Freedom Behavioral Hospital of Monroe

“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: 50453 Based on observation and interview, the hospital failed to ensure each patient has the right to personal privacy. This deficient practice was evidenced by failing to provide window coverings to obscure the view from the outside into 6 (Room ‘o’, ‘s’-‘w’) of 12 patient rooms observed on Unit A. Findings: Review of hospital policy titled, “Patient Rights: Patient Rights and Responsibilities,” effective date 12/2023, revealed in part: “PURPOSE: To provide a written policy to describe the rights of patients and the means by which these rights are protected, exercised, and supported within the mission statement. This policy is in compliance with the legal, civil, constitutional, and statutory rights of each patient. The patient shall have the right to: Privacy.” Observations during a tour on 06/02/2026 from 10:59 AM - 12:48 PM revealed the following patient rooms on Unit A lacked any covering over the windows in the bedrooms: Room ‘o’, Room ‘s’ - Room ‘w’ Further observations of the above-mentioned rooms revealed the windows failed to provide privacy and the rooms could be viewed from outside the building by a passerby. In an interview during the tour, S2ADON confirmed that a person standing outside of the building would be able to see into the patient rooms, and personal privacy was not provided.”

“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 observations, record reviews and interviews, the hospital failed to ensure that patients received care in a safe setting. This deficient practice is evidenced by: 1) failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients; 2) failure to test glucometer controls per hospital policy to meet safety needs of the patients; and 3) failure to ensure contraband items were not accessible to patients. Findings: 1) Failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients. Review of hospital policy titled, “Provision of Care - Suicide Precautions,” effective date 12/2023, revealed in part: “PURPOSE: To ensure a safe environment for potentially self-destructive patients and to establish specific guidelines for staff observation of these patients. POLICY: All patients placed on suicide precautions will be assigned an acuity level based upon the severity of the suicidal thoughts, plan or behavior. The levels are as follows: Every 15 minutes observation: This is moderately restrictive toward the patient and involves continuous monitoring every 15 minutes on the Nursing Observation Record, with check marks documenting such. Nursing staff must be within eyesight of the patient at all times, except for patient toileting and showering wherein the staff can see the bathroom or shower door and be within hearing range.” Observations during a tour of Campus A on 06/02/2026 from 10:59 AM - 12:48 PM revealed the following: -Geriatric unit revealed 9 hinged toilet seats that were secured down with a sealant. -Adult unit revealed 12 (Room ‘l’ - Room ‘w’) of 12 patient rooms with hinged, moveable toilet seats present in the bathrooms. In an interview during the tour, S2ADON confirmed the above-mentioned safety hazards in the Adult Unit patient bathrooms. Review of the patient precautions for the Adult unit revealed 9 of the 22 patients who were currently on suicide precautions. Further observations during the tour failed to reveal staff observing patients to see if the patient went into their room to use the bathroom. In an interview on 06/02/2026 at 1:10 PM, S1AIT confirmed that she was unaware that the toilet seats on the adult unit were hinged and moveable. S1AIT was unable to answer how staff would mitigate the risk for patients on suicide precautions. In an interview on 06/02/2026 at 1:50 PM, S2ADON stated that the mental health technicians were supposed to monitor patients when they go to the bathroom in their rooms. S2ADON stated that only patients who were on increased level of observations were watched while they were in the bathroom. S2ADON confirmed there was no mitigation plan for patients with suicidal precautions who were on every 15 minute observations. S2ADON further confirmed that during the tour of the adult unit, patients were in and out their rooms without staff observing to see if they were in the bathroom or not. Observation of Room ‘k’ on 06/02/2026 at 11:55 AM revealed a large trash can containing an empty black plastic bag, with an additional empty black plastic bag hanging over the side. Observation of Room ‘k’ on 06/02/2026 at 12:11 PM revealed a large trash can containing an empty black plastic bag, with an additional empty black plastic bag hanging over the side. In an interview on 06/02/2026 at 12:11 PM, S7RN confirmed the above finding. S7RN revealed Room ‘k’ “stays locked” and empty plastic bags were not accessible to patients when staff were not present. Upon conclusion of the interview, S7RN and surveyor exited Room ‘k’. Observation upon exiting room k revealed no staff were in the room, and the door remained open to the hallway. Observation of Room ‘k’ on 06/02/2026 at 12:18 PM revealed a large trash can containing an empty black plastic bag, with an additional empty black plastic bag hanging over the side. The door to room k remained open to the hallway, accessible to patients, and no staff were in Room ‘k’. Observation of Room ‘k’ on 06/02/2026 at 2:19 PM revealed a large trash can containing an empty black plastic bag, with an additional empty black plastic bag hanging over the side. The door to room k was open to the hallway, accessible to patients, and no staff were in Room ‘k’. 2) Failure to test glucometer controls per hospital policy to meet safety needs of the patients. Review of hospital policy titled, “Provision of Care - Blood Glucose Monitoring,” effective date 12/2023, revealed in part: “PROCEDURE: Quality control assessment shall be completed daily and stored in the memory of the monitoring device by the Unit Secretary of the Charge Nurse in the absence of the Unit Secretary. If the monitoring device has not been used in 24 hours, the operator shall perform a quality control assessment prior to use. Quality control shall include calibration and quality control check. When the quality control check falls outside of the expected range, the monitoring device should be cleaned and the test repeated. If the values continue to be out of range, the monitoring device shall be replaced.” Review of June’s Glucose Control Log with S2ADON for Unit B on 06/02/2026 at 11:28 AM revealed Glucose controls had not been performed. Further review of the log for May 2026 revealed the most recent control test was completed on 05/31/2026 at 11:00 PM. In an interview on 06/02/2026 at 11:30 AM, S2ADON confirmed that 2 patients on Unit B were currently receiving blood glucose checks. S2ADON further confirmed that glucose controls were not being performed according to hospital policy. 3) Failure to ensure contraband items were not accessible to patients. Review of hospital policy titled, “Environment of care - Contraband and Restricted Articles,” effective date 12/2023, revealed in part: “PURPOSE: To ensure a safe environment. To provide a monitoring system for patients who are utilizing sharps or items designated as contraband. POLICY: Items, which are considered a danger or potential danger to patients and others, will be locked in the contraband closet and administered to the patients on request and under staff supervision. PROCEDURE: Items considered to be restricted: Other potentially sharp objects; Clothing items deemed potentially dangerous such as belts, cords, and long shoelaces.” During a tour of Campus B on 06/03/2026 from 8:00 AM - 9:00 AM revealed the following: -Room ‘x’: One pair of shoes with shoestrings. -Room ‘y’: One pair of shoes with shoestrings. -Room ‘z’: Hygiene products which could potentially be used to cause harm to patients or others, including: toothbrush, toothpaste, comb, and a brush. In an interview during the tour, S6RN confirmed the above-mentioned findings. 51596”

“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: 50453 Based on observation, interview, and record review, the facility failed to ensure each patient received care in accordance with the needs assessed at the time of admission and remained free of neglect. The deficient practice is evidenced by failure to monitor and assist a patient identified as a fall risk and requiring assistance with activities of daily living while showering. Findings: Observations during a tour of Campus B on 06/03/2026 from 8:00 AM - 9:00 AM revealed the following: -1 MHT with 5 patients in the day room, 6 patients outside with 1 MHT, 1 nurse in the medication room, and 1 nurse sitting at the nurse station. -Observation of shower room revealed the door was propped open with a towel. Further observation at 8:38 AM revealed Patient #R18 was alone in the shower room without staff monitoring. Review of Patient #R18’s Close Observation Sheet revealed in part: 7:30 AM- Location: Bath or Shower; Behavior: angry/aggressive; no staff initials. 7:45 AM- Location: Bath or Shower; Behavior: angry/aggressive; no staff initials. The Observation Sheet had no documented observations between 7:45 AM and 8:38 AM. In an interview during the tour, S6RN confirmed Patient #R18 was left alone in the shower room without staff monitoring and assisting the patient. S6RN further confirmed the last time staff documented an observation on Patient #R18 was at 7:45 AM (45 minutes). S6RN verified Patient #R18 had been in the shower for more than an hour. Review of Patient #R18’s medical record revealed that Patient #R18 had the following levels of assist: -Ambulation with wheelchair support; -Needs assist with: Toileting, Grooming, and Dressing; -Limitations: Weakness; and -Unsteady Gait. Further review revealed Patient #R18 was on fall precautions with alteration of mental orientation and impaired physical mobility. In an interview on 06/03/2026 at 9:42 AM, S3DON confirmed the above-mentioned assist levels and confirmed staff should have remained with Patient #R18.”

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d)(1) The patient has the right to the confidentiality of his or her clinical records. This Standard is not met as evidenced by: 51596 Based on observation, record review, and interview, the hospital failed to safeguard the contents of the patient’s medical record for 18 (R19 - R36) of 36 sampled patients. Findings: Review of the hospital’s policy titled “Health Information Management - Confidentiality and Security of Protected Health Information” dated 12/2023, revealed in part: “The hospital shall maintain an individual’s right to privacy and confidentiality of Protected health Information. Information contained in the patient’s medical record shall be treated as confidential and will be released in appropriate circumstances only with the written consent of the patient or legal guardian. Information concerning patients shall be managed with the highest degree of approriateness and confidentiality, pursuant to organization-wide policies and procedures.” Observation of Area ‘A’ on 06/02/2026 between 2:05 PM and 2:12 PM revealed an unlocked cabinet which contained papers. The uppermost stapled papers were removed and were identified as “08/13/2025 Unit B Morning Census Total: 18”. Review revealed the census contained the patient name, MD, admission date, code status, admitting diagnosis, age, sex, code, observation level, legal status, food and drug allergies, admit from/discharge to facility, diet, and precautions/comments for R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, and R36. In an interview conducted at the time of the discovery, S5Therapist verified patients had access to the unlocked cabinet. S5Therapist confirmed the cabinet contained patient information, and the hospital failed to safeguard the contents of the medical record for R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, and R36.”

“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 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 hospital policy. This deficient practice is evidenced by: 1) failure of the Registered Nurse to document observations every hour for 22 (#3-#6, #R1-#R18) of 22 Close Observation sheets reviewed; 2) failure of the Registered Nurse to supervise staff and ensure timely observation rounds were performed for 11 (#5, #6, #R8-#R10, #R12-#R18) of 12 Patient Close Observation sheets reviewed; and 3) failure of the Registered Nurse to assign Observation Levels in 1(#4) of 6 reviewed patient records. Findings: Review of hospital policy titled, “Admission Assessment Management - Close Observation,” effective date 12/2023, revealed in part: “POLICY: To ensure a safe environment for patients and staff, and to establish specific safety guidelines for monitoring of patients, close observations are performed on every patient admitted to the hospital. An accurate record of the patient’s whereabouts will be maintained during each shift. PROCEDURE: Every patient must be seen by a staff member every fifteen (15) minutes, or more frequently as needed, and checked off on the Close Observation Sheet as present.” 1) Failure of the Registered Nurse to document observations every hour for 22 (#3-#6, #R1-#R18) of 22 Close Observation sheets reviewed. Review of the patient Close Observation (12-hour shift report) Sheets for Unit A on 06/02/2026 failed to reveal documented evidence that the Registered Nurse completed patient observations every hour between 7:00 AM - 12:15 PM for 9 (#3, #4, #R1-#R7) of 9 patients. In an interview on 06/02/2026 at 12:16 PM, S2ADON confirmed the RN did not document that observations were performed every hour on the above-mentioned patients. Observations of the patient Close Observations (12-hour shift report) Sheets for Unit C on 06/03/2026 failed to reveal documented evidence that the Registered Nurse completed patient observations every hour between 7:00 AM - 8:30 AM. for 12 (#5, #6, #R8-#R18) of 12 patients. In an interview on 06/03/2026 at 8:34 AM, S6RN confirmed the above-mentioned findings. In an interview on 06/03/2026 at 9:45 AM, S3DON confirmed the RN is required to document observations on each patient every hour on the Close Observation Sheet. 2) Failure of the Registered Nurse to supervise staff and ensure timely observation rounds were performed for 11 (#5, #6, #R8-#R10, #R12-#R18) of 12 Patient Close Observation sheets reviewed. During a tour of Unit C, observations revealed that the patient Close observation Sheets were on 2 clipboards inside the nurse station. Review of the Close Observations (12-hour shift report) Sheets for Unit C revealed the following incomplete documentation on 06/03/2026 between 7:00 AM - 8:30 AM: Review of Patient #5, #6, #R8-R10, and #R12-#R15’s Close Observation Sheets revealed the following: 7:00 AM - 8:30 AM: no documented evidence of observations. Review of Patient #R16’s Close Observation Sheet revealed the following: 7:00 AM - 8:00 AM: missing initials of staff observing. 8:15 AM - 8:30 AM: no documented evidence of observations. Review of Patient #R17’s Close Observation Sheet revealed the following: 7:00 AM - 8:00 AM: missing patient behavior and initials of staff observing. 8:15 AM - 8:30 AM: no documented evidence of observations. Review of Patient #R18’s Close Observation Sheet revealed the following: 7:00 AM - 7:45 AM: missing initials of staff observing. 8:00 AM - 8:30 AM: no documented evidence of observations. In an interview on 06/03/2026 at 8:34 AM, S6RN confirmed the above-mentioned findings. S6RN confirmed that the Close Observation Sheets should be completed at the time the observation is made. 3) Failure of the Registered Nurse to assign Observation Levels in 1( #4) of 6 reviewed patient records. Review of the medical record for Patient #4 revealed an undated close obsevation sheet (12-hour shift report) with no documented level of observation for the patient. Futher review revealed the form was partially filled out for a PM to AM shift and the Registered Nurse failed to complete patient observations every hour between 4:00 AM and 7:00 AM. In an interview on 6/3/2026 at 11:35 AM, S3DON confirmed close observation sheets should be completed by registered nurse and assigned mental health technician (MHT). S3DON futher confirmed the close observation sheets should be complete including signatures and observation levels. 53243”

“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: 51596 Based on record review and interview the registered nurse failed to ensure nursing staff followed hospital policies and procedures. The deficient practice is evidenced by: 1) failure to record the temperature of the medication refrigerator on a daily basis; and 2) failure to record the temperature of the biohazard/laboratory refrigerator on a daily basis. Findings: 1) Failure to record the temperature of the medication refrigerator on a daily basis. Review of the hospital’s policy titled “Infection Control and Prevention - Refrigerator Temperature Monitoring” dated 12/2023, revealed the following: “Purpose: The purpose of refrigerator temperature checks is to increase protection of medications and supplies, which may be damaged by becoming too hot or too cold. Also required is for the hospital to keep a log of refrigerator temperature checks, which records the date of each check. Procedure: All medication, patient food and lab specimen refrigerators will have temperature checked daily and recorded in the log provided. The Environmental Services and IC Representative will be responsible for ensuring that all refrigerator temperatures are checked and recorded daily.” Observation of Room ‘dd’ on 06/03/2026 at 8:17 AM revealed the posted Refrigerator Temperature Monitoring Log - Medication Storage Only was blank. In an interview conducted at the time of the observation, S6RN confirmed medications were stored in the refrigerator and the temperature should have been recorded daily, but had not been. 2) Failure to record the temperature of the biohazard/laboratory refrigerator on a daily basis. Observation of the biohazard refrigerator in Room ‘cc’ on 06/03/2026 at 8:05 AM revealed the Refrigerator Temperature Monitoring Log dated 06/2026 was blank. In an interview conducted at the time of the observation, S6RN confirmed the temperature of the biohazard refrigerator had not been recorded daily, but should have been.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 53243 Based on observation and interview, the hospital failed to properly store medical records ensuring protection from fire and water damage. Findings: Tour of the hospital on 06/02/2026 at 10:59 AM to 12:48 PM revealed three cardboard boxes containing paper medical records of discharged patients on the floor of Room ‘a’. Further observation revealed the paper medical records were not protected from fire or water. Interview on 06/02/2026 at 11:45 AM, S2ADON confirmed the cardboard boxes contained paper medical records of discharged patients.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 50453 Based on observation and interview, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use. Findings: Observations during a tour of Campus A on 06/02/2026 from 10:59 AM - 12:48 PM revealed in Room ‘i’ the following expired medications available for use: -Lidocaine 1% 20mg/2ml vials, quantity 24 vials, expiration date of 04/2026; and -Benadryl 50mg/ml, quantity 1 vial, expiration date of 05/2026 in the Emergency Medication Box. In an interview during the tour, S2ADON confirmed the above mentioned findings were expired and available for patient use.”

“STAFF ACCESS TO DRUG INFORMATION CFR(s): 482.25(b)(8) §482.25(b)(8) - Information relating to drug interactions and information of drug therapy, side effects, toxicology, dosage, indications for use, and routes of administration must be available to the professional staff. This Standard is not met as evidenced by: 51596 Based on observation, record review, and interview, the hospital failed to ensure staff had immediate access to up-to-date electronic or hard copy reference material on drug therapy. Findings: Review of the hospital’s policy titled “Medication Management - Medication Administration” dated 12/2023, revealed in part: “Up-to-date medication information shall be available to the individual administering the medication. Available information shall include, but not be limited to: -Information on drug therapy, side effects, toxicology, dosage, indications for use, route of administration; -Potential drug-to-drug interactions; -Potential allergies or cross sensitivities; -Proper dose ranges; and -Proper instructions for administration.” Observation of Room ‘i’ on 06/02/2026 at 11:30 AM failed to reveal reference material on drug therapy. In an interview conducted at the time of the observation, S2ADON confirmed staff did not have access to electronic or hard copy reference material on drug therapy, but should have.”

“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: 50453 51596 53243 Based on observation, record review, and interview, the hospital failed to maintain an acceptable level of cleanliness and safety in the facility. This deficient practice was evidenced by: 1) failure to inspect/test equipment for performance and safety before initial use; and 2) failure to maintain a clean and safe environment throughtout the facility. Findings: 1) Failure to inspect/test equipment for performance and safety before initial use. Review of the hospital’s policy titled “Environment of Care - Medical Equipment Management Plan” dated 12/2023, revealed in part: “all new equipment shall be inventoried and inspected prior to use for patient care or any other use. There is a current inventory of all equipment included in the equipment management program.” Review of the hospital’s policy titled “Environment of Care - Inventory and Inspection of New Equipment” dated 12/2023, revealed in part: “after receipt of any new equipment, but prior to installation, equipment must be inspected. Electrical and mechanical tests shall be performed, and the Engineering Department/EOC shall determine that it meets all appropriate safety standards. After passing inspection, the new equipment is assigned an identification number and is placed on a maintenance schedule to be monitored.” During a tour of Campus B on 06/03/2024 between 8:00 AM and 9:00 AM, observation of the following equipment failed to reveal evidence of preventative maintenance: -Riester Blood Pressure Monitor; -LPOW Digital Thermometer; -VacAssist Suction Unit (contained in a clear plastic bag); and -Medtronic Lifepak 1000 Defibrillator. In an interview conducted at the time of the observation, S6RN confirmed the above findings. S6RN confirmed the blood pressure monitor and digital thermometer had been used to assess patients’ vital signs. S6RN confirmed the suction unit and defibrillator were on the hospital’s crash cart and available for use. In an interview on 06/04/2026 at 11:30 AM, S4EOC revealed the hospital did not have a current inventory of all equipment included in the equipment management program at Campus B. S4EOC confirmed the equipment at Campus B had not been inventoried or inspected/tested prior to being available for patient use, but should have been. 2) Failure to maintain a clean and safe environment throughout the facility Observations during a tour of Campus A on 06/02/2026 from 10:59 AM - 12:48 PM revealed the following: -Room ‘a’ revealed wall thermostat that was not secured and exposing wires; -Outside of Room ‘f’ the fire extinguisher door handle was loose with exposed screws, -Unit A soiled utility room revealed plastic from linen bag covering the fire sprinkler spout and had 1 missing ceiling tile; -Unit A Clean Equipment Storage had 3 stained ceiling tiles that are bowed down and sagging; -Room ‘n’ contained an overhead bathroom light with 3 missing screws; -Outside of Room ‘w’ the fire extinguisher door had a gap in the glass covering -Room ‘w’ had a hole behind the door with exposed sheet rock; and -Room ‘w’ bathroom had part of the toilet seat broken off. In an interview during the tour, S2ADON confirmed the above-mentioned findings.”

“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, record review, and interview, the hospital failed to have an effective infection prevention and control program. This deficient practice was evidenced by: 1) failure to maintain a clean and sanitary environment; 2) failure to effectively treat rooms/furnishings/personal items to ensure elimination of bed bugs. 3) failure to record the temperatures of all dietary refrigerator/freezer equipment on a daily basis; and 4) failure to ensure food was stored in a safe and sanitary manner. Findings: 1) Failure to maintain a clean and sanitary environment. Observation during a tour on 06/02/2026 from 10:59 AM - 12:48 PM revealed the following: Room ‘b’: -chipped wood on bottom of bathroom door. Room ‘c’: -chipped wood on bottom of bathroom door; -chipped paint on the toilet; and -flakey red-brown residue on shower drain. Room ‘d’: -tan substance on side of shower. Room ‘e’: -flakey red-brown residue on shower drain. Room ‘f’: -soiled shower curtain; -chipped wood on side of sink counter; and -glue protruding between toilet seat and bowl. Room ‘g’: -flakey red-brown residue around shower screws. Room ‘h’: -cracked toilet seat sealant; and -corner of the wall at base of shower not flush with the wall. Room ‘k’: -flakey red-brown residue on floor under ice machine. Room ‘m’: -section of baseboard missing by entry door. Room ‘p’: -flakey red brown residue on ceiling frame. Room ‘q’: -flakey red-brown r residue on bathroom ceiling and shower rail. Room ‘u’: -Chipped wood laminate on top of both clothing shelves. Room ‘w’: -Laminate missing around sink; and -Dry red/brownish substance on the wall above bed. Room ‘aa’: -glue protruding between toilet seat and bowl. In an interview during the tour, S2ADON confirmed the above-mentioned findings and confirmed the surfaces could not be adequately cleaned and were an infection control issue. Observation of Room ‘ff’ on 06/04/2026 at 8:51 AM revealed a tear to the mattress. In an interview conducted at the time of the observation, S3DON confirmed the above-mentioned finding and confirmed the surface could not be adequately cleaned and was an infection control issue. 2) Failure to effectively treat rooms/furnishings/personal items to ensure elimination of bed bugs. Review of the hospitals Pest Control Service Agreement dated 06/24/2021, revealed in part: “this agreement does not include the control or prevention of bed bugs.” Review of EOC staff Work Order Requests revealed documentation referring to bed bugs and/or treatment of bed bugs on 04/22/2026, 04/26/2026, 04/27/2026, 05/06/2026, 05/12/2026, 05/19/2026, 05/21/2026, and 05/22/2026. In an interview on 06/03/2026 at 10:08 AM, S1AIT confirmed the above-mentioned findings and revealed the contracted extermination company had been called and treated Room ‘f’ for bed bugs on 05/06/2026. S1AIT revealed the treatment “didn’t help” and an alternate exterminator treated Room ‘f’ for bed bugs on 05/19/2026. S1AIT revealed when bed bugs were identified, staff washed the affected patient’s clothes in hot water, ensured the patient took a bath, and moved the patient to another room. In an interview on 06/03/2026 at 10:21 AM, S3DON revealed when bed bugs were identified, staff placed the affected patient’s clothes in a bag, took the bag to the laundry room, removed the clothes from the bag and placed them into the dryer, dried the clothes on the hottest setting for an unknown amount of time, and then washed and dried the clothing. S3DON revealed the dryer was not sanitized between loads of laundry. S3DON confirmed bedbugs were identified in the hospital on 04/22/2026 and 04/25/2026. Review of the hospital’s Laundry Room Washer Daily Cleaning Check List dated 04/20/2026 through 04/29/2026 revealed there was no documented evidence of any patient laundry being washed on 04/22/2026 or 04/25/2026. In an interview on 06/03/2026 at 10:47 AM, S4EOC revealed he sprayed Ecologic Bed Bug Killer in any room where there was a suspicion or sighting of bed bugs. Review of product revealed the primary active ingredient was Lemongrass oil 3%. In an interview on 06/03/2026 at 10:47 AM, S1AIT confirmed the hospital did not have a policy/procedure for how to handle/treat rooms/furnishings/personal items when bed bugs had been identified. In a telephone interview on 06/04/2026 between 8:19 AM and 8:32 AM, the hospital’s contracted exterminator revealed the following: Routine monthly pest control service provided does not include treatment for bed bugs; They were called for bed bugs in Room ‘f’ on 05/06/2026. Two bed bugs were identified and Room ‘f’ was treated; They did not examine or treat any other rooms on 05/06/2026; “We don’t recommend any products ...it may counteract what we put down”; Application of product containing Lemongrass oil could make it harder to find and kill bed bugs; and They have not been called back to the facility or rechecked the facility since treating Room ‘f’ on 05/06/2026. Review of the hospital’s Service Inspection Report for the contracted exterminator revealed Room ‘f’ was treated for bed bugs on 05/06/2026. Review of the hospital’s Appointment Record & Invoices for the alternate exterminator revealed 1 bathroom and 2 bedrooms were treated for bed bugs on 05/19/2026, one bedroom was treated on 05/21/2026, and one bedroom was treated for bedbugs on 06/02/2026. Observation of Room ‘f’ on 06/04/2026 at 9:01 AM revealed a bed bug crawling on the wall near the head of bed A. Several dried drops of a dark red substance were noted to the floor at the side of bed A, under a fall mat. In an interview conducted at the time of the observation, S3DON confirmed the above-mentioned findings. 3) Failure to record the temperatures of all dietary refrigerator/freezer equipment on a daily basis. Review of the hospital’s policy titled “Dietary Management - Temperature Log” dated 12/2023, revealed in part: “Policy: To ensure that the equipment is working properly and prevent potential food-borne illnesses. To record temperatures of all refrigerator/freezer equipment on a daily basis. Procedure: Logs are to be completed daily by the Nursing staff.” A tour of Campus B on 06/03/2026 between 8:05 AM and 9:00 AM, revealed the Meal/Refrigerator Logs posted on the dietary refrigerators in Room ‘ee’ and Area B were blank. In interviews conducted at the time of the observations, S6RN confirmed the temperatures of dietary refrigerators had not been recorded daily, but should have been. 4) Failure to ensure food was stored in a safe and sanitary manner. A tour of Campus B on 06/03/2026 between 8:05 AM and 9:00 AM, revealed the refrigerators in Room ‘ee’ and Area B contained patient and staff foods. In interviews conducted at the time of the observations, S6RN confirmed patient and staff food items were stored in the same refrigerator, but should not have been. In an interview conducted on 06/03/2026 at 2:51 PM, S3DON confirmed patient and staff food items should not have been stored in the same refrigerator. 51596 53243”

“IC PROFESSIONAL DOCUMENTATION CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (ii) All documentation, written or electronic, of the infection prevention and control program and its surveillance, prevention, and control activities. This Standard is not met as evidenced by: 50453 Based on record review and interview, the Infection Control Officer failed to document infection surveillance, prevention and control activities. This deficient practice is evidenced by failing to show any evidence of ongoing activities of tracking and trending infections, handwashing surveillance, and environmental rounds. Findings: The hospital failed to provide any evidence of ongoing infection control surveillance, prevention, and control activities upon request. On 06/02/2026 at 10:17 AM, during entrance conference with S1AIT, a document request was provided which outlined the initial request for a copy of the hospital’s current infection control activities. On 06/03/2026 at 1:20 PM, a 2nd request for infection control activities was made to S3DON. S3DON confirmed she was over infection control. S3DON stated she had antibiotic stewardship data that she could present surveyors. On 06/03/2026 at 4:09 PM, a 3rd request for the infection control activities was made by the surveyor. On 06/04/2026 at 11:39 AM, 4th request for the infection control activities was made by the surveyor. Review of antibiotic stewardship data provided by S3DON revealed in part: patient names and the name of the antibiotic the patient was prescribed. By exit conference on 06/04/2026 at 1:45 PM S3DON confirmed she had no additional documented evidence of infection control activity that she could provide the surveyors. This included tracking and trending infections, environmental rounds and handwashing surveillance.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 17450 Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient’s rights as evidenced by: Failure of the hospital to provide supervision as ordered by the physician for 2 patients on LOS observation levels (Patient #3 and #4) and 16 of 30 total patients on every 15 minute routine observation levels (Patients #R1-R16). This resulted in an Immediate Jeopardy Situation. S1Administrator was notified on 9/25/2024 at 2:30 p.m. The hospital provided the following plan of removal for the Immediate Jeopardy situation: 1. The MHT that clearly displayed incompetence of patient observations will be immediately removed from providing care with disciplinary actions per Human Resource and Code of Conduct Guidelines. 2. Each RN and MHT that did not complete duties previously trained on as required while being observed today by State Surveyor will have a written disciplinary action completed and put in their HR record within the next 2 hours. 3. Hospital Leadership team members will meet with each individual staff member presently on duty, and on the next scheduled shifts for the next 48 hours, to review/educate on the requirements and importance of patient observations. 4. A Training & Acknowledgement form will be signed by all staff members and placed in their HR record stating that they understood the requirement/importance of patient observations being performed accurately and appropriately. Each staff member will also be provided with corresponding policies for review. 5. All full time and prn nursing department staff will complete this training EOD Friday, September 27, 2024 or they will not be scheduled to work. 6. A separate Training & Acknowledgement form will be completed with all RNs on staff today and the rest by EOD, September 27, 2024, indicating their understanding of RN duties related to safety rounds and signing off on observation sheets completed by the MHTs. 7. Ongoing, monitoring will be established and completed on each shift effective 09/25/2024. On 09/25/2024 at 14:20 p.m., the Immediate Jeopardy Situation was lifted but there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared therefore the deficiency remains at a Condition level (See findings in A0144).”

“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: 17450 Based on observation, record review, and interview, the hospital failed to ensure patients receive care in a safe setting as evidenced by failure of the hospital to provide supervision as ordered by the physician for 2 patients on LOS observation levels (Patient #3 and #4) and 16 of 30 total patients on every 15 minute routine observation levels (Patients #R1-R16). Findings: Review of the hospital policy titled, Suicide Precautions (dated 10/24/2019) revealed in part that Line of Sight observation is very restrictive towards the patient and involves continuous visual monitoring at all times. Staff must be within visual contact at all times with the exception of toileting and showering. A staff member may observe more than one patient on LOS observations only while those patients remain in an area for a scheduled activity. If a staff member is observing more than one patient and one or more of the patients go to separate areas, the staff must transfer responsibility for LOS to other staff members so that there is continuous observation of all patients on line of sight. Nursing staff must maintain a continuous log which indicates the patient’s location every 15 minutes and documents the patient’s behaviors throughout each shift. Review of the hospital policy titled, Admission/Assessment - Close Observation (dated 10/24/2019) revealed in part that patients on regular precautions or close observations must be seen by a staff member every 15 minutes, or more frequently as needed, and checked off on the Close Observation Sheet as present. A staff member will be assigned by the Charge Nurse each shift to be responsible for monitoring the Close Observation Sheet. On 09/25/2024 at 9:35 a.m., observation revealed S2MHT sitting in a chair in the hallway. The surveyor requested to review the tech’s Close Observation sheets but he stated they were in the nurses station. S2MHT obtained the sheets and review revealed the last documented evidence of an observation of the 4 geri-psych patients (Patients #R1-R4) assigned to the MHT were at 9:00 a.m. The patients were on routine every 15 minute observations. S2MHT was asked why the Close Observation sheets were not current and S2MHT stated there was an incident earlier that he was dealing with. S2MHT confirmed he was behind on his observations. On 09/25/2024 at 9:45 a.m., observation revealed S5MHT was in the nurses station talking to S4MHT. At that time, the surveyor asked the techs for their Close Observation sheets. They both stated that their sheets were on a clipboard on the top of the refrigerator in the day room. The surveyor obtained the sheets from the top of the refrigerator and review of S5MHTs Close Observation sheets, for geri-psych patients #R5-R8, revealed the last documented observation was at 8:15 a.m. (1 ½ hours earlier). Review of S4MHT’s (orientee) Close Observation sheet for Patient #R9 revealed the last observation was at 8:30 a.m. (1 hour, 15 minutes earlier). On 09/25/2024 at 9:50 a.m., interview with S5MHT revealed that she was training S4MHT and that she had not had time to observe her assigned patients. S5MHT stated that all of her assigned patients were on routine, every 15 minute observations, and confirmed she was late performing the observations. At that time, interview with S5MHT confirmed that she was in orientation and that she was late performing observations for her only assigned patient, Patient #R9, who was also on a routine observation level. On 09/25/2024 at 9:52 a.m., upon entering the adult psychiatric unit, observation revealed S6MHT sitting in a chair near the door. Interview with S6MHT revealed that there was an issue with the door lock, so she was having to sit near the door to make sure patients did not attempt to exit. Further interview with S6MHT revealed that she was currently assigned seven patients and two were on LOS observation level, with the other patients being routine, every 15 minute observation levels. The surveyor asked where the LOS patients were currently and S6MHT pointed out one patient that was walking down the hall (Patient #4) and stated the other patient was in her room (Patient #3). Observation revealed Patient #3’s room door was closed. When the surveyor asked S6MHT what LOS observation level meant, she stated that they must be checked on every 10-15 minutes and you must “keep your eye on them a little more”. S6MHT then stated that she actually checks on Patient #3 about every 10 minutes because she was suicidal and may wrap a blanket around her neck. When asked if Patient #3 was allowed to keep her door shut, S6MHT stated yes, but it must be cracked. When asked if Patient #3 was in constant visual sight, S6MHT stated no. During this interview, Patient #4 was observed to walk on the other side of the unit, out of sight from S6MHT. S6MHT stated that the staff on the other side watch the patient when she is over there. On 09/25/2024 at 9:56 a.m., observation revealed S7MHT was sitting in the hallway on the adult unit with two stacks of Close Observation sheets in front of her. Review of the sheets revealed one stack was S7MHT’s assigned patients and the other stack was S8MHT’s assigned patient sheets. Review of S8MHT’s Close Observation sheets revealed the last documented observation of Patients #R10-R16 were at 9:15 a.m. (45 minutes earlier). S7MHT stated that S8MHT was making coffee in the nurses station. When S7MHT was asked if she was responsible for observing S8MHT’s assigned patients, she stated no. On 09/25/2024 at 10:10 a.m., S8MHT was observed in the nurses station handing out snacks to patients. On 09/25/2024 at 10:25 a.m., interview with S8MHT confirmed that she had not observed her assigned patients since 9:15 a.m. (almost one hour earlier). S8MHT stated she was busy making coffee, handing out snacks and getting the discharges ready to go home. When asked who was observing her assigned patients as she was doing these tasks, she shrugged her shoulders. On 09/25/2024 at 12:15 p.m., interview with S1ADM revealed that all patient Close Observation sheets should be current and the nurses should be ensuring that the patient observations are performed as ordered. S1ADM further stated that S6MHT should not have been assigned to watch two LOS patients as well as five other routine observation patients. S1ADM confirmed the lack of patient observations put the patients at risk for serious injury, serious harm, serious impairment or even death.”