staff members and processes involved in events for training, education, or process improvement. 7. The Quality Director and Hospital Administrator are mandatory reviewers of all incidents. 9. The Quality Director shall track and trend all incident types. 10. All aggregated data should be brought forward to the appropriate committee for performance improvement activities.” Review of hospital policy number MM-01, titled “Medications,” last revised 12/01/2024, revealed in part: “POLICY: The hospital will ensure that all medications related to the patient in patient stay are ordered, dispensed, labeled, stored, transcribed, administered, and documented in the medical record in accordance with Federal and State Law and industry best practices. Evaluation of Medication Management System: DON: Collects and analyses data on performance of the medication management system. Compares data over time to identify risk points, levels of performance, patterns, trends and variations. Research literature and external sources for new technologies and best practices. PI Committee Process: Based on aforementioned actions identifies opportunities to improve and recommends same. Continues to evaluate actions to confirm implemented opportunity resulted in improvement. Take additional action when improvements are not achieved or not sustained. Undertakes an annual evaluation at minimum, of medication management system.” Review of the hospital incident log revealed in part: 07/08/2025: Patient #1, Incident Category: Medication Variance Review of the incident report involving Patient #1 revealed in part: Date/Time: 07/08/2025 at 2:00 PM - Medication Variance Provide a brief factual description of the incident: 14 units of Humulin R given at 12:00 PM instead of 18 units of Humalog 14 units of Humulin R given at 2:00 PM. MD states that he only wanted it one time not every 2 hours. Related Causes and Factors: Transcription error Actions taken post incident: MD notified, Supervisor notified, Treatment/evaluation conducted, accuchecks ordered every hour. Follow Up/Resolution (QD): Blank Follow Up/Resolution (DON): Blank Follow Up/Resolution (CEO): Blank Administrator/CEO Reviewed: No Quality Director Reviewed: No Review of Patient #1’s medical record revealed in part the following nursing notes: 07/08/2025 at 12:05 PM- Checked patients CBG at 11:45. CBG too high to read. 14 units of Humulin R given per Humulin R sliding scale. Notified RN. Documented as a late entry by S9LPN on 07/10/2025 at 11:06 AM. 07/08/2025 at 12:09 PM- Notified NP of critical blood glucose lab result from labcorp and recheck of current blood glucose which was too high to read on the Accucheck monitor. Per NP check patient blood sugar every 2 hours and give sliding scale insulin. Documented by S8RN on 07/10/2025 at 10:43 AM. 07/08/2025 at 2:00 PM- Check patients CBG at 2:00 PM. CBG too high to read. Administered 14 units of Humulin R insulin. Notified NP. NP clarified that the order for sliding scale insulin was not meant to be given every 2 hours, only for the initial accucheck at 11:45 PM. New orders noted to recheck CBG every hour and notify NP of readings. Documented by S9LPN on 07/10/2025 at 11:14 AM. 07/08/2025 at 3:00 PM- Notified S1DON that incorrect insulin was given. Rechecked CBG at 3:00 PM. CBG too high to read. Notified MD of incorrect medication given and new accucheck reading for 3:00 PM. No new orders at this time. Documented by S9LPN on 07/10/2025 at 11:21 AM. 07/08/2025 at 4:00 PM- Rechecked CBG at 4:00 PM. Accucheck 517. Notified NP. No new orders noted. Documented by S9LPN on 07/10/2025 at 11:28 AM. Review of Patient #1’s physician orders revealed in part the following: Order date 07/07/2025- Discontinue date 07/16/2025: -Insulin Lispro (Humalog) subcutaneously before meals and at bedtime - SEE SLIDING SCALE- Capillary Blood Glucose less than or equal to 60, give orange juice orally (if allergic to orange juice, give Glucagon 1mg IM). Recheck Blood glucose in 10 minutes. If BG still less than or equal to 60, call MD immediately. Capillary Blood Glucose greater than 400, give 18 units, call MD or NPP and recheck CBG in 30 minutes and continue with sliding scale. If Capillary Blood Glucose still greater than 400 after 30 minutes, call MD or NPP for further orders. SLIDING SCALE: 61-99= 0 units; from 100-150=3 units; from 151-200= 6units; from 201-250= 9 units; from 251-300= 12 units; from 301-350= 15; from 351-400= 18 units; greater than 400 call MD/NP= 18 units. Further review of Patient #1’s medical record failed to reveal orders for Humulin R entered by the provider. Review of Patient #1’s MAR for 07/08/2025 revealed in part: 11:30 AM: Humalog- documented as not given. Reason- Other reason/pharmacy consult. Documented by S9LPN. The MAR failed to reveal that Patient #1 received 2 doses of Humulin R (28 units total). During an interview on 08/07/2025 at 12:17 PM, S1DON verified that she was made aware of the medication error when Patient #1 received the wrong insulin, stating the provider “refused” to enter an order for the Humulin R that was administered by S9LPN. S1DON stated that a verbal order was taken by S8RN from the provider after receiving the critical lab glucose result to obtain BG every 2 hours. S1DON also verified that S9LPN did not scan the patient armband and check the medication against the MAR prior to administration. S1DON confirmed the provider did not change the order for the Humalog sliding scale insulin. S1DON further confirmed at the time of the incident Patient #1 had no order for Humulin R on the patient MAR.”

“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: 50453 Based on observations, record reviews, and interviews, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by: 1) failure of the Registered Nurse to document patient observations every 2 hours per hospital policy for 8 (#R23-R30) of 38 (#R1-#R38) Patient Observation Check Sheets reviewed; and 2) failure of the Registered Nurse to supervise staff to ensure timely observation rounds were performed for 26 (#R2-#R20, #R23-#R30) of 38 (#R1-#R38) Patient Observation Check Sheets reviewed. Findings: Review of hospital policy number CS-23, titled “Level of Observations,” last revised 03/01/2023, revealed in part: “PURPOSE: To provide staff with a framework for monitoring patients to ensure safety. Observations should be both safe and therapeutic. Respect should be shown for the patient’s need for autonomy while ensuring safety. Observation Levels: Every 15 minutes- the staff member will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities. PROCEDURE: 3. Staff members utilize the close observation form (Q15 check sheet) to document the ongoing observation and location of the patient. The observing staff initials the 15 minute increments on the form to indicate the patient was observed. The Registered Nurse (RN) will conduct routine rounds to visually observe each patient for safety at least once every 2 hours (unless more often is warranted) and will validate rounds by initialing in the appropriate section(s) of the form.” 1) Failure of the Registered Nurse to document patient observations every 2 hours per hospital policy for 8 (#R23-R30) of 38 (#R1-#R38) Patient Observation Check Sheets reviewed. Observations during a walk-through on 08/06/2025 from 11:25 AM-12:00 PM revealed that the last RN observations were performed at 9:00 AM on Observation Check Sheet/Graphic Flowsheet. Further review of the Observation Check Sheet/Graphic Flowsheet failed to reveal that RN observations were performed every 2 hours per hospital policy from 9:15 AM-11:30 AM on Patients #R23-#R30. In an interview during the tour, S1DON confirmed the above mentioned findings. 2) Failure of the Registered Nurse to supervise staff to ensure timely observation rounds were performed for 26 (#R2-#R20, #R23-#R30) of 38 (#R1-#R38) Patient Observation Check Sheets reviewed. Observations during a walk-through on 08/06/2025 revealed the following on Unit B: S6MHT was assigned to Patients #R23-#R25. Review of Patient #R23-#R25 Observation Check Sheet/Graphic Flowsheets failed to reveal that Q15 minute observations were performed at 11:15 AM or 11:30 AM for Patient #R23-#R25. In an interview on 08/06/2025 at 11:34 AM, S1DON confirmed the above mentioned findings. S7MHT was assigned to Patients #R26-#R30. Review of Patient #R26-#R30 Observation Check Sheet/Graphic Flowsheets revealed that S7MHT had pre-signed the 11:45 AM observation round for all 5 patients she was observing. Further review of S7MHT’s observation flowsheets revealed that Patient #R30 was not in Room #d with the other patients S7MHT was observing. In an interview on 08/06/2025 at 11:38 AM, S1DON confirmed that the Observation Check Sheet/Graphic Flowsheets were pre-signed for the 11:45 AM observation round on Patients #R26-#R30. S7MHT verified that Patient #R30 was in Room #e, which could not be visualized from where she was sitting. Observations during a walk-through on 08/06/2025 revealed the following on Unit A: Review of Patient #R2-#R20’s Observation Check Sheet/Graphic Flowsheets for Unit A failed to reveal that Q15 minute observations were performed at 7:00 AM, 7:15 AM, 7:30 AM, or 7:45 AM. Further review of Patient #R2’s observation flowsheet also failed to reveal that Q15 minute observations were performed at 11:00 AM. Further review of Patient #R3’s observation flowsheet also failed to reveal that Q15 minute observations were performed at 11:30 AM or 11:45 AM. In an interview on 08/06/2025 at 11:55 AM, S1DON confirmed the above mentioned findings.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50453 Based on record review and interview, the Director of Nursing failed to ensure nursing staff adhered to the policies and procedures of the hospital. This deficient practice was evidenced by failure of the nursing staff to monitor blood glucose results or document provider notifications for out of range blood glucose results per provider orders in 1 (#1) of 3 (#1-#3) patients reviewed. Findings: Review of hospital policy number MM-17, titled “Insulin administration,” last revision 08/01/2025, revealed in part: “PURPOSE: To provide guidelines for the safe administration of insulin and the correct dose of insulin based on the measurement of capillary blood glucose levels (CBG). To provide guidelines for the monitoring and treatment of high blood sugar/hyperglycemia and low blood sugar/hypoglycemia. POLICY: Insulin is used to control hyperglycemia in patients with diabetes mellitus. Insulin injections will be administered in accordance with the following procedures by licensed nursing staff. Each hospital’s sliding scale insulin therapy will be approved by its medical staff and will be utilized in giving the licensed nurse direction for management in controlling capillary blood glucose levels of diabetic patients. Accurate glycemic control using a safe and effective sliding scale insulin therapy can reduce risks for complications of diabetes mellitus and the patient’s length of stay. Indications: Treatment of hyperglycemia and hypoglycemia will consist of orders contained within each hospital’s sliding scale insulin protocol.” Review of Patient #1’s medical record revealed that Patient #1 was admitted on 06/28/2025-07/02/2025 and sent to ED for evaluation of Hyperglycemia and Hyperkalemia. Patient #1 was readmitted on 07/07/2025. Admit diagnosis Psychosis, behavioral disturbance, and cognitive disorder. Patient #1 had a history of Dementia, Hypertension, Diabetes Mellitus type 2, Coronary Artery Disease, Hyperlipidemia, and Hypokalemia. Patient #1 was discharged on 07/16/2025. Review of Patient #1’s provider orders for 06/28/2025-07/02/2025 revealed in part the following: 06/28/2025: Finger stick Blood Glucose before meals and at Bedtime Sliding Scale orders revealed in part: 06/28/2025: Insulin Regular (Humulin R) subcutaneously before meals and at bedtime - SEE SLIDING SCALE- Capillary Blood Glucose less than or equal to 60, give orange juice orally (if allergic to orange juice, give Glucagon 1mg IM). Recheck Blood glucose in 10 minutes. If BG still less than or equal to 60, call MD immediately. Capillary Blood Glucose greater than 400, give 14 units, call MD or NPP and recheck CBG in 1 hour. If Capillary Blood Glucose still greater than 400 after 1 hour, call MD or NPP for further orders. Discontinue date 07/04/2025. Review of Blood Glucose values on 06/28/2025-07/02/2025 revealed in part the following: 06/29/2025 at 11:58 AM- BG=498 (Not rechecked within 1 hour per provider order. BG rechecked 2 hours later. No provider notification) 06/29/2025 at 2:01 PM- BG= 357 06/29/2025 at 9:13 PM- BG=400 (Not rechecked within 1 hour per provider order. BG rechecked 8 hours later. No provider notification) 06/30/2025 at 5:30 AM- BG=45 06/30/2025 at 5:30 AM- BG=97 06/30/2025 at 11:03 PM- BG=508 (Not rechecked within 1 hour per provider order. BG rechecked 5.5 hours later) 07/01/2025 at 4:35 AM- BG=58 (Not rechecked within 10 minutes per provider order. BG rechecked 7.5 hours later. No provider notification) 07/01/2025 at 11:58 AM- BG=356 07/02/2025 at 11:30 AM- BG=586 (Not rechecked within 1 hour per provider order. Patient #1 sent to ED for evaluation on 07/02/2025 at 3:40 PM) Review of Patient #1’s provider orders for 07/07/2025-07/16/2025 revealed in part the following: 07/07/2025: Finger stick Blood Glucose before meals and at Bedtime 07/07/2025: Humalog Sliding Scale- Blood glucose less than or equal to 60, give orange juice orally (if allergic to orange juice, give Glucagon 1mg IM). Recheck Blood glucose in 10 minutes. Blood glucose greater than 400, administer 18 units, recheck BG after 30 minutes and continue with sliding scale. If capillary BG still greater than 400 after 30 minutes, call MD or NPP for further orders. Discontinued at discharge. 07/08/2025 at 12:33 PM: Finger stick Blood Glucose every 2 hours. 07/08/2025 at 4:12 PM: Finger stick Blood Glucose every 1 hour. 07/08/2025 at 11:29 PM: Finger stick Blood Glucose every 2 hours. 07/09/2025 at 6:15 AM: Finger stick Blood Glucose before meals and at Bedtime, with sliding scale insulin orders for Blood glucose less than or equal to 60, give orange juice orally (if allergic to orange juice, give Glucagon 1mg IM). Recheck Blood glucose in 10 minutes. Blood glucose greater than 400, administer 18 units, recheck BG after 30 minutes and continue with sliding scale. If capillary BG still greater than 400 after 30 minutes, call MD or NPP for further orders. Discontinued at discharge. Review of Blood Glucose values on 07/07/2025-07/16/2025 revealed in part the following: 07/07/2025 at 5:00 PM- Patient #1 readmitted to facility. 07/07/2025 at 9:44 PM- BG=144 documented by S10LPN 07/07/2025 at 9:53 PM- BG= documented as “Refused/Unable” by S10LPN (No provider notification) 07/08/2025 at 4:35 AM- ordered blood work drawn by lab corp 07/08/2025 at 6:58 AM- BG= 104 documented by S10LPN 07/08/2025 at 10:32 AM- BG= 104 documented by S9LPN 07/08/2025 at 11:00 AM- critical lab glucose result of 409 called to hospital. 07/08/2025 at 11:45 AM- BG= HI (Not rechecked within 30 minutes per provider order. BG rechecked 2 hours later) 07/08/2025 at 2:00 PM- BG=HI (provider order for BG Q2 hours initiated) 07/08/2025 at 4:13 PM- BG=517 (provider order for BG Q1 hour initiated) 07/08/2025 at 5:03 PM- BG=317 07/09/2025 at 3:28 PM- BG=598 (Not rechecked within 30 minutes per provider order. BG rechecked 5 hours later) 07/09/2025 at 8:13 PM- BG=411 (Not rechecked within 30 minutes per provider order. BG rechecked 3 hours later) 07/09/2025 at 11:09 PM- BG=145 07/10/2025 at 12:23 PM- BG=468 (Not rechecked within 30 minutes per provider order. BG rechecked 4 hours later. No provider notification) 07/10/2025 at 4:21 PM- BG=145 07/13/2025 at 11:43 AM- BG=400 (Not rechecked within 30 minutes per provider order. BG rechecked 10 hours later. No provider notification) 07/13/2025 at 9:30 PM- BG=366 In an interview, during medical record review, on 08/07/2025 from 9:12 AM-12:30 PM, S1DON confirmed the above mentioned findings. S1DON further confirmed that the nursing staff did not monitor Patient #1’s blood glucose per provider orders or notify the provider for out of range blood glucose results.”

“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: 50453 Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered according to the physician’s orders. The deficient practice is evidenced by failure of the nursing staff to administer Patient #1’s medications per physician order. Findings: Review of hospital policy number MM-01, titled “Medications,” last revised 12/01/2024, revealed in part: “POLICY: The hospital will ensure that all medications related to the patient in patient stay are ordered, dispensed, labeled, stored, transcribed, administered, and documented in the medical record in accordance with Federal and State Law and industry best practices. MEDICATION ADMINISTRATION: Before administering a medication, the licensed independent practitioner or qualified individual administering the medication does the following: Verifies that the medication selected for administration is the correct one based on the medication order, prescriber instructions, MAR and product label. Verifies that there is no contraindication for administering the medication. Verifies that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. Advises the patient or, if appropriate, the patient’s family about any potential clinically significant adverse reaction or other concerns about administering a new medication. Reports any untoward or side effects to the physician/NPP, and documents all communication, findings, and status in the medical record and completes a medication variance form. DOCUMENTATION: All medications shall be documented on the patient’s Medication Administration Record (MAR) immediately after administration. RN/LVN/LPN: 2. If a dose of scheduled medication is withheld or not given, circles the hour of administration for the medication in question and initials next to circled time, or appropriately indicates the withheld or not given medication in the EMR, as applicable. Records a full explanation in the integrated progress notes and/or MAR. Physician must be notified, and documentation entered into the progress notes of physician/NPP notification. (Medication variance must be completed and submitted to nursing leadership).” Review of Patient #1’s medical record revealed that Patient #1 was admitted on 06/28/2025-07/02/2025 and 7/07/2025-07/16/2025. Admit diagnosis Psychosis, behavioral disturbance, and cognitive disorder. Patient #1 had a history of Dementia, Hypertension, Diabetes Mellitus type 2, Coronary Artery Disease, Hyperlipidemia, and Hypokalemia. Patient #1 was discharged on 07/16/2025. Review of Patient #1’s physician orders revealed in part the following: Order date 06/28/2025- Discontinue date 07/04/2025: -Insulin Glargine (Lantus) 30 units subcutaneously at Bedtime. Indication: type 1 diabetes mellitus. -Insulin Regular (Humulin R) subcutaneously before meals and at bedtime - SEE SLIDING SCALE- Capillary Blood Glucose less than or equal to 60, give orange juice orally (if allergic to orange juice, give Glucagon 1mg IM). Recheck Blood glucose in 10 minutes. If BG still less than or equal to 60, call MD immediately. Capillary Blood Glucose greater than 400, give 14 units, call MD or NPP and recheck CBG in 1 hour. If Capillary Blood Glucose still greater than 400 after 1 hour, call MD or NPP for further orders. SLIDING SCALE: 61-200= 0 units; from 201-250=3 units; from 251-300= 6units; from 301-350= 9 units; from 351-400= 12 units; greater than 400 call MD/NP=14 units. Review of Patient #1’s MAR revealed in part the following: 07/01/2025 9:19 PM: Humulin R- documented as not given. BG=241. Reason- Parameter Not Met. Patient accepted 30 units Lantus at HS. Held Sliding Scale. Documented by S11LPN. Further review of Patient #1’s medical record failed to reveal that the Humulin R was administered per physician order or that the provider was notified. In an interview on 08/07/2025 at 9:56 AM, S1DON confirmed the Humulin R was not administered per physician order. S1DON also confirmed there was no documented evidence that the provider was notified that the medication was not given. Review of Patient #1’s physician orders revealed in part the following: Order date 07/07/2025- Discontinue date 07/11/2025: -Insulin Glargine (Lantus) 15 units subcutaneously twice a day. Indication: type 2 diabetes mellitus. Review of Patient #1’s MAR revealed in part the following: 07/07/2025 9:53 PM: Lantus 15 units- documented as not given. BG=refused. Reason- Refused. Documented by S10LPN. 07/10/2025 9:33 PM: Lantus 15 units- documented as not given. BG=124. Reason- Parameter not met. Documented by S11LPN. Further review of Patient #1’s medical record failed to reveal that the Lantus was administered per physician order or that the provider was notified. In an interview on 08/07/2025 at 11:45 AM, S1DON confirmed the Lantus was not administered per physician order. S1DON also confirmed there was no documented evidence that the provider was notified that the medication was not given. S1DON verified that the order for Lantus does not have parameters. Review of Patient #1’s physician orders revealed in part the following: Order date 07/07/2025- Discontinue date 07/16/2025: -Insulin Lispro (Humalog) subcutaneously before meals and at bedtime - SEE SLIDING SCALE- Capillary Blood Glucose less than or equal to 60, give orange juice orally (if allergic to orange juice, give Glucagon 1mg IM). Recheck Blood glucose in 10 minutes. If BG still less than or equal to 60, call MD immediately. Capillary Blood Glucose greater than 400, give 18 units, call MD or NPP and recheck CBG in 30 minutes and continue with sliding scale. If Capillary Blood Glucose still greater than 400 after 30 minutes, call MD or NPP for further orders. SLIDING SCALE: 61-99= 0 units; from 100-150=3 units; from 151-200= 6units; from 201-250= 9 units; from 251-300= 12 units; from 301-350= 15; from 351-400= 18 units; greater than 400 call MD/NP= 18 units. Review of Patient #1’s MAR revealed in part the following: 07/07/2025 9:53 PM: Humalog- documented as not given. BG=144. Reason- Refused. Documented by S10LPN. Further review failed to reveal documented evidence that the provider was notified. 07/08/2025 6:30 AM: Humalog- documented as not given. BG=104. Reason- Medication parameter not met. Documented by S10LPN. 07/10/2025 6:26 AM: Humalog- documented as not given. BG=126. Reason- Medication parameter not met. Documented by S11LPN. 07/10/2025 10:31 PM: Humalog- documented as not given. BG=124. Reason- Medication parameter not met. Documented by S11LPN. 07/11/2025 5:57 AM: Humalog- documented as not given. BG=127. Reason- Medication parameter not met. Documented by S11LPN. 07/15/2025 9:32 PM: Humalog- documented as not given. BG=122. Reason- Medication parameter not met. Documented by S11LPN. Review of sliding scale revealed that Patient #1 should have received 3 units of Humalog. Further review failed to reveal the Humalog was administered per sliding scale physician order or that the provider was notified. 07/15/2025 6:30 AM: Humalog- documented as 3 units given. BG=202. Documented by S11LPN. Review of sliding scale revealed that Patient #1 should have received 9 units of Humalog. Further review failed to reveal the Humalog was administered per sliding scale physician order. In an interview during medical record review, on 08/07/2025 from 9:12 AM-12:30 PM, S1DON confirmed the above mentioned findings. S1DON verified that the nursing staff were not following the sliding scale parameters or administering medication per provider order. Review of Patient #1’s physician orders revealed in part the following: Order date 07/11/2025- Discontinue date 07/16/2025: -Insulin Glargine (Lantus) 15 units subcutaneously at bedtime. Indication: type 2 diabetes mellitus. Review of Patient #1’s MAR revealed in part the following: 07/15/2025 9:32 PM: Lantus 15 units- documented as not given. BG=122. Reason- Medication parameter not met, CBG does not meet parameters. Documented by S11LPN. Further review of Patient #1’s medical record failed to reveal that the Lantus was administered per physician order or that the provider was notified. In an interview on 08/07/2025 at 12:15 PM, S1DON confirmed the Lantus was not administered per physician order. S1DON also confirmed there was no documented evidence that the provider was notified that the medication was not given. S1DON verified that the order for Lantus does not have parameters.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 50453 Based on observation and interview, the facility failed to maintain an infection prevention and control program which includes surveillance, prevention, and control of HAIs, and maintains a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities. This deficient practice was evidenced by failing to store patient nutritional supplies in a sanitary condition. Findings: Observations during a tour of North campus on 08/06/2025 revealed the following expired nutritional supplies in the refrigerator in Room #c: Skim Milk, quantity 2, expiration date 08/03/2025 Glucerna, quantity 3, expiration date 07/15/2025 In an interview on 08/06/2025 at 11:58 AM by S3DOQ and S4ADN confirmed the above mentioned findings.”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 50453 Based on record review and interview, the facility failed to ensure each patient had an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This deficient practice is evidenced by the facility failing to include the patient’s ordered precautions in the nursing care plan for 1 (#1) of 3 (#1-#3) patient care plans reviewed for the inclusion of all medical and psychological needs of a patient. Findings: Review of Patient #1s medical record revealed Patient #1 was admitted on 06/28/2025. Review of Patient #1’s provider orders revealed orders for violence, fall, and elopement precautions. Review of Patient #1’s nursing care plan failed to reveal risk for elopement as part of the care plan. Further review of Patient #1’s medical record revealed Patient #1 was re-admitted on 07/07/2025. Review of Patient #1’s provider orders revealed orders for violence, fall, and elopement precautions. Review of Patient #1’s nursing care plan failed to reveal risk for violence as part of the care plan. In an interview on 08/07/2025 at 11:42 AM, S1DON confirmed the above mentioned findings. S1DON also confirmed that provider precaution orders should be included in the nursing care plan for each patient.”

“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: 48051 Based on observation, medical record review and interview, the hospital failed to ensure the patient’s right to received care in a safe setting. This deficient practice was evidenced by the hospitals failure to ensure Unit B’s exterior, patient courtyard was properly secured. Findings: Observations during a facility walk though on 04/07/2025 at 10:02 AM revealed Unit B’s exterior, patient courtyard, used by the patients who smoke, enclosed by a 10 - 12 foot tall wood fence. The emergency exit gate from this courtyard was not secured when pushed on by the surveyor. The latch on the wood fencing gate was missing 1 of 2 screw fasteners and the remaining screw fastener was loosely secured to the wood fencing. Further, the magnetic locking system on this wood gate was not functioning. This gate opened to the rear parking area and service entry/delivery area of the hospital. The area in which the gate opened was not secured or enclosed. A review of Unit B’s bed board provided by S2DON revealed 13 (#1 - #12, #14) of 16 (#1 - #16) patients with altered mental status related to dementia and 1 (#5) of 16 (#1 - #16) patients had elopement precautions assigned. 4 (#2, #14 - #16) of 16 (#1 - #16) patients were identified as patients whom would use this courtyard 5 times per day for cigarette smoking. 2 (#2, #14) of 4 (#2, #14 - #16) patients identified on the bed board as cigarette smokers, had a diagnosis related to dementia and were not on elopement precautions. Although these patients were being monitored by mental health techs (MHT) while in this courtyard area, the MHTs do not maintain a position at the gate. The potential for these patients to wander or attempt elopement via the unsecured gate existed and could potentially place all patients in an unsafe situation with the potential for harm and/or injury. In an interview on 04/07/2025 at 1:15 PM and present during the facility walk through, S2DON confirmed the above mentioned findings and the potential for patient(s) accessing the exterior, patient courtyard for the purpose of smoking cigarettes would be in an unsafe situation if they successfully wandered off or eloped via the unsecured gate.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 48050 Based on interviews and record review, the hospital failed to ensure accountability of the medical staff for the quality of care provided to patients. The deficient practice was evidenced by: 1)Failure of the admitting practitioner’s to order medical care based on the medical diagnoses at the time of admission to the facility in 1 (#4) of 5 (#1-#5) patient records reviewed for the sample; and 2)Failure of the admitting practitioners’ to update the Electronic Medical Record (EMR) with a new allergy identified during the Psychiatric Evaluation and/or History & Physical intake on 3 (#3, #4, #5) of 5 (#1-#5) patient records reviewed. Findings: 1)Failure of the admitting practitioner’s to order medical care based on the medical diagnoses at the time of admission to the facility in 1 (#4) of 3 (#1-#5) patient records reviewed for the sample. Review of Patient #4’s medical record revealed Patient #4 was admitted on 02/12/2025. Review of Patient #4’s History & Physical dated 02/13/2025 revealed documentation by the provider that Patient #4 had a questionable diabetes diagnosis so the plan would be to monitor/trend CBGs. Further review of Patient #4’s provider orders did not reveal an order to check CBGs. Review of Patient #4’s Plan of Care dated 02/12/2025 Alteration of glucose related to diabetes as evidenced by history of diabetes was identified as problem #2 with an intervention of nursing to provide education on results of testing and a short term goal of CBGs within normal limits daily for 3 consecutive days within 7 days. In an interview on 03/26/2025 at 1:57 PM, S1DON verified the above mentioned findings. 2)Failure of the admitting practitioners’ to update the EMR with a new allergy identified during the Psychiatric Evaluation and/or History & Physical intake on 3 (#3, #4, #5) of 5 (#1-#5) patient records reviewed. Review of Patient #3’s medical record revealed Patient #3 was admitted on 02/07/2025. Review of Patient #3’s Psychiatric Evaluation dated 02/07/2025 revealed the provider documented Patient #3 was allergic to Buspar. Further review of Patient #3’s EMR revealed Patient #3’s allergies were PCN, Lithium, Sulfa, Morphine, and Klonopin. In an interview on 03/26/2025 at 10:46 AM, S1DON verified that the provider documented in Patient #3s Psychiatric Evaluation dated 02/07/2025 Patient #3 was allergic to Buspar, but Patient #3’s EMR only had allergies to PCN, Lithium, Sulfa, Morphine, and Klonopin. In an interview on 03/26/2025 at 10:46 AM, S1DON verified that the provider documented in Patient #3s Psychiatric Evaluation dated 02/07/2025 Patient #3 was allergic to Buspar, but Patient #3’s EMR only had allergies to PCN, Lithium, Sulfa, Morphine, and Klonopin. Review of Patient #4’s medical record revealed Patient #4 was admitted on 02/12/2025. Review of Patient #4’s History & Physical dated 02/13/2025 revealed the provider documented Patient #4 was allergic to Risperdal. Further review of Patient #4’s EMR revealed Patient #4 had no known allergies. In an interview on 03/26/2025 at 1:10 PM, S1DON verified that the provider documented in Patient #4’s History & Physical on 02/13/2025 Patient #4 was allergic to Risperdal, and Patient #4’s EMR revealed Patient #4 had no known allergies. Review of Patient #5’s medical record revealed Patient #5 was admitted on 02/13/2025. Review of Patient #5’s History & Physical dated 02/13/2025 revealed the provider documented Patient #5 was allergic to peanuts. Further review of Patient #5’s EMR revealed Patient #5 had no known allergies. In an interview on 03/26/2025 at 2:35 PM, S1DON verified that the provider documented in Patient #5’s History & Physical on 02/13/2025 Patient #5 was allergic to peanuts, and Patient #5’s EMR revealed Patient #5 had no known allergies.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 48050 Based on observations and interviews, the hospital failed to ensure each patient has the right to personal privacy. This deficient practice was evidenced by failure to ensure each patient has the right to personal privacy by failing to provide complete window coverings to obscure the view from the outside into 5 (Rooms A, E, G, I, J) of 10 (Rooms A-K) patient rooms observed. Findings: Observations during a tour on 03/27/2025 from 8:30 AM to 9:05 AM revealed 5 (Rooms A, E, G, I, J) of 10 (Rooms A-K) patient rooms lacked complete window coverings to obscure the view from outside into 5 (Rooms A, E, G, I, J)of 10 (Rooms A-K) patient rooms observed. In an interview during the tour on 03/27/2025 at 8:50 AM, S1DON and S2ADON confirmed that the partial window coverings were not providing the patients with personal privacy.”

“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: 48050 Based on observation, record review, and interview, the psychiatric hospital failed to ensure patients received care in a safe setting as evidenced by: 1)Failure to ensure patients were being monitored per provider order on 1(#1) of 5 (#1-#5) patients medical record reviewed; 2)Failure to ensure 2 hour observation rounds were performed by Registered Nurse on 15 (#R1-#R15) of 15 (#R1-#R15) patients on the unit; and 3)Failure to test glucometer controls to meet the safety needs of the patients. Findings: 1)Failure to ensure patients were being monitored per provider order on 1(#1) of 5 (#1-#5) patients medical record reviewed. Review of the hospital policy number AS-01 titled, “Assessment Process Inpatient,” last revised date 09/01/2024, revealed in part: “PURPOSE: To provide a comprehensive assessment process which improves efficiency and maximizes interdisciplinary cohesiveness and integration for each patient across the continuum of care. To assess the immediate presenting problem for acuity criteria and determine the appropriate intensity of care. Admitting Physician: 1. If admission is necessary, will give approval and provide medical certification for admission. The admission order set will contain an admitting preliminary diagnosis, precautions, orders for treatment, legal status, preliminary plan of care, and diagnostic impression. 2. Initiates initial treatment plan problem(s) to be followed up on by nursing, to include goals and interventions to meet patient transition/safety/discharge planning needs.” Review of Patient #1’s medical record revealed Patient #1 was admitted on 01/25/2025 with Bipolar Disorder with Psychotic Features and Intellectual Disability. Review of Patient #1’s Admit orders dated 01/26/2025 at 4:24 AM revealed in part: Choking Precautions with diet of mechanical soft chopped meat, cardiac moist and assist with feeding. Further review of Patient #1’s plan of care did not address the choking precautions or diet needs. Review of Patient #1’s nursing progress note dated 02/02/2025 at 10:55 PM Patient #1 received Ativan 2mg, Benadryl 50mg, and Haldol 5mg IM for severe psychosis. Then at 11:32 PM on 02/02/2025 the RN reached out to medical provider to report Patient #1’s oxygen saturation levels were between 86-88% on room air so Patient #1 was placed on oxygen via non-rebreather mask. Further review of Patient #1’s nursing progress note dated 02/03/2025 at 12:57 AM documented Patient #1 experiencing gurgling with low oxygen saturation and medical provider notified who ordered Patient #1 to be transferred to higher level of care. Patient #1 was transferred to Hospital B on 02/03/2025 at 12:42 AM. Review of the medical record for Patient #1 from Hospital B revealed the patient was in respiratory distress upon arrival and was immediately intubated. Patient was admitted to ICU at Hospital B with diagnosis of Aspiration Pneumonia. In an interview on 03/25/2025 at 12:50 PM, S1DON verified the above mentioned findings. 2)Failure to ensure 2 hour observation rounds were performed by Registered Nurse 15 (#R1-#R15) of 15 (#R1-#R15) patients on the unit. Review of the hospital policy number CS-23 titled, “Level of Observations”, revealed in part: “PURPOSE: To provide staff with a framework for monitoring patients to ensure safety. Observation should be both safe and therapeutic. Respect should be shown for patient’s needs for autonomy while ensuring safety. PROCEDURE: 3. The Registered Nurse (RN) will conduct routine rounds to visually observe each patient for safety at least once every 2 hours (unless more often is warranted) and will validate rounds by initialing in the appropriate sections(s) of the form.” Observations during a tour of Campus B on 03/27/2025 from 8:30 AM to 9:05 AM revealed a census of 15 patients. Review of the Observation Check Sheets for all 15 patients on the unit revealed no RN rounding from 7:00 AM to 9:00 AM. An interview on 03/27/2025 at 9:03 AM, S2ADON verified the RN had not documented rounding on the Observation Check Sheets for the 15 patients on Unit C. On 03/27/2025 at 1:25 PM, review of video footage navigated by S1ADON of Campus B on 03/27/2025 from 6:45 AM to 7:25 AM revealed at 7:22 AM RN exited the nursing station and walked around the Unit C looking into one doorway which S1ADON identified as the Group Room but couldn’t confirm if patients were in the Group Room. S3RN was not seen looking in any other Patient doorways or coming into contact with any patients on the Unit C returning to the nurses’ station at 7:25 AM. On 03/27/2025 at 1:30 PM, S1ADON verified the RN made a walking round around the Unit C at Campus B from 7:22 AM to 7:25 AM, but couldn’t confirm the RN rounded on patients or oversee the MHT monitoring patients. 3)Failure to test glucometer controls to meet the safety needs of the patients. Observations during a tour of Campus A on 03/24/2025 from 12:45 PM to 2:00PM revealed an open bottle of Glucose Control Solution that were not dated for day opened or expiration date. The log titled Glucose Control Log Sheet for Unit A for February and March 2025 were reviewed. Further review of the Glucose Control Log Sheet failed to reveal that daily quality controls were completed for the glucometer on 03/18/2025. Observations during a tour of Campus A on 03/24/2025 from 12:45 PM to 2:00PM revealed a log titled Glucose Control Log Sheet for Unit B for February and March 2025. Further review of the Glucose Control Log Sheet failed to reveal that daily quality controls were completed for the glucometer on 02/27/2025, 02/28/2025, 03/04/2025, 03/05/2025, 03/16/2025, 03/17/2025, and 03/18/2025. In an interview on 03/24/2025 at 1:10 PM, S1DON verified the glucose controls are to be checked daily.”

“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: 48050 Based on record review and interview, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by: 1)Failure of the Registered Nurse to obtain a MD order to perform a tasks; 2)Failure of the Registered Nurse to document patient observations every 2 hours per hospital policy; 3)Failure of the Registered Nurse to assign Observation Levels for 5 of 5 (Patients #1-#5) Patients’ Observation Check Sheets reviewed; 4)Failure of the Registered Nurse to supervise staff to ensure timely observation rounds performed for 4 (#2, #3, #4, #5) of 5 (#1-#5) Patients’ Observation Check Sheets reviewed; and 5)Failure of the Registered Nurse to supervise staff to ensure preventative/comfort measures were performed every 2 hours for 1 (#1) of 5 (#1-#5) Patients’ Observation Check Sheets reviewed. Findings: 1)Failure of the Registered Nurse (RN) to obtain a MD order to perform a task. Review of Patient #1’s medical record revealed Patient #1 was admitted on 01/25/2025 with Bipolar Disorder with Psychotic Features and Intellectual Disability. Review of Patient #1’s Nursing Assessment dated 01/30/2025 at 12:48 PM revealed the RN removed a fecal impaction. Review of Patient #1’s Nursing Assessment dated 01/30/2025 at 6:44 PM revealed the RN inserted a 16 french/5cc ballon foley catheter. Further review of Patient #1’s medical record failed to reveal a MD order for removal of a fecal impaction or foley catheter insertion. In an interview on 03/25/2025 at 12:58 PM, S1DON verified the RN performed the above mentioned tasks without an MD order. 2) Failure of the Registered Nurse to document patient observations every 2 hours per policy. Review of the Patient #1’s Observation Check Sheet dated 01/25/2025, failed to reveal documentation that the patient observations were completed every 2 hours within the timeframes below by the RN: 01/25/2025 between 10:15 PM - 6:45 AM. In interview on 03/25/2025 at 1:09 PM, S1DON confirmed that the RN did not document that observations were performed every 2 hours per hospital policy. Review of Patient #2’s Observation Check Sheets failed to reveal documentation that the patient observations were completed every 2 hours within the timeframes below by the RN: -On 08/22/2024 at 3:00 PM and 5:00 PM RN observations not performed -On 08/25/2024 between 7:00 AM to 5:00 PM RN observations not performed -On 08/27/2024 between 7:00 AM to 5:00 PM RN observations not performed In interview on 03/26/2025 at 10:26 AM, S1DON confirmed that the RN did not document that observations were performed every 2 hours per hospital policy. Review of Patient #3’s Observation Check Sheet dated 02/14/2025 failed to reveal documentation that the RN performed observations every 2 hours per hospital policy on 02/15/2025 at 5:00 AM. In interview on 03/26/2025 at 11:44 AM, S1DON confirmed that the RN did not document that observations were performed every 2 hours per hospital policy. Review of Patient #4’s Observation Check Sheets failed to reveal documentation that the patient observations were completed every 2 hours within the timeframes below by the RN: -On 02/15/2025 at 5:00 AM RN observation not performed. -On 02/20/2025 at 5:00 AM RN observations not performed. In interview on 03/26/2025 at 12:50 PM, S1DON confirmed that the RN did not document that observations were performed every 2 hours per hospital policy. Review of Patient #5’s Observation Check Sheet dated 02/14/2025 failed to reveal documentation that the RN performed observations every 2 hours per hospital policy on 02/15/2025 at 5:00 AM. In interview on 03/26/2025 at 2:50 PM, S1DON confirmed that the RN did not document that observations were performed every 2 hours per hospital policy. 3)Failure of the Registered Nurse to assign Observation Levels for 5 (#1-#5) of 5 (#1-#5) Patients’ Observation Check Sheets reviewed. A review of the Patient Observation Check Sheet for Patient #1 dated 01/25/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse. In interview on 03/25/2025 at 1:09 PM, S1DON confirmed that the RN did not assign observation level per physician order on the above observation check sheet per hospital policy. A review of the Patient Observation Check Sheets for Patient #2 dated 08/26/2024 and 08/27/2024, failed to reveal an assigned observation level checked per physician order by the Registered Nurse. In interview on 03/26/2025 at 10:26 AM, S1DON confirmed that the RN did not assign observation level per physician order on the above observation check sheets per hospital policy. A review of the Patient Observation Check Sheets for Patient #3 dated 02/07/2025, 02/11/2025, 02/12/2025, 02/13/2025 and 02/17/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse. In interview on 03/26/2025 at 11:44 AM, S1DON confirmed that the RN did not assign observation level per physician order on the above observation check sheets per hospital policy. A review of the Patient Observation Check Sheets for Patient #4 dated 02/12/2025, 02/16/2025, 02/17/2025, and 02/21/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse. In interview on 03/26/2025 at 12:50 PM, S1DON confirmed that the RN did not assign observation level per physician order on the above observation check sheets per hospital policy. A review of the Patient Observation Check Sheets for Patient #5 dated 02/17/2025 and 02/21/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse. In interview on 03/26/2025 at 2:50 PM, S1DON confirmed that the RN did not assign observation level per physician order on the above observation check sheets per hospital policy. 4)Failure of the Registered Nurse to supervise staff to ensure timely Mental Health Technician (MHT) observation rounds performed every 15 minutes for 4 (#2, #3, #4, #5) of 5 (#1-#5) Patients’ Observation Check Sheets reviewed. Review of Patient #2’s Observation Check Sheets revealed the RN did not ensure timely MHT observation rounds every 15 minutes per hospital policy. Further review failed to reveal rounds performed by the MHT on the following dates/times: -08/25/2024 between 11:45 AM to 5:45 PM -08/27/2024 between 7:00 AM to 7:00 PM In interview on 03/26/2025 at 10:26 AM, S1DON confirmed that the MHT did not document observation rounds every 15 minutes on the above observation check sheets per hospital policy. Review of Patient #3’s Observation Check Sheets revealed the RN did not ensure timely MHT observation rounds every 15 minutes per hospital policy. Further review failed to reveal rounds performed by the MHT on the following dates/times: -02/12/2025 between 7:00 PM to 8:00 PM -02/13/2025 between 7:00 PM to 7:45 PM -02/17/2025 at 7:00 PM In interview on 03/26/2025 at 11:44 AM, S1DON confirmed that the MHT did not document observation rounds every 15 minutes on the above observation check sheets per hospital policy. Review of Patient #4’s Observation Check Sheets revealed the RN did not ensure timely MHT observation rounds every 15 minutes per hospital policy. Further review failed to reveal rounds performed by the MHT on the following dates/times: -02/12/2025 at 8:00 PM -02/13/2025 between 7:00 PM to 7:45 PM -02/17/2025 at 7:00 PM MHT did not document observation rounds every 15 minutes. -02/18/2025 between 6:00 PM to 6:45 PM and 9:00 PM -02/20/2025 at 5:15 PM and 5:30 PM In interview on 03/26/2025 at 12:50 PM, S1DON confirmed that the MHT did not document observation rounds every 15 minutes on the above observation check sheets per hospital policy. Review of Patient #5’s Observation Check Sheets revealed the RN did not ensure timely MHT observation rounds every 15 minutes per hospital policy. Further review failed to reveal rounds performed by the MHT on the following dates/times: -02/17/2025 between 6:15 PM to 7:00 PM -02/20/2025 between 5:15 PM and 5:30 PM In interview on 03/26/2025 at 2:50 PM, S1DON confirmed that the MHT did not document observation rounds every 15 minutes on the above observation check sheets per hospital policy. 5)Failure of the Registered Nurse to supervise staff to ensure preventative/comfort measures were performed every 2 hours for 1 (#1) of 5 (#1-#5) Patients’ Observation Check Sheets reviewed. Review of Patient #1’s medical record revealed Patient #1 was admitted on 01/25/2025 with Bipolar Disorder with Psychotic Features and Intellectual Disability. Review of Patient #1’s Nursing Admission Assessment dated 01/26/2025 at 5:00 AM revealed Patient #1 was incontinent of urine with unsteady gait with recent falls and wheelchair bound. Further review of Patient #1’s Observation Check Sheets revealed the MHT did not offer the patient water, perform incontinence care, or reposition every 2 hours on the following dates/times: -01/25/2025 between 10:15 PM to 01/26/2025 6:45 AM MHT did not document that Patient #1 was repositioned every 2 hours. -01/29/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 01/30/2025 6:45 AM Patient #1 was not repositioned every 2 hours. -01/30/2025 between 7:00 AM to 9:45 AM and 5:00 PM MHT did not document that Patient #1 was repositioned every 2 hours -01/31/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 02/01/2025 6:45 AM Patient #1 was not repositioned every 2 hours. -02/01/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 02/02/2025 6:45 AM Patient #1 was not repositioned every 2 hours.. -02/02/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 11:45 PM Patient #1 was not repositioned every 2 hours. In an interview on 03/25/2025 at 12:58 PM, S1DON verified above findings mentioned.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure that the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. This deficient practice is evidenced by the failure to update the care plans of 2 (#1, #4) of 5 (#1-#5) patient reviewed for completed and updated care plans. Findings: A review of the hospital’s policy, “Treatment Planning: Integrated/Multidisciplinary,” Policy Number: CS-02, revised date of 07/01/2024, revealed in part: PURPOSE: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of the patient’s treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. PROCEDURE: 2. The admitting nurse is responsible for the following: formulating the initial treatment plan based on physician’s orders/ initial plan and findings and conclusions from the Pre-admission Assessment, Nursing Assessment, related measurement-based tools and family/significant other information within 24 hours of admit or sooner if patient’s needs warrants immediate action. 4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT). If the patient is unable and/or unwillingness shall be documented in the patient’s medical record. A review of the hospital’s policy number NSG-39 last revised 10/01/2023 titled, “Skin/Wound Care”, revealed in part: PURPOSE: To identify patients at risk for skin break down and pressure injury formation and skin abnormalities and provide interventions for the prevention, assessment, and treatment of such. PROCEDURE: Braden Scale Risk Assessment: 2. If the Braden score is less than 18, the start of care skin care guideline will be initiated. 3. An impaired skin integrity treatment plan will be initiated or updated according ot the patient’s assessed results. Review of Patient #1’s medical record revealed Patient #1 was admitted on 01/25/2025 with Bipolar Disorder with Psychotic Features and Intellectual Disability. Review of Patient #1’s Admit orders dated 01/26/2025 at 4:24 AM revealed in part: Choking Precautions with diet of mechanical soft chopped meat, cardiac moist and assist with feeding. Further review of Patient #1’s plan of care did not address the choking precautions or diet needs. Review of Patient #1’s plan of care dated on 01/26/2025 addressed impaired skin integrity related to actual evidenced by skin tear, but didn’t address a Braden score of 12 that indicates a high risk to develop pressure injury requiring different interventions and goals needed for Patient #1. In an interview on 03/25/2025 at 2:11 PM, S1DON verified the above mentioned findings. Review of Patient #4’s medical record revealed Patient #4 was admitted on 02/12/2025 with the following diagnoses Schizoaffective Disorder Bipolar Type and Anxiety Disorder. Review of admit orders indicated an order for violence precautions which was not addressed on the Patient #4’s care plan. In an interview on 03/26/2025 at 1:57 PM, S1DON verified the above mentioned findings.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to administer drugs in accordance with accepted standards of practice. This deficient practice was evidenced by the failure to document the effects of an administered as needed medication in 4 (#1-#4) of 5 (#1 - #5) patient medical records reviewed. Findings: Review of Patient #1’s medication administration record revealed the following PRN medications were administered: 01/31/2025 at 11:51 PM Geodon 10mg IM X one dose for severe psychosis. 02/01/2024 11:35 PM Ativan 2mg, Haldol 5mg, Benadryl 50mg IM X 1 dose for psychotic disorder Further review of Patient #1’s medication administration record failed to reveal a re-evaluation of the effectiveness of the medications listed above. In an interview on 03/25/2025 12:32 PM, S1DON confirmed the above mentioned findings and verified that there was no documented re-evaluation of effectiveness. S1DON also confirmed that all PRN medications and interventions should be re-evaluated by the nurse. Review of Patient #2’s medication administration record revealed the following PRN medication was administered on 08/25/2024 11:34 PM Seroquel 100mg PO for insomnia. Further review of Patient #2’s medication administration record failed to reveal a re-evaluation of the effectiveness of the medications listed above. In an interview on 03/25/2025 4:11 PM, S1DON confirmed the above mentioned findings and verified that there was no documented re-evaluation of effectiveness. S1DON also confirmed that all PRN medications and interventions should be re-evaluated by the nurse. Review of Patient #3’s medication administration record revealed the following PRN medication was administered on 02/12/2025 8:34 PM Clonidine 0.1mg PO PRN SBP >160 DBP >90 for BP 150/094. Further review of Patient #3’s medication administration record failed to reveal a re-evaluation of Patient #3’s BP to ensure the effectiveness of the medications listed above. In an interview on 03/26/2025 11:30 AM, S1DON confirmed the above mentioned findings and verified that there was no documented re-evaluation of effectiveness. S1DON also confirmed that all PRN medications and interventions should be re-evaluated by the nurse. Review of Patient #4’s medication administration record revealed the following PRN medication was administered on 02/14/2025 10:45 AM Ativan 2mg, Haldol 5mg, Benadryl 50mg IM X 1 dose for aggression. Further review of Patient #4’s medication administration record failed to reveal a re-evaluation of the effectiveness of the medications listed above. In an interview on 03/26/2025 1:20 PM, S1DON confirmed the above mentioned findings and verified that there was no documented re-evaluation of effectiveness. S1DON also confirmed that all PRN medications and interventions should be re-evaluated by the nurse.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 48050 Based on observation and interview, the hospital failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured. This deficient practice was evidenced by failing to maintain the physical plant in good repair. Findings: Observations during a tour of Campus B on 03/27/2025 8:30 AM - 9:08 AM revealed slimy reddish discoloration in the ice machine tray in Room K. In an interview during the hospital tour, S2DON and S4LPNQ confirmed the Room K’s ice machine had been serviced on 03/10/2025, but were unsure the last time the ice machine was cleaned.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 48050 Based on observation and interview, the facility failed to ensure facilities, supplies and equipment, were maintained to an acceptable level of safety and/or quality. This deficient practice is evidenced by failure to ensure the emergency cart was inspected daily. Findings: A review of the hospital’s policy number CS-28 last revised 07/01/2024 titled, “Emergency Cart”, revealed in part: PURPOSE: To provide access to life support medical equipment, the facility has made available an emergency cart to house needed supplies. PROCEDURE: 6. The emergency cart is inspected daily by the designated nursing staff on the designated shift. This inspection includes the following: a. Inspection, stock, and clean cart as needed. B. Identify, remove, and replace any expired items. C. Document the completed emergency cart checks on the provided checklist. Observations during a tour on 03/24/2025 from 12:50 PM to 2:00 PM revealed an Emergency Cart log on Unit A missing daily checks on 03/22/2025 and 03/23/2025. In an interview on 03/24/2025 at 1:10 PM, S1DON confirmed the findings above and verified that the Emergency Cart should be checked daily.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48050 Based on record review and interview, the facility failed to ensure infection control standards were maintained. The deficient practice is evidenced by failure to ensure food was free from spoilage and bacterial growth. Findings: A review of the hospital’s policy number: NS-34 last revised 07/01/2024 titled, “Food Preparation”, revealed in part: PURPOSE: To provide guidelines to ensure the preparation of quality products according to preplanned menus under safe and sanitary conditions for hospitals who operate a kitchen. PROCEDURE: 15. Temperature checks using metal stem thermometers are made using frequently during preparation and holding to guarantee safety of prepared food. 18. COOKING: Food is cooked/reheated to required temperatures. Final cooking temperatures are recorded on the Production and Food Temperature Log. Tour of the Campus A room L on 03/24/2025 at 1:25 revealed March 2025 Food Temperature Log missing temperature checks for 03/18/2025 for breakfast and lunch and 03/21/2025 for dinner. In an interview on 03/24/2025 at 1:30 PM, S6DC verified the food temperature log was missing temperatures for 03/18/2025 for breakfast and lunch and 03/21/2025 for dinner. S6DC further stated that she was unaware of the food temperature parameters. Tour of Campus B room K on 03/27/2025 at 8:44 AM revealed March 2025 Food Temperature Log missing temperature check on 03/24/2025 for dinner. In an interview on 03/27/2025 at 8:45 AM, S1ADON verified the Food Temperature Log was missing a temperature check on 03/24/2025 for dinner.”

“Social Service Records CFR(s): The social service records, including reports of interviews with patients, family members, and others, must provide an assessment of home plans and family attitudes, and community resource contacts as well as a social history. This Standard is not met as evidenced by: 48050 Based on record review and interview the facility failed to ensure social service records included all interviews with patients, family members and others, assessment of home plans, family attitudes, and community resource contacts as well as a social history. This deficiency is evidenced by failure of social services to complete the psychosocial assessment for 1 (#4) of 5 (#1-#5) patients medical records reviewed. Findings: Review of Patient #4’s Psychosocial Assessment dated on 02/13/2025 at 4:29 PM revealed the assessment was completed by S5MSWI and not co-signed by a MSW. In an interview on 03/26/2025 at 1:55 PM, S4Adm verified S5MSWI was a student who should have a MSW review and sign Patient #4’s psychosocial assessment. S4Adm also verifies that the psychosocial assessment is incomplete without the MSW review/signature.”

“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: 48051 Based on record review and interview, the facility failed to have a registered nurse supervise and evaluate the nursing care for each patient. This deficient practice is evidenced by the registered nurse failing to screen 1 (#1) of 3 (#1 - #3) patients for the risk of elopement upon admission to the facility per facility policy. Findings: A review of facility policy, “Elopements,” policy #CS-34, with an effective date of 01/11/2016 and last revised on 12/01/2023, reveal in part, Purpose: To identify those at risk for elopement and to prevent the occurrence. Procedure: 1. Upon admissions to the inpatient facility, all patients are screened for the risk of elopement. An electronic medical record (EMR) review of Patient #1’s record did not reveal a screening for the risk of elopement upon admission to the facility. In an interview on 06/03/2024 at 3:42 p.m. S2IDON/QD confirmed the above mentioned findings.”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 48051 Based on record review and interview, the facility failed to ensure each patient had an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This deficient practice is evidenced by the facility failing to include the patient’s risk for self-harm in the nursing care plan of 1 (#1) of 3 (#1 - #3) patient care plans reviewed for the inclusion of all medical and psychological needs of a patient. A review of facility policy, “Suicide/Homicide Risk Assessment,” Policy #AS-19 with an effective date of 01/11/2016 and last revised on 11/01/2023, revealed in part, Policy: All patients admitted will be screened for the risk of suicide using a validated tool ... Procedure: Inpatient: 2. The RN will complete the Suicide & Homicide/Violence Risk Assessment as a part of the Admit Nursing Assessment. Suicide/Homicide/Violence risk level will be determined and appropriate precautions are implemented and incorporated into the treatment plan if applicable. 5. Levels of Risk Stratification and appropriate interventions will be used in the assessment and to mitigate any suicide/homicide/violence risk. Suicidal ideation with intent or intent with plan in past month would indicate a HIGH Suicide Risk Stratification with one of the corresponding inventions, “Initiate a ‘Potential for Self-Harm’ treatment plan.” 6. Multidisciplinary team members will assess patient, update treatment plan, and individualize goals and interventions. An electronic medical record (EMR) review of Patient #1’s record revealed an admissions of 05/02/2024 at 5:15 a.m. An Inpatient Psychiatric Evaluation from 05/02/2024 at 3:20 p.m. by S4PMHNP indicated the patient was on a Physician Emergency Certificate (PEC) after an intentional overdose of fentanyl today. Physician orders initiated upon admissions included a Precaution level: Suicide/Self Harm Precautions. A review of the Plan of Care did not reveal a problem associated with the Potential for Self-Harm. In an interview on 06/04/2024 at 3:42 p.m. S2IDON/DQ confirmed the above mentioned findings.”

“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: 48051 50453 Based on observation and interview, the hospital failed to ensure patients requiring inpatient psychiatric care received care in a safe setting. This deficient practice was evidenced by: 1) Observation of the plastic liners in trash cans and unlocked cabinets containing personal care items in patient care areas; and 2) Observation of a non-functioning nurse call button in a patient bathroom. Findings: 1) Observation of the plastic liners in trash cans and unlocked cabinets containing personal care items in patient care areas A facility policy regarding the personal care items allowed to be in a patient care area and in the possession of a patient was not available. An observation during a tour of the North campus on 04/24/2024 from 7:20 a.m. to 9:15 a.m. revealed the following: a) Plastic garbage bags in the following patient care areas: Room #a and Room #b; and b) A storage cabinet in the Room #c was not locked and secured which would allow patient access to personal care items not allowed on the unit without supervision. In an interview on 04/24/2024 during the tour, S2DON and S3QD confirmed the above mentioned findings and further confirmed a patient is not allowed to have access to personal care items without supervision. 2) Observation of a non-functioning nurse call button in a patient bathroom An observation during a tour of the North campus on 04/24/2024 from 7:20 a.m. to 9:15 a.m. revealed Room #f bathroom’s nurse call button in non-functioning condition. In an interview on 04/24/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour.”

“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: 48051 Based on record review and interview, the hospital failed to ensure reports of potential patient abuse/neglect of care were reported to Louisiana Department of Health - Health Standards Section (LDH-HSS) within 24 hours of awareness of the allegation, as required by LDH-HSS. This deficient practice is evidenced by the facility failing to report to LDH-HSS an incident of potential neglect related to a psychiatric patient who was attending the hospital’s IOP (Intensive Outpatient Program), climbing on to the roof of the facility. Findings: Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed “Department” shall mean the Department of Health and Hospitals. “Unit” means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity, “Abuse” is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. “Neglect” is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer’s well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer’s physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report. Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Department of Health and Hospitals (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence. A review of medical record revealed Patient #2 recently admitted under a Physician Emergency Certificate (PEC) for suicidal ideations. The patient was attending IOP at this facility prior to admission. On 04/23/2024, the patient arrived at IOP via facility bus transportation and attended group session #1 with S9T as the group leader. A Multidisciplinary Progress Note from 04/23/2024 at 1:00 p.m. and signed by S9T on 04/24/2024 at 4:11 p.m. revealed in part, upon the initiation of group session #2, S9T noticed Patient #2 was not in the group session and notified his supervisor who begin to search for the patient. The patient was unable to be located, S9T contacted the patient’s mother. The mother pinged the patient’s phone via location services and it revealed the patient’s phone was currently located at this facility. S9T contacted the patient by phone with the patient revealing his location as being on the facility’s roof. S9T was able to talk the patient down off of the roof and once on the ground safely, S9T noted, “Therapist processed with patient after being on ground, patient was anxious, delusional, suicidal, and constantly reported, ‘I don’t want another failed suicide attempt.’” The patient was admitted to the facility’s inpatient program under a PEC. Inpatient Psychiatric Evaluation on 04/24/2024 at 12:22 revealed, “Patient with suicide attempt yesterday during break at IOP. Found on roof of building contemplating jumping. Has HX (history) of medically and psychiatrically significant suicide attempts in the past including attempting to hang self while admitted.” Further the evaluation noted in part, the patient had a history of suicidal ideations with an attempt at hanging self during a hospitalization in 12/2023. The patient had been admitted to inpatient psychiatric care 6 times since 12/2023. The History and Physical on 04/24/2024 at 10:33 a.m. revealed, “Patient admitted from IOP due to attempted suicide when he was trying to jump off of the top of the hospital.” Initial Nursing Assessment from 04/23/2023 at 3:01 p.m. noted Reason for Admission: “increased depression with an attempt to jump off the roof of IOP today.” Further, the Initial Nursing Assessment noted in part, the Suicidal Risk Stratification on admission: High Suicidal Risk: Suicidal Ideation with intent or intent with a plan in the past month. The Initial Nursing Assessment summarization included, “current SI (suicidal ideation) with attempt today.” Psychosocial Assessment from 04/25/2024 at 2:30 p.m. revealed the Presenting Problem, “I climbed the roof of a building, because I was feeling overwhelmed.” Stressors included, “In the IOP, I was depressed about a heartbreak.” Patient reported SI, “to be honest, but I wasn’t going to jump because I didn’t want to break both my legs.” Contact with state office on 04/24/2024 at 4:00 p.m. revealed the facility had not self-reported to LDH-HSS the above mentioned event. In an interview on 04/25/2024 at 7:45 a.m. S5RVP and S1Adm confirmed the above mentioned findings. 50453”

“PHARMACY DRUG RECORDS CFR(s): 482.25(a)(3) Current and accurate records must be kept of the receipt and distribution of all scheduled drugs. This Standard is not met as evidenced by: 48051 Based on observation, record review and interview, the hospital failed to ensure there were current and accurate records kept on the receipt and disposition of all scheduled drugs. This deficient practice is evidenced by: 1) Failing to log and verify a narcotics count every shift by two nurses; and 2) Failing to destroy medication not returned to a patient at discharge. Findings: Review of the hospital policy revised 06/01/2022 titled Medications: Medication Management revealed in part, STANDARD: Special Considerations: 5. Destruction of Medications: Expired or unused medications, including those not returned to the patient at discharge will be destroyed at the hospital according to their classification. All controlled substances such as patient-specific narcotics, expired institutionally owned narcotics, and patient specific narcotics that patients bring from home not returned at discharge will be destroyed using the drug dispose all containers in which the medications will be dropped into a chemical solution that destroys the drugs rendering them non retrievable. Individual patient specific narcotics will be counted and verified every shift by two nurses until the patient is discharged on the patient’s individual narcotic count sheet. Once the patient is discharged and the final count is documented, the drugs are to be destroyed utilizing the drug dispose all containers in the presence of two nurses signing off on the final count. 1) Failure to log and verify a narcotics count every shift by two nurses An observation of Room #g on 04/25/2024 at 8:20 a.m. revealed Patient #4’s home medication Clonazepam 0.5mg was being held in the locked narcotics box. Patient #4 was discharged on 02/22/2024. A review of Patient #4’s Individual Narcotic Count Sheet revealed the last narcotic count being completed on 02/05/2024 at 4:57 p.m. Patient #4’s home narcotic medication was not accounted for on 17 days of his admission and since his discharge of 02/22/2024. In an interview on 04/24/2024 at 8:20 a.m. S2DON and S3QD confirmed the above mentioned findings. An observation of Room #i on 04/25/2024 at 9:00 a.m. revealed Patient #3’s home medication Percocet 5mg/325mg was being held in the locked narcotics box. A review Patient #3’s Individual Narcotic Count Sheet revealed counts being completed on 04/22/24 at 7:00 a.m., 04/23/2024 at 10:00 a.m. and 04/24/2024 at 6:57 a.m. This would reflect the narcotics being counted and verified once per 24 hour period and not per policy of once every shift. In an interview on 04/24/2024 at 9:02 a.m. S3QD confirmed the above mentioned findings. 2) Failure to destroy medication not returned to patient at discharge An observation of Room #g on 04/25/2024 at 8:20 a.m. revealed Patient #4’s home medication Clonazepam 0.5mg was being held in the locked narcotics box. A review of Patient #4’s Individual Narcotic Count Sheet revealed the last narcotic count being completed on 02/05/2024 at 4:57 p.m. with a total count of 108 tablets. Patient #4 was discharged on 02/22/2024. Per policy, the medication was not properly disposed of after patient discharge. In an interview on 04/24/2024 at 8:20 a.m. S2DON and S3QD confirmed the above mentioned findings. 50453”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 48051 Based on observations, record review and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment were maintained in such a manner that the safety and well-being of patients were assured. This deficient practice was evidenced by failing to maintain the physical plant in good repair. Findings: Observations during a tour of the South campus on 04/23/2024 from 2:25 p.m. to 3:45 p.m. revealed the following: 1) There was wood in disrepair and within arms-reach of a patient. This wood could serve as a source of self-injury or injury to others. a) The plywood paneling covering the walls of the Room #d had a 1 inch by 2 inch rectangular piece of layering, on its top edge, peeling away and splintering and exposing the underlying wood; and b) The wood paneling and trim in the corner of the exterior recreation area to the left of the dining room windows had water damaged which has resulted in peeling, flaking and splintering wood pieces. 2) Stained ceiling tile noted outside the entrance to room #e. In an interview on 04/23/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour. 50453”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 48051 Based on observation, record review, and interview, the facility failed to ensure facilities, supplies and equipment, were maintained to an acceptable level of safety and/or quality. This deficient practice is evidenced by: 1) Observation of current glucose meter controls and test strips had no open date recorded; 2) Failing to perform control testing on the glucometer per facility policy; 3) Failing to ensure expired supplies were not available for patient use; 4) Failing to maintain exhaust vents for optimal performance; and 5) Failing to maintain the patient clothes dryer in a safe operating condition. Findings: 1) Observation of current glucose meter controls and test strips had no open date recorded A review of facility policy, “Glucometer Method for Obtaining CBGs,” with an effective date of 01/11/2016 and last revised on 07/01/2022, revealed in part, Care of Meter and Strips: Test strips and control solutions must be labeled with the open and discard dates according to the manufacturer’s guidelines. A review of the facility’s Glucose Control Log Sheet revealed a note at the top of the sheet, “All opened control solution bottles MUST have “open date” and 90 day expire Date.” Also, a note on the bottom of the sheet revealed in part, Test strip bottles must be labeled with open date and 6 month discard date. A review of the Medline EVENCARE G3 Blood Glucose Monitoring System User Guide revealed in part, notes regarding control solutions and test strips. Record the date on the bottle when opening a new bottle of control solution, discard any unused control solution 3 months after the opening date, and control solutions are good for 3 months after opening or until the expiration date on the bottle, whichever comes first. Record the date on the vial test strips when opening a new bottle and discard any unused test strips 6 months after opening. Vial test strips are good for 6 months after opening or until the expiration date on the bottle, whichever comes first. An observation on 04/23/2024 at 3:25 p.m. of the Medline EVENCARE G3 Glucose Control Solutions (Level 1 bottle and Level 3 bottle) and Test Strips currently being used at the South campus were not properly labeled with an open date. In an interview on 04/23/2024 at 3:26 p.m. S2DON and S3QD confirmed the above mentioned findings. 2) Failing to perform control testing on the glucometer per facility policy A review of facility policy, “Glucometer Method for Obtaining CBGs,” with an effective date of 01/11/2016 and last revised on 07/01/2022, revealed in part, Confirm System Performance/Control Test: A control test confirms that the system is functioning properly. Control tests are to be performed every 24 hours of patient use and anytime there is a question about the blood glucose test results. An observation on 04/23/2024 at 3:25 p.m. of the South campus’ Glucose Control Log Sheet revealed control testing not being performed on 04/18/2024 and 04/19/2024. In an interview on 04/23/2024 at 3:26 p.m. S2DON and S3QD confirmed the above mentioned findings. 3) Failing to ensure expired supplies were not available for patient use Observations during a tour of the South campus on 04/23/2024 from 2:25 p.m. to 3:45 p.m. revealed the following expired supplies available for patient use: a) Medline Medgel Adult Resting Tab Electrode 500 count per box, Quantity 5 unopened boxes, expired on 04/28/2023; and b) Hudson RCI STAR Lumen Oxygen Tubing, 25 feet, Quantity 3, expired on 05/30/2022. In an interview on 04/23/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour. Observations during a tour of the North campus on 04/24/2024 from 7:20 a.m. to 9:15 a.m. revealed the following expired supplies available for patient use: a) BD Vacutainer Urine C & S Preservation Tubes in the Clean Supply Room - 33 tubes expired 12/31/2023, 4 tubes expired 10/31/2023, and 9 tubes expired 01/31/2024; b) Ecolab Hand Sanitizer, 2 - 1 gallon containers, expired 09/2021, located in Room #g and Room #h; and c) Room #i contained a blue bin of single use packets of Lubricating Jelly, expired 10/28/2023 and a blue bin of single use Sureprep Protective Wipes, expired 11/2023. In an interview on 04/24/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour. 4) Failing to maintain exhaust vents for optimal performance Observations during a tour of the South campus on 04/23/2024 from 2:25 p.m. to 3:45 p.m. revealed greyish fuzzy substances on the exhaust vent coverings located in Rooms #j, #k, and #l. In an interview on 04/23/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour. 5) Failing to maintain the patient clothes dryer in a safe operating condition A review of facility policy, “Laundry and Linen Service,” Policy Number: EOC-76, with an effective date of 01/11/2016 revealed in part, Purpose: to ensure the patient’s personal laundry are properly cleaned. Procedure: Patient’s Personal Clothes: The following process will be followed when laundering the patient’s personal clothes: Washing machine and dryer: The lint filter on the dryer will be cleaned with each use by the hospital staff. An observation of the patient laundry room revealed the dryer lint filter was completely full with lint to the extent that when the filter was removed, a second section of lint, the size of the lint filter, was attached to the bottom of the filter. The Laundry Usage and Sanitizing Log was last completed on 04/16/2024. This log is used to indicate the washer had been sanitized and lint had been removed from the dryer lint filter after each use. In an interview on 04/23/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour. 50453”

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 48051 Based on observation and interview, the facility failed to ensure proper ventilation was maintained to an acceptable level of safety and quality in the patient care areas. This deficient practice is evidenced by a non-functioning exhaust vent in the male shower stall area. Findings: An observation on 04/23/2024 at 3:07 p.m. of male shower stall #2 revealed a non-functioning exhaust vent, with its covering pulled away from the ceiling exposing the inner mechanical parts, wiring and fan blade. In an interview on 04/23/2024 at 3:07 p.m. S2DON confirmed the above mentioned findings. 50453”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48051 Based on observation, record review and interview, the facility failed to maintain an infection prevention and control program which includes surveillance, prevention, and control of HAIs, and maintains a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities. This deficient practice was evidenced by: 1) Failing to maintain the temperature log for the patient nourishment refrigerator/freezer; 2) Failing to prevent storage of previously consumed items in the patient nourishment refrigerator; 3) Failing to maintain the patient washing machine in sanitary condition; 4) Failing to maintain patient rooms in a sanitary condition; and 5) Failing to store patient nutritional supplies in a sanitary condition. Findings: A review of facility policy, “Infection Control Plan,” Policy Number IC-01.03, with an effective date of 01/11/2016 and last revised 09/01/2024, revealed in part, Purpose: The Infection Control Plan is implemented for the purpose of preventing and controlling the acquisition and transmission of infectious agents throughout the hospital. Systems are implemented to communicate with physicians and other independent practitioners, staff, patients, visitors and families. Priorities Areas and Strategic Goals: The Hospital establishes goals to reflect the current trends and environmental factors. At a minimum, the following goals are established: Maintain a clean and sanitary environment to avoid sources and transmission of infection. 1) Failing to maintain the temperature log for the patient nourishment refrigerator/freezer Observations during a tour of the South campus on 04/23/2024 from 2:25 p.m. to 3:45 p.m. revealed the temperature log for the patient nourishment refrigerator/freezer was not checked on 04/01/2024, 04/02/2024, 04/07/2024, 04/08/2024, and 04/21/2024. In an interview on 04/23/2024, S2DON confirmed the above mentioned findings during the facility tour. 2) Failing to prevent storage of previously consumed items in the patient nourishment refrigerator Observations during a tour of the North campus on 04/24/2024 from 7:20 a.m. to 9:15 a.m. revealed a McDonald’s bag and an opened bottle of Coke stored in the refrigerator and not assigned or labeled to a patient. In an interview on 04/24/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour. 3) Failing to maintain the patient washing machine in sanitary condition A review of facility policy, “Laundry and Linen Service,” Policy Number: EOC-76, with an effective date of 01/11/2016 revealed in part, Purpose: to ensure the patient’s personal laundry are properly cleaned. Procedure: Patient’s Personal Clothes: The following process will be followed when laundering the patient’s personal clothes: Washing machine and dryer: The lint filter on the dryer will be cleaned with each use by the hospital staff. The washer will be cleaned between washing each patient’s cloths by making sure all solids are removed from the basket and utilizing an EPA - registered disinfectant around the lip of the basket and the inside of the basket. The lid is opened to wipe off any excess dirt or soap. Observations during a tour of the South campus on 04/23/2024 from 2:25 p.m. to 3:45 p.m. revealed the patient washing machine log incomplete. The last recorded date on the Laundry Usage and Sanitizing Log clipboard located in the laundry room was 04/16/2024. The log included a date, MHT name and a room number. This log did not indicate what this information reflected. A review of the Laundry Usage and Sanitizing Log utilized for this documentation revealed the log for the MHT to complete. The columns headings include patient room, wash (yes), sanitized (yes), lint removed (yes), MHT signature and date. This form was not being used. In an interview on 04/23/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour. 4) Failing to maintain patient rooms in a sanitary condition Observations during a tour of the North campus on 04/24/2024 from 7:20 a.m. to 9:15 a.m. revealed the following: a) Room #b’s mattress and bed platform contained a dry, brown substance along the side and under the mattress. This substance also appeared on the bed platform. In an interview on 04/24/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour and confirmed the room had been cleaned and was ready for patient use. b)Room #n bed platform contained a puddle of liquid under the mattress. Also, a reddish/brown substance was smeared on the window and the window seal. In an interview on 04/24/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour and confirmed this room was currently occupied. c) Room #m had 5 blankets stacked on the floor between the chairs. In an interview on 04/24/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour. d) Room #o’s bathroom shower was covered in a yellow and foul smelling fluid. In an interview on 04/24/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour. e) Failing to store patient nutritional supplies in a sanitary condition Observations during a tour of the North campus on 04/24/2024 from 7:20 a.m. to 9:15 a.m. revealed paper plates and napkins, being stored in a cabinet of Room #p which contained an open, sewer drainage line from the ice machine. In an interview on 04/24/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour. 50453”