Compass Behavioral Center of Alexandria, Inc.

“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 observation and interview, the hospital failed to ensure the condition of the physical plant was maintained in such a manner that the safety and well-being of the patients are assured. This deficient practice was evidenced by: 1) Failure to ensure the maintenance of the roof was maintained as evidenced by multiple ceiling tiles stained and discolored in Units FA, FC and FD; and 2) Failure to ensure ventilation vents and the surrounding ceiling area were free of grey and black fuzzy substances in Units FA, FC and FD; 3) Failure to ensure functioning lighting in the patient care area; Findings: 1) Failure to ensure the maintenance of the roof was maintained as evidenced by multiple ceiling tiles stained and discolored in Units FA and FD Observations during walk-through of the Alexandria facility on 01/21/2026 from 8:30 a.m. to 10:05 a.m. revealed brown stained ceiling tiles resembling water markings in the following rooms: --Unit FA, Room “Fd” had 2 ceiling tiles above the dish sink and 1 ceiling tile above the hand sink stained and discolored; --Unit FA, Room “Fe” had 4 of 16 ceiling tiles stained and discolored; --Unit FA, Room “Ff” had 15 ceiling tiles stained and discolored; In an interview on 01/21/2026 and present during the walk-through, S1FCEO confirmed the above-mentioned findings. Observations during a walk-through of the Marksville facility on 01/22/2026 from 9:10 a.m. to 11:25 a.m., revealed brown stained ceiling tiles resembling water markings in the following rooms: --Unit FB hallway entry to Room “Fg” had 7 ceiling tiles stained and discolored; and --Unit FB, Room “Fh’ had 1 ceiling tile stained and discolored. In an interview on 01/22/2026 and present during the walk-through, S1FCEO confirmed the above-mentioned findings. 2) Failure to ensure ventilation vents and the surrounding ceiling area were free of grey and black fuzzy substances in Units FA and FD Observations during walk-through of the Alexandria facility on 01/21/2026 from 8:30 a.m. to 10:05 a.m. revealed grey and black fuzzy substances on heating and ventilation air conditioning (HVAC) vents and exhaust vents in the following locations: --Unit FA, Room “Fd” had 3 HVAC outflow vents and the surrounding ceiling and 1 HVAC return vent; --Unit FA, Room “Ff” had 1 HVAC outflow vent; --Unit FA, Room “Fi” had 2 HVAC vents; In an interview on 01/21/2026 and present during the walk-through, S1FCEO confirmed the above-mentioned findings. Observations during walk-through of the Marksville facility on 01/22/2026 from 9:10 a.m. to 11:25 a.m. revealed grey and black fuzzy substances on heating and ventilation air conditioning (HVAC) vents and/or the exhaust vents in the following locations: --Unit FD, Room “Fj” had 1 exhaust vent; --Unit FD, Room ‘Fk” had 12 HVAC vents, this would include every HVAC vent in this room; and --Unit FD, Room “Fl” had 1 restroom exhaust vent; and -- Unit FD, Room “Fm” had 1 restroom exhaust vent. In an interview on 01/22/2026 and present during the walk-through, S1FCEO confirmed the above-mentioned findings. 3) Failure to ensure functioning lighting in the patient care area Observations during walk-through of the Alexandria facility on 01/21/2026 from 8:30 a.m. to 10:05 a.m. revealed Room “Fp” one light fixture nonfunctioning and the other light fixture partially functioning. The room was inadequately illuminated. In an interview on 01/21/2026 and present during the walk-through, S1FCEO 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: 48051 Based on observation and interview, the hospital failed to maintain a clean and sanitary environment. This deficient practice was evidenced by: 1) Failure to ensure used urinal did not remain in the restrooms Unit FA’s 3 patient restrooms (“Fa,” “Fb,” and “Fc”); 2) Failure to ensure exposed drywall was repaired and painted; 3) Failure to ensure patient equipment with cracked and/or peeling surfaces was removed from patient use; 4) Failure to ensure floor cleaning equipment was not stored in the patient care area; 5) Failure to ensure brown corrugated cardboard shipping boxes were not used as storage containers; 6) Failure to ensure dirty patient supplies and belongings were not stored in the clean linen room; 7) Failure to ensure the surfaces of Room “Ft” were free of brown, flaky substances; and 8) Failure to ensure the ceilings of Room “Ft’s” shower stalls were free of black substances; Findings: 1) Failure to ensure used urinal did not remain in the restrooms Unit A’s 3 patient restrooms (“Fa,” “Fb,” and “Fc”) A review of hospital policy titled, “IC-100: Infection Prevention and Control Program,” with an effective date of 07/02/2012 and last revised on 01/12/2016, revealed in part: “POLICY The hospital has established hospital-wide Infection Control programs for the surveillance, prevention, and control of infection and communicable diseases for patients, personnel, and all other persons within and utilizing its facility or its services. The goal of the infection control program is to minimize the possibility of transmitting infection by: limiting unprotected exposure to pathogens; Limiting the transmission of infection associated with the use of medical equipment, devices and supplies. Responsibilities A. The I.C. Committee is responsible for: 1. Identifying risks for acquiring and transmitting infection annually and whenever significant changes occur, based on: ii. Community and population served; iii. Care, Treatment and Services provided; iv. Analysis of surveillance activities. B. The infection control nurse is responsible for: 4. Developing a system for identifying, reporting, investigating, preventing and controlling spread of infections and communicable diseases among patients, visitors. and hospital staff. 5. Ensuring the education of staff in infection control prevention and control activities. Observations during walk-through of the Alexandria facility on 01/21/2026 from 8:30 a.m. to 10:05 a.m. revealed dirty urinals hanging on the handrails of Unit FA’s 3 patient restrooms (“Fa,” “Fb,” and “Fc”). An observation of restroom “Fa” revealed a urinal with #RF4’s name and a urinal with #RF5’s name written on the side of each corresponding urinal and hanging from the handrail next to the toilets. Each urinal was empty and both urinals were discolored with a dried urine color (dark yellow). An observation of restroom “Fb” revealed a urinal with #RF6’s name written on the side of the urinal. This urinal was empty and discolored with a dried urine color (dark yellow). An observation of restroom “Fc” revealed a urinal with #RF7’s name written on the side of the urinal. This urinal was empty and discolored with a dried urine color (dark yellow). The presence of these used urinals hanging on the handrails of these restrooms created multiple unsanitary conditions and potential modes of infectious disease transmission for the patients assigned to use these urinals and the patients attempting to use the handrails while toileting. In an interview on 01/21/2026 at S2FLPN confirmed the above-mentioned findings and further confirmed these urinals were for the male patients that could not transfer to the toilets. 2) Failure to ensure exposed drywall was repaired and painted; Observations during walk-through of the Alexandria facility on 01/21/2026 from 8:30 a.m. to 10:05 a.m. revealed dry wall exposure and/or peeling paint in the following locations: --Unit FB, Room “Fp” had exposed dry wall under the left side of the window ledge and Bed B headboard had multiple area of peeling paint; --Unit FB, Room “Fq” had exposed dry wall to the right of the entry door. Exposed drywall cannot be properly cleaned and sanitized which could create a medium for the transmission of infectious disease. In an interview on 01/21/2026 and present during the walk-through, S1FCEO confirmed the above-mentioned findings. 3) Failure to ensure patient equipment with cracked and/or peeling surfaces was removed from patient use Observations during walk-through of the Marksville facility on 01/22/2026 from 9:10 a.m. to 11:25 a.m. revealed two geriatric chairs currently in use with patients - one chair located in Room “Fn” and one chair in Room “Fo.” Each chair’s covering around the upper back portion of the chair, where the patient’s head would rest/lean against and the covering under both arm rests were cracked and peeling. The conditions of the coverings on these geriatric chairs would prohibit the proper cleaning and sanitizing of these surfaces between patients. In an interview on 01/22/2026 and present during the walk-through, S1FCEO confirmed the above-mentioned findings. 4) Failure to ensure equipment used for cleaning was not stored in the patient care area Observations during walk-through of the Marksville facility on 01/22/2026 from 9:10 a.m. to 11:25 a.m. revealed equipment used to clean and buff floors was being stored in Room “Fr” which would be used for patient care if needed. This room would be considered a clean room and would need to be ready for patient use at any time. The equipment located within this room would not be considered a patient care item nor was this equipment clean. In an interview on 01/22/2026 at 9:30 a.m., S8FLPN confirmed Room “Fr” would be used if a patient needed to be examined. In an interview on 01/22/2026 and present during the walk-through, S1FCEO confirmed the above-mentioned findings. 5) Failure to ensure brown corrugated cardboard shipping boxes were not used as storage containers Observations during walk-through of the Marksville facility on 01/22/2026 from 9:10 a.m. to 11:25 a.m. revealed 5 brown corrugated cardboard boxes being used as storage containers in Room “Fs”. The 5 corrugated cardboard boxes contained patient sock-slippers and each box contained a corresponding size - Medium, Large, X-Large, XX-Large and Bariatric. Corrugated cardboard is not conducive to a clean environment as it attracts insects and contains dirt and dust which cannot be properly cleaned because corrugated cardboard has absorbent surfaces. In an interview on 01/22/2026 and present during the walk-through, S1FCEO confirmed the above-mentioned findings. 6) Failure to ensure dirty patient supplies and belongings were not stored in the clean linen room; Observations during walk-through of the Marksville facility on 01/22/2026 from 9:10 a.m. to 11:25 a.m. revealed the following items being stored atop a clean lined cart in Unit FC, Room “Fs”: --pair of Reebok brand men’s briefs; and --2 open packages of Equate Flushable Wipes, quantity 48 wipes each. All of these items would be considered single-patient use items and upon opening, should be labeled and stored amongst the patient’s belongings and away from clean items. The storage of these items within this room could create a means of infectious disease transmission. In an interview on 01/22/2026 at 10:35 a.m. S10FMHT and S11FRN confirmed the above-mentioned findings and confirmed the items should not be stored in the clean utility. In an interview on 01/22/2026 and present during the walk-through, S1FCEO confirmed the above-mentioned findings. 7) Failure to ensure the surfaces of Room “Ft” were free of brown, flaky substances Observations during walk-through of the Marksville facility on 01/22/2026 from 9:10 a.m. to 11:25 a.m. revealed Room “Ft” shower stalls #1 and #2 had metal door frames leading into each stall. These metal door frames had multiple lines and patches of brown, flakey areas resembling rust. These types of surfaces cannot be properly cleaned and sanitized between patients which created a potential medium for infectious disease transmission. In an interview on 01/22/2026 and present during the walk-through, S1FCEO confirmed the above-mentioned findings. 8) Failure to ensure the ceilings of Room “Ft’s” shower stalls were free of black substances Observations during walk-through of the Marksville facility on 01/22/2026 from 9:10 a.m. to 11:25 a.m. revealed Room “Ft” shower stalls #1 and #2 had black substances on the surfaces of the ceiling. These black substances could potentially be infectious disease-causing substances. In an interview on 01/22/2026 and present during the walk-through, S1FCEO confirmed the above-mentioned findings.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 44763 Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. This deficient practice was evidenced by: 1.) failing to provide an adequate notice of its grievance investigation and decision to 1 (#5) of 3 sampled patients reviewed for grievances (see findings A-0123); 2.) failing to ensure a patient’s right to file a grievance without retaliation and denial of future access of care was maintained for 1 (#5) of 3 patients sampled for grievances (see findings A-0129); 3.) failing to provide adequate heating due to the heating system being inoperable to the inpatient adolescent psychiatric unit (see findings A-0144); 4.) failing to ensure a patient was observed in accordance with the physician orders for 1 (#8) of 5 patients’ observations reviewed from a total sample of 8 (see findings A-0144); 5.) failing to ensure each order for restraints for the management of violent or self-destructive behavior was renewed every 2 hours for children and adolescents 9 to 17 years of age for 1 of 1 (#1) patient records reviewed for restraint use from a total sample of 8 patients (see findings A-0171); 6.) failing to ensure staff monitored the condition of the patient who was in restraints according to hospital policy for 1 of 1 (#1) patient records reviewed for restraints from a total sample of 8 (see findings A-0175). An Immediate Jeopardy situation was identified on 12/03/2025 at 4:54 PM and reported to S1CEO. The Immediate Jeopardy situation was a result of the hospital failing to provide adequate heating due to the heating system being inoperable to the inpatient adolescent psychiatric unit. The Immediacy was lifted on 12/04/2025 at 1:16 PM after observations and interviews were conducted and S1CEO was notified of the approval of the hospital’s written removal plan. The plan included the following: The IT services for the Compass Behavioral Center of Alexandria has created a VPN tunnel for the technician from [stated company], the company contracted for our environmental control system, to be able to consistently access the environmental control system for the unit. Additionally, [stated company] is putting together a proposal for a device to allow staff to access the environmental control system to allow us to address electronic problems with the control system. A laser thermometer will be purchased for the unit today, 12/04/2025. A member of the nursing staff will obtain the temperature of the unit and patient rooms twice per shift and document the temperature to ensure that the unit is at the appropriate temperature. Nursing staff will be educated on this process via groupme message, a memo in the nurse’s station, and via shift report from the previous nursing staff. In the event that temperatures on the unit are outside of appropriate range, the nursing staff will immediately inform the administrative staff. Administrative staff will contact IT, [stated company], and a local HVAC company to quickly identify and address any issues with the temperature control or HVAC system. In the event that this cannot be done in a timely manner, administrative staff will initiate transfer of patients to appropriate facilities.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 48537 Based on record review, hospital policy review and interviews, the hospital failed to provide an adequate notice of its grievance investigation and decision to 1 (#5) of 3 sampled patients reviewed for grievances. Findings: Review of the hospital’s policy #PC-816 titled “Grievances” effective July 10, 2012, revealed in part: “Purpose: To provide a mechanism to patients/family to express their concerns/complaints relating to the quality of care, and to receive assistance in a timely manner for resolution of these problems/issues when needed. Procedure: 6. The Lead Investigator shall ensure a complete investigation is conducted and prepare a report for the PI Committee. (The lead investigator may designate other staff members to participate in the investigation.) 7. The Lead Investigator will develop a corrective plan of action to resolve current grievance and to prevent future grievances. The Corrective Plan of Action will be submitted to the PI Committee for approval. 8. The Lead Investigator will provide the following written communication to the complainant within 7 days. a. Description of complaint b. Steps taken to resolve complaint c. Date of completion/resolution.” Review of the hospital’s grievance log requested from 07/01/2024 to 12/01/2025 revealed one listed grievance for the Intensive Outpatient Psychiatric (IOP) program dated 02/18/2025. The log revealed the following information: Date of Grievance Filed: 02/18/2025 Date Admin/CCO/DON/PD notified (Within 24 hours of Receipt of Grievance): 02/18/2025 Name of Lead Investigator: S9CCO Date Initial Written Communication Provided Acknowledging Grievance and Notifying of Contact Person: 02/18/2025 Date Written Communication Provided to Complainant: 02/21/2025 Date Report/Corrective Plan of Action Submitted to PI Committee: N/A Review of Patient #5’s medical record revealed she was admitted to the facility on 01/15/2025 for IOP services four times per week for a diagnosis of severe recurrent major depressive disorder without psychotic features. Review of Patient #5’s handwritten grievance to S10PD revealed it was dated on 02/13/2025 and outlined an incident between Patient #5 and one of the counselors, S11CSW, who had been leading the group therapy session. Review of the hospital’s final notification letter sent to Patient #5 on 02/21/2025 regarding her grievance read as followed: “Dear Patient #5, Thank you for the opportunity to respond to your concerns regarding the treatment you received while at [the IOP outpatient program]. I [S9CCO] am sincerely sorry that we did not meet your expectations for the care that you received and I want to let you know that we take your concerns seriously. Please be advised that I have carefully reviewed this matter and systems are being reviewed and modified to improve the quality of care. Staff are being counseled and re-educated on your areas of concern. I assure you that at [the Hospital] we strive to provide a safe and therapeutic environment for all of our patients. We take steps on a daily basis to improve the quality of services that we provide, and we will most definitely use our findings in this matter for that purpose. We value your feedback and appreciate you assisting us to implement positive changes within our organization.” Review of the hospital’s Performance Improvement (PI) committee meeting minutes from all meetings in 2025 (01/02/2025, 05/01/2025, 08/20/2025 and 11/04/2025) revealed no plan of action submitted for review by the lead investigator of Patient #5’s submitted grievance. On 12/04/2025 at 10:50 AM, S10PD confirmed the letter dated 02/21/2025 from S9CCO to Patient #5 was the hospital’s final notification of grievance decision.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 48537 Based on record review, hospital policy review and interview, the hospital failed to ensure a patient’s right to file a grievance without retaliation and denial of future access of care was maintained for 1 (#5) of 3 patients sampled for grievances. Findings: Review of the hospital’s policy #PC-816 titled “Grievances” effective 07/10/2012, revealed in part: “Purpose: To provide a mechanism to patients/family to express their concerns/complaints relating to the quality of care, and to receive assistance in a timely manner for resolution of these problems/issues when needed. Policy: All patients or attending family member shall receive a Patient’s Bill of Rights upon admission and will be informed through this Bill of Rights of their right to complain concerning the quality of care. Presentation of a complaint does not compromise a patient’s future access to care. It is against the law for the facility to retaliate against anyone who files a grievance or cooperates in the investigation of a grievance.” Review of the hospital’s policy #OP-402 titled “Patient’s Rights” effective 07/02/2012, revealed in part: “Purpose: To insure that all patients are aware of their rights while being treated at this facility. Policy: It is policy that all patients shall receive a copy of the Patient’s Rights Statement. Procedure: 1. The patient is to be given a copy of the Patient’s Rights Statement at the initial appointment. 2. A copy of the Patient’s Rights Statement shall be available in the patient area.” Review of the hospital’s undated “Patient’s Rights Statement” document revealed in part: “Notice of Rights and Services: - You, your family, or your legal guardian shall be full informed about the following items: K. The right to initiate a complaint or grievance procedure, and the appropriate means of requesting a hearing or review of the complaint. Grievances: - You may voice grievances concerning your care without fear or discrimination or reprisal; you may expect prompt efforts for the resolution of grievances.” Review of the hospital’s policy #OP-500 titled “Discharge of Patient” last revised 07/01/2022 revealed in part: “Policy: It is the policy of the program to discharge patients in an orderly and efficient manner ensuring that adequate aftercare arrangements are in place. Discharges may only be initiated via order by the treating provider. Procedure: A patient is discharge from treatment services according to the following procedure: 1. Provider writes or dictates an order for discharge. 3. Licensed therapist verifies that adequate after-care plans are in place. 4. Licensed therapist meets with the patient, discusses the discharge plan, and notes patient’s response in the medical record. Any unusual circumstances or unusual reactions will be communicated to the physician immediately. Reason(s) for discharge include but are not limited to: 3. Non-compliance with treatment Review of Patient #5’s medical record revealed she was admitted to the facility on 01/15/2025 for IOP services four times per week for a diagnosis of severe recurrent major depressive disorder without psychotic features. On 02/13/2025, Patient #5 provided a handwritten grievance to S10PD which outlined an incident between Patient #5 and one of the counselors, S11CSW, who had been leading the group therapy session earlier that morning. Patient #5 had become upset because she felt S11CSW was not treating her fairly during a trivia game where participants were rewarded with a piece of candy when the question was answered correctly. During the incident between Patient #5 and S11CSW, S11CSW asked Patient #5 to leave the group therapy session due to her behavior. Patient #5, per her written grievance statement felt S11CSW had raised her voice at her, kicked her out of the group therapy session, and treated her unfairly. Review of a multi-disciplinary note in Patient #5’s record written by S10PD on 02/13/2025 and signed at 4:56 PM revealed at around 12:00 PM on 02/13/2025, S10PD met with Patient #5 to discuss that due to her (Patient #5’s) alleged behaviors and verbal aggression shown during the 10:20-11:05AM group session which had been reported to her (S10PD) by S11CSW, she would be discharged from the IOP program. Further review of S10PD’s note revealed S12APRN was made aware of Patient #5’s behavior and the decision made to discharge Patient #5 by text from S13LPN. Review of the physician’s discharge order for Patient #5 revealed: On 02/13/2025 at 1:05 PM - D/C pt from IOP services to home d/t non-compliance. VORB: S12APRN/ S13LPN (Signed off by S12APRN on 02/26/2025 at 8:45 PM) (noted by S13LPN on 02/13/2025 at 1:05 PM) Review of the discharge summary completed by S14SW on 02/14/2025 at 2:19 PM revealed in part: Plan: Patient was discharged due to aggressive behavior towards staff. Condition on Discharge: Discharge due to non-compliance Prognosis: Poor On 12/04/2025 at 2:10 PM, an interview was conducted with S10PD. S10PD stated after the incident between Patient #5 and S11CSW had taken place on 02/13/2025, S10PD met with Patient #5 to let her know she was being discharged from the IOP program due to non-compliance for her behavior during the morning group therapy session. S10PD stated after meeting with Patient #5, was when S13LPN reached out to S12APRN via text message to make her aware of the situation and to let S12APRN known Patient #5 was discharged from the IOP program and an official discharge order was needed. S10PD confirmed prior to speaking with Patient #5 about her behavior in the group therapy session and receiving her written grievance letter that morning, there had been no discussion regarding a planned discharge for Patient #5 for 02/13/2025.”

“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: 44763 Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by: 1.) failing to provide adequate heating due to the heating system being inoperable to the inpatient adolescent psychiatric unit; and 2.) failing to ensure a patient was observed in accordance with the physician orders for 1 (#8) of 5 patients’ observations reviewed from a total sample of 8. Findings: 1.) Failing to provide adequate heating due to the heating system being inoperable to the inpatient adolescent psychiatric unit. Review of the hospital’s policy titled “PC-803: Patient Rights and Responsibilities”, effective 08/06/2012, revealed in part, “Policy: The following specific rights will be offered to each patient of the hospital: Personal Safety: The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned.” Observation was conducted on 12/03/2025 at 11:05 AM - 11:51 AM of the inpatient adolescent psychiatric unit accompanied by S1CEO. Using an infrared laser thermometer the following temperatures were recorded and confirmed by S1CEO: 66 degrees Fahrenheit in hallway. 61 degrees Fahrenheit in room ‘a’. 65 degrees Fahrenheit in room ‘b’. 62 degrees Fahrenheit in room ‘c’. 65 degrees Fahrenheit in room ‘d’. In an interview during the observation, S1CEO stated on Monday (12/01/2025) it was reported to him that the heater was not working in the hospital. S1CEO stated he called someone out on Monday to inspect the heater. S1CEO stated the HVAC company told him there was nothing wrong with the heater itself and the environmental control system box was not properly engaging the heater. S1CEO then stated he was notified yesterday (12/02/2025) morning that the heater was not working in the hospital. In an interview on 12/03/2025 at 1:42 PM, S1CEO stated there was no estimated time of when the heating system would be repaired. S1CEO stated it is cold in here. S1CEO stated the plan for tonight is to provide extra blankets for the patients to maintain warmth as they sleep. S1CEO confirmed extra blankets were provided to the patients last night as well. S1CEO stated he thinks it will get down to about 45 degrees Fahrenheit outside tonight. Per the weather channel, the low temperature for 12/03/2025 was predicted to be 44 degrees Fahrenheit. In an interview on 12/03/2025 at 1:52 PM, S3MHT stated it was chilly in the unit today. S3MHT stated she was not sure how long the heat has been out. In an interview on 12/03/2025 at 1:54 PM, S4MHT stated it was a little chilly in the unit today. S4MHT stated some patients said they were cold. S4MHT stated they cannot regulate the temperature. In an interview on 12/03/2025 at 2:02 PM, S5MHT stated the temperature in the unit is cold. S5MHT stated a couple of girl patients were saying there were cold today. S5MHT stated 1 patient reported that she had 4 blankets on her bed last night because it was cold. In an interview on 12/03/2025 at 2:07 PM, S6MHT stated the temperature in the unit is cold today. S6MHT stated patients reported they were cold. S6MHT stated the staff gave the patients extra blankets. In an interview on 12/03/2025 at 3:20 PM, Patient #R1 stated he was cold and uncomfortable. Patient #R1 stated it has been cold like this for 2 days. Patient #R1 stated the staff gave him an extra blanket last night. Patient #R1 stated he was still cold after the staff gave him the extra blanket. Patient #R1 stated he asked for another blanket and staff did not give him another one. Observation revealed he was wearing a sweatshirt and lounge pants. In an interview on 12/03/2025 at 3:31 PM, Patient #R2 stated it was freezing in the hospital. Patient #R2 stated she has been here for 2 days. Patient #R2 stated the first day was not as cold as it was today. Patient #R2 stated it was cold last night. Patient #R2 stated she had 2 blankets last night. Patient #R2 stated she was cold this afternoon during naptime. Patient #R2 stated she was wearing 3 sweaters, 2 pairs of pants, and 2 pairs of socks. As she was stating this, she showed surveyor the sleeves of 3 sweaters, the bottom of the pant legs of each pair of pants, and both pairs of socks. In an interview on 12/03/2025 at 3:36 PM, Patient #8 stated the temperature was cold in the hospital. Patient #8 stated she was so cold last night she needed 3 extra blankets. Patient #8 stated the extra blankets helped and she was comfortable with the blankets. Patient #8 stated it has been cold for about 3 days. Patient #8 stated the patients are not allowed to have blankets outside of their room. Observation revealed she was wearing a sweatshirt and lounge pants. In an interview on 12/03/2025 at 3:40 PM, Patient #R3 stated she was cold today. Patient #R3 stated the temperature was fine last night. Patient #R3 stated staff asked last night if she wanted extra blankets. Patient #R3 stated she did not want an extra blanket last night. Observation revealed she was wearing 2 shirts, 1 being a sweatshirt and lounge pants. 2.) Failing to ensure a patient was observed in accordance with the physician orders for 1 (#8) of 5 patients’ observations reviewed from a total sample of 8. Review of the hospital’s policy titled “PC-1013: Levels of Patient Observation”, revised 07/31/2012, revealed in part, “Policy: All patients are monitored as to their location and activity at regular intervals. The degree of this monitoring is dependent upon the individual patient’s assessed psychiatric condition. Procedure: The charge RN, in conjunction with staff providing direct patient care, is responsible for assessing the observation status of all patients and increasing the level of observation when required, until Physician’s Order can be obtained. Any decrease in observation status requires a physician’s order prior to decrease in status. All patients admitted to the hospital will be assigned routine level of observation unless the physician orders a special level of observation.” Review of Patient #8’s medical record revealed Patient #8 was admitted on 11/24/2025. Review of Patient #8’s admission orders dated 11/24/2025 at 9:15 PM revealed in part, level of observation: Q15 minutes. Review of Patient #8’s observation sheet dated 11/24/2025 revealed in part, the following observations were not every 15 minutes according to the physician order: 10:00 PM - 10:34 PM (34 minutes) 11:01 PM - 11:17 PM (16 minutes) Review of Patient #8’s observation sheet dated 11/25/2025 revealed in part, the following observations were not every 15 minutes according to the physician order: 12:15 AM - 12:32 AM (16 minutes) 12:46 AM - 1:02 AM (16 minutes) 1:02 AM - 1:19 AM (17 minutes) 2:16 AM - 2:32 AM (16 minutes) 3:30 AM - 3:46 AM (16 minutes) 4:31 AM - 4:49 AM (18 minutes) 5:02 AM - 5:18 AM (16 minutes) 5:18 AM - 5:34 AM (16 minutes) 6:00 AM - 6:17 AM (17 minutes) 6:31 AM - 7:05 AM (34 minutes) 8:15 AM - 8:31 AM (16 minutes) 9:00 AM - 9:18 AM (18 minutes) 9:30 AM - 9:46 AM (16 minutes) 9:46 AM - 10:05 AM (19 minutes) 10:15 AM - 10:32 AM (17 minutes) 11:01 AM - 11:17 AM (16 minutes) 11:17 AM - 11:46 AM (29 minutes) 11:46 AM - 12:02 PM (16 minutes) 12:17 PM - 12:39 PM (22 minutes) 12:45 PM - 1:01 PM (16 minutes) 1:01 PM - 1:22 PM (21 minutes) 1:22 PM - 1:38 PM (16 minutes) 2:15 PM - 2:32 PM (17 minutes) 3:00 PM - 3:22 PM (22 minutes) 4:16 PM - 4:43 PM (27 minutes) 5:17 PM - 5:40 PM (23 minutes) 5:45 PM - 6:01 PM (16 minutes) 6:01 PM - 6:25 PM (24 minutes) 6:31 PM - 7:00 PM (29 minutes) 7:00 PM - 7:27 PM (27 minutes) 8:03 PM - 8:47 PM (44 minutes) 8:47 PM - 9:06 PM (19 minutes) 9:06 PM - 9:23 PM (17 minutes) 9:34 PM - 9:56 PM (22 minutes) 10:45 PM - 11:05 PM (20 minutes) Review of Patient #8’s observation sheet dated 11/26/2025 revealed in part, the following observations were not every 15 minutes according to the physician order: 2:15 AM - 2:46 AM (31 minutes) 3:30 AM - 3:46 AM (16 minutes) 5:00 AM - 5:28 AM (28 minutes) 5:31 AM - 5:53 AM (22 minutes) 6:02 AM - 6:19 AM (17 minutes) 6:19 AM - 6:40 AM (21 minutes) 7:02 AM - 7:29 AM (27 minutes) 7:36 AM - 7:57 AM (21 minutes) 8:02 AM - 8:20 AM (18 minutes) 8:33 AM - 8:52 AM (19 minutes) 9:16 AM - 9:34 AM (18 minutes) 9:34 AM - 9:51 AM (17 minutes) 10:00 AM - 10:20 AM (20 minutes) 10:20 AM - 10:44 AM (24 minutes) 11:00 AM - 11:22 AM (22 minutes) 12:00 PM - 12:22 PM (22 minutes) 12:30 PM - 12:52 PM (22 minutes) 12:52 PM - 1:15 PM (23 minutes) 1:34 PM - 1:50 PM (16 minutes) 2:00 PM - 2:17 PM (17 minutes) 3:15 PM - 3:38 PM (23 minutes) 3:46 PM - 4:04 PM (18 minutes) 4:04 PM - 4:21 PM (17 minutes) 4:31 PM - 4:54 PM (23 minutes) 5:45 PM - 6:16 PM (31 minutes) 6:32 PM - 6:53 PM (21 minutes) 6:53 PM - 7:12 PM (19 minutes) 7:15 PM - 7:31 PM (16 minutes) 7:31 PM - 7:47 PM (16 minutes) 8:15 PM - 8:38 PM (23 minutes) 9:00 PM - 9:17 PM (17 minutes) 10:30 PM - 10:49 PM (19 minutes) 11:00 PM - 11:17 PM (17 minutes) In an interview on 12/09/2025 at 1:20 PM S1CEO confirmed the above stated observations were not in accordance with the physician order for Patient #8.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 44763 Based on record review and interview, the hospital failed to ensure each order for restraints for the management of violent or self-destructive behavior was renewed every 2 hours for children and adolescents 9 to 17 years of age for 1 of 1 (#1) patient records reviewed for restraint use from a total sample of 8. Findings: Review of the hospital’s policy titled “PC-1502: Restraints and Seclusion Use”, revised 06/02/2025, revealed in part, “Orders: (C) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: a. 4 hours for adults 18 years of age or older b. 2 hours for children and adolescents 9 to 17 years of age.” Review of Patient #1’s medical record revealed Patient #1 had been placed in restraints on 09/10/2025 at 5:50 PM for violent behavior and released at 8:00 PM (2 hours and 10 minutes). Further review of the record failed to reveal a physician order of renewal for the restraints. In an interview on 12/04/2025 at 2:10 PM, S1CEO confirmed the time limit of the restraint order was 2 hours. S1CEO confirmed Patient #1 was in restraints for 2 hours and 10 minutes which exceeded the time limit of the order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 44763 Based on record review and interview, the hospital failed to ensure staff monitored the condition of the patient who was in restraints according to hospital policy for 1 of 1 (#1) patient records reviewed for restraints from a total sample of 8. Findings: Review of the hospital’s policy titled “PC-1502: Restraints and Seclusion Use”, revised 06/02/2025, revealed in part, “Monitoring: (E) The physical and psychological well being of the patient who is restrained or secluded must be monitored including, but not limited to the patient’s respiratory and circulatory status, skin integrity, vital signs and any special needs of the patient. (F) Continuous monitoring shall include: a. Respiratory and Circulatory checks every 15 minutes b. Fluids offered every hour c. Toileting offered every hour d. Meals/snacks offered every four hours e. Personal hygiene offered every 2 hours as needed f. Comfort measures offered every 2 hours g. RN assessment every hour for continued need for restraint/seclusion h. Range of motion, release 1 limb at a time every 2 hours i. Vital signs every 4 hours j. Skin integrity monitored every hour k. Orientation/mental status assessed every hour” Review of Patient #1’s medical record revealed Patient #1 had been placed in restraints on 09/10/2025 at 5:50 PM and released at 8:00 PM. Review of the Adolescent Behavioral Restraint/Seclusion Flow Sheet 24 Hour Record failed to reveal documentation of patient monitoring beyond 6:00 PM on 09/10/2025. In an interview on 12/04/2025 at 3:15 PM, S1CEO confirmed staff should have documented on the Adolescent Behavioral Restraint/Seclusion Flow Sheet 24 Hour Record every 15 minutes. S1CEO further confirmed there was no documentation after 6:00 PM.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to recognize opportunities for improvement and initiate changes to ensure compliance of medical records as evidenced by physician orders not being signed within 10 days and medical records not complete within 30 days of discharge including discharge summary. Findings: Review of the hospital’s Performance Improvement Plan, revised 01/2025, revealed in part, “The Performance Improvement Committee maintains responsibility to: c.) Ensure that findings from PI activities are analyzed to develop and implement improvement activities.” Review of the hospital’s 2025 Performance Improvement Indicators revealed the following: Indicator: verbal/telephone orders authenticated within 10 days September: 50% October 60% Indicator: medical record complete within 30 days of discharge, including discharge summary September 70% Review of the hospital’s Bylaws, Rules, and Regulations of Medical Staff revealed in part, Article XX: Rules and Regulations for the Professional Medical Staff Performance Improvement: Section 3. Medical Records: 14. Each medical record shall be completed within 30 days after discharge of the patient or the record becomes delinquent. On a continuous basis, the Medical Director shall review incomplete records. At this time, any physician who has any delinquent charts shall be so notified by phone. If the records are still incomplete two weeks after being notified, he/she shall automatically suffer suspension of admitting privileges. He/she shall be notified of such suspension in writing by the Medical Record Director. Privileges may be restored by the Medical Director when he/she has been notified by the Medical Record Director that the delinquent records have been completed. In an interview on 12/09/2025 at 9:40 AM, S1CEO stated the previous DON was reviewing medical records when patients were discharged and filling out record deficiency forms. S1CEO stated the previous DON was no longer employed and he found the documentation in the office. S1CEO confirmed there was no action taken by the hospital regarding the physician orders that were not signed. In a phone interview on 12/09/2025 at 10:06 AM, S17RQC stated they usually reeducate the staff to get the charts to the physicians to have them sign within 10 days. She stated it is a continuous ongoing process. She stated during med staff meetings the providers are shown the percentages and then they discuss. She confirmed she did not talk to any providers when they got the percentages from the performance improvement indicators for the months of September and October. She further confirmed she had not held a meeting with staff to reeducate. In an interview on 12/09/2025 at 10:19 AM, S1CEO confirmed the physician orders not being signed was not addressed with the providers in the med staff meeting on 11/04/2025. S1CEO further confirmed no documentation of discharge summaries in patient medical records were not addressed with the providers during the med staff meeting on 11/04/2025. In an interview on 12/09/2025 at 11:15 AM, S1CEO confirmed the process for delinquent medical records in the med staff bylaws was not done by the hospital.”

“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: 48537 Based on record review, hospital policy review and interview, the hospital failed to ensure a nursing staff developed a nursing care plan to reflect the patient’s goals and nursing care provided to meet the patient’s needs, which was made evident by the failure to: 1.) Create a nursing care plan for 1 (#5) of 3 patients reviewed for nursing care plans; and 2.) Include assistance with medication administration for 1 (#6) of 3 IOP program patients reviewed for medication administration during IOP program hours. Findings: Review of the hospital’s policy #OP-202 titled “Admission Procedures” revised 04/03/2022, revealed in part: “Purpose: To establish guidelines for the completion of the admission process. Procedure: Nursing Staff - 5. The Nursing Care Plan/Preliminary Treatment Plan is completed within one day and presenting problems are listed on the master problem list.” Review of the hospital’s policy #OP-314 titled “Treatment Planning” effective 07/02/2012, revealed in part: “Policy: The interdisciplinary treatment plan is a dynamic working document that directs the care of the patient throughout the continuum of care. The treatment plan is individualized, based on the problems of the patient. The treatment plan is developed through an integrated process using the Psychiatric Evaluation, Psychosocial Assessment, & Nursing Assessment. The interdisciplinary treatment plan is reviewed and modified on a regular basis.” Review of the hospital’s policy #OP-303B titled “Medication Management” revised 07/2019, revealed in part: “Purpose: To define the policy on how the outpatient program may assist its patients in managing medications. Policy: It is policy that only nursing staff may provide medication management assistance to currently admitted patients as part of the patient’s treatment plan. Procedure: 1. If the treatment team deems it necessary to provide assistance with a patient’s medication management the need for assistance must be documented, this medication management must be ordered by the physician, and it shall be reflected in the patient’s multidisciplinary treatment plan.” 1.) Failure to create a nursing care plan for 1 (#5) of 8 patients reviewed for nursing care plans. Review of Patient #5’s medical record revealed she was admitted to the facility on 01/15/2025 for IOP services four times per week for a diagnosis of severe recurrent major depressive disorder without psychotic features. Review of Patient #5’s master treatment plan which included the following documents: Plan Name: Master Treatment Plan Plan Type: Initial Plan Date: 01/17/2025 Last Updated By: S14SW Plan Name: MTP Update Play Type: 30-Day Plan Date: 02/05/2025 Last Updated By: S15CSW Next Review Date: 03/12/2025 No nursing care plan was identified within either the initial master treatment plan or the 30-day update document. On 12/04/2025 at 2:05 PM, an interview was conducted with S10PD during record review of Patient #5’s electronic medical record. S10PD confirmed no nursing care plan had been completed for Patient #5 and should have been. 2.) Failure to include assistance with medication administration for 1 (#6) of 3 IOP program patients reviewed for medication administration during IOP program hours. Review of Patient #6’s medical record revealed he was admitted to the facility from a local nursing home on 01/08/2025 for IOP services four times per week for a diagnosis of severe depressive bipolar disorder in conjunction of a medical diagnosis of diabetes mellitus type II. Review of the physician’s orders on admit, 01/08/2025, for Patient #6, revealed the following medications to be given during IOP program hours: -Humalog SQ AC per sliding scale Review of the nursing notes from 01/09/2025 to 01/30/2025 for Patient #6 revealed the following: On 01/09/2025 at 12:15 PM - “Pt CBG 261. 4 units of Humalog given as directed per SS. Pt tolerated well.” Signed by S13LPN On 01/13/2025 at 12:06 PM - “Pt CBG 301. 6 units of Humalog given as directed per SS. Pt tolerated well.” Signed by S13LPN On 01/16/2026 at 11:54 AM - “Pt CBG 271. 4 units of Humalog given as directed per SS. Pt tolerated well.” Signed by S13LPN On 01/23/2025 at 11:30 AM - “CBG 259. 4 units of Humalog given. Per S/S. Tolerated well.” Signed by S10PD. On 01/28/2025 at 12:04 PM - “Pt CBG 279. 4 units of Humalog given as directed per SS. Pt tolerated well.” Signed by S13LPN On 01/29/2025 at 12:18 PM - “Pt CBG 294. 4 units of Humalog given as directed per SS. Pt tolerated well.” Signed by S13LPN On 01/30/2025 at 12:09 PM - “Pt CBG 337. 6 units of Humalog given as directed per SS. Pt tolerated well.” Signed by S13LPN Review of Patient #6’s 30-day MTP Update dated 01/31/2025 updated by S15CSW, which included the nursing care plan completed by S13LPN completed on 01/10/2025 which revealed the following in part: Problem: Alteration in health maintenance as evidenced by medical diagnosis of DM Goal: Pt will not have any medical exacerbations while attending IOP. Objective: Pt will take all prescribed medications as ordered by the MD/NP On 12/04/2025 at 2:52 PM, an interview was conducted with S10PD during record review of Patient #6’s electronic medical record. S10PD stated if a patient were to need assistance with medications during IOP program hours, for example insulin injections at lunch time, it would be documented in their treatment team and nursing care plan and nursing would document a note each time the medication was administered. S10PD confirmed Patient #6 did receive his insulin injections by the IOP program nursing staff at lunch time. S10PD reviewed Patient #6’s treatment team and nursing care plan and confirmed it was not documented for Patient #6 to receive nursing assistance with medication administration and it should have been.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient’s needs. Findings: Review of the hospital’s policy titled “PC-1401: Nursing Shift Assignment”, effective 07/10/2012, revealed in part, “Purpose: To assign duties for nursing personnel for each shift. Policy: The charge nurse will complete a shift assignment sheet, which outlines the duties of each staff member for each shift.” In an interview on 12/09/2025 at 12:38 PM, S6MHT confirmed the MHTs decide among themselves what patients they will conduct observations on. S6MHT confirmed once it’s decided by the MHTs, then the MHTs will let the charge nurse know who they will be conducting observations on. In an interview on 12/09/2025 at 12:43 PM, S4MHT stated early in the morning the MHTs will split up the patients. S4MHT stated it’s usually the front of the hallway, the middle of the hallway, and the back of the hallway is how they usually split the patients between the MHTs to conduct observations. S4MHT confirmed the MHTs discuss among themselves on who they will conduct observations on. S4MHT confirmed they let the nurse know who they are conducting observations on. In an interview on 12/09/2025 at 12:50 PM, S8RN confirmed the MHTs decide which patients they will conduct observations on. S8RN confirmed the MHTs tell her which patients they will conduct observations on, then she writes the assignments on the paper. S8RN stated she then makes adjustments as needed. S8RN confirmed she had not had any time to adjust the assignments this morning since S6MHT came in.”

“RN POLICY FOR OUTPATIENT DEPTS CFR(s): The hospital must have policies and procedures in place establishing which outpatient departments, if any, are not required under hospital policy to have a registered nurse present. The policies and procedures must: (i) Establish the criteria such outpatient departments must meet, taking into account the types of services delivered, the general level of acuity of patients served by the department, and the established standards of practice for the services delivered; (ii) Establish alternative staffing plans; (iii) Be approved by the director of nursing; (iv) Be reviewed at least once every 3 years This Standard is not met as evidenced by: 48537 Based on record review and interviews, the hospital failed to have a registered nurse present at the IOP program while patients were present and/or have written hospital policies and procedures established which outpatient departments, if any, were not required to have registered nurses present due to patient acuity. Findings: Review of the employee list provided to the surveyor by S1CEO on 12/03/2025 listed one nurse, S16LPN. No other nurses either LPNs or RNs are listed on the employee list. On 12/04/2025 at 1:45 PM, an interview was conducted with S10PD who stated she was by license an LPN, but currently worked as the program director for the IOP program. S10PD confirmed there were no hired RNs working in the IOP program. On 12/08/2025 at 10:56 AM, an interview was conducted with S1CEO who stated he was not aware of any hospital policy and/or procedure requirement of establishing outpatient departments to deem if it is necessary or not to have an RN present or not. S1CEO did confirm there were no RNs hired to work in the IOP program.”

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure all orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner for 5 (#1, #2, #3, #4, #8) of 8 patient records reviewed. Findings: Review of the hospital’s policy titled “PHARM-202: Written Orders, Verbal Orders, Telephone Orders, Automatic Stop Dates”, revised 03/01/2018, revealed in part, “Procedure: 3. A physician may order medications/controlled drugs verbally and via telephone in case of necessity. c. Verbal and telephone orders should be signed by the physician within 10 days.” Patient #1 Review of Patient #1’s medical record revealed Patient #1 had been placed in restraints on 09/10/2025 at 5:50 PM and released at 8:00 PM. Review of the physician order for the restraints dated 09/10/2025 revealed the order was not signed by the ordering practitioner. In an interview on 12/04/2025 at 2:10 PM, S1CEO confirmed the physician order for restraints dated 09/10/2025 was not signed by the ordering physician. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 09/07/2025. Review of the physician orders revealed the following orders were not signed by the ordering practitioner/physician: 09/07/2025 7:12 PM 1) Encourage fluids 2) Recheck urine via urinalysis on Tuesday 09/09/2025 4:05 PM Discontinue repeat urinalysis 09/11/2025 11:32 AM Increase observation level to LOS 09/13/2025 8:25 AM Change level of observation to Q15 minutes In an interview on 12/08/2025 at 3:15 PM, S1CEO confirmed the above stated physician orders were not signed by the ordering physician. Patient #3 Review of Patient #3’s medical record revealed Patient #3 was admitted on 09/07/2025. Review of the physician orders revealed an order dated 09/07/2025 at 10:20 AM Start: Zoloft 25mg PO Q day, after consent. Further review of the order revealed the order was not signed by the ordering physician. In an interview on 12/08/2025 at 2:15 PM, S1CEO confirmed the above stated physician order was not signed by the ordering physician. Patient #4 Review of Patient #4’s medical record revealed Patient #4 was admitted on 09/09/2025. Review of the physician orders revealed an order dated 09/13/2025 at 10:10 AM Apply Triamcinolone cream 0.1% area on right forearm BID. Further review of the order revealed the order was not signed by the ordering practitioner. In an interview on 12/08/2025 at 3:27 PM, S1CEO confirmed the above stated physician order was not signed by the ordering physician. Patient #8 Review of Patient #8’s medical record revealed Patient #8 was admitted on 11/24/2025. Review of the admission physician orders dated 11/24/2025 revealed the admission orders were not signed by the ordering physician. Further review of the physician orders revealed the following orders were not signed by the ordering physician: 11/25/2025 at 1:45 PM Prazosin 1mg PO QHS to prevent nightmares 11/28/2025 at 11:30 AM Increase Celexa to 20mg PO QHS. In an interview on 12/09/2025 at 11:48 AM, S1CEO confirmed the physician orders dated 11/25/2025 and 11/28/2025 were not signed by the ordering physician within 10 days. In an interview on 12/09/2025 at 1:46 PM, S1CEO confirmed Patient #8’s admission orders were not signed by the ordering physician.”

“CONTENT OF RECORD: DISCHARGE SUMMARY CFR(s): 482.24(c)(4)(vii) [All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to include a discharge summary in the medical record within 30 days of discharge according to hospital policy for 3 (#1, #2, #3) of 8 patient records reviewed. Findings: Review of the hospital’s policy titled “HIM-04: Discharge Summaries”, revised 06/2018, revealed in part, “Policy: The attending physician will develop a Discharge Summary to be included in the patient’s record within 30 days of discharge.” Patient #1 Review of Patient #1’s medical record revealed Patient #1 was admitted on 09/08/2025 and discharged on 09/16/2025. Further review of Patient #1’s medical record failed to reveal a discharge summary. In an interview on 12/04/2025 at 3:42 PM, S1CEO confirmed there was no documentation of a discharge summary included in Patient #1’s medical record. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 09/07/2025 and discharged on 09/14/2025. Further review of Patient #2’s medical record failed to reveal a discharge summary. In an interview on 12/08/2025 at 12:25 PM, S1CEO confirmed there was no documentation of a discharge summary included in Patient #2’s medical record. S1CEO further confirmed the physician has 30 days from discharge to complete the discharge summary. Patient #3 Review of Patient #3’s medical record revealed Patient #3 was admitted on 09/07/2025 and discharged on 09/17/2025. Further review of Patient #3’s medical record failed to reveal a discharge summary. In an interview on 12/08/2025 at 3:08 PM, S1CEO confirmed there was no documentation of a discharge summary included in Patient #3’s medical record.”

“Neurological Examination CFR(s): When indicated, a complete neurological examination must be recorded at the time of the admission physical examination. This Standard is not met as evidenced by: 48537 Based on record review, hospital policy review and interview, the hospital failed to ensure a complete neurological examination including cranial nerve assessments were completed on 2 (#5 & #6) of 3 IOP patients sampled for review. Findings: Review of the hospital’s policy #OP-202 titled “Admission Procedures” revised 04/03/2020, revealed in part: “Purpose: To establish guidelines for the completions of the admission process. The following shall be instituted following admission orders being given by the admitting physician. Procedure: Psychiatrist - 1. The psychiatrist performs a psychiatric evaluation to include evaluation of the following: Psychiatric and medical history, mental status exam, risk assessment as well as vocational, pastoral, educational and legal issues.” Patient #5 Review of Patient #5’s medical record revealed she was admitted to the facility on 01/15/2025 for IOP services four times per week for a diagnosis of severe recurrent major depressive disorder without psychotic features. Review of Patient #5’s physician initial IOP admit orders dated 01/15/2025 by S12APRN revealed in part: Psychiatric Evaluations and Treatment (including H&P) Review of Patient #5’s medical record revealed no documented neurological or cranial nerve assessment. On 12/04/2025 at 1:56 PM, an interview was conducted with S10PD during record review of Patient #5’s electronic medical record. S10PD stated Patient #5 had an established PCP who had the copy of her most recent H&P which likely included the neurological/cranial nerve assessment. S10PD confirmed the hospital did not have a neurological/cranial nerve assessment for Patient #5’s in her medical record. Patient #6 Review of Patient #6’s medical record revealed he was admitted to the facility from a local nursing home on 01/08/2025 for IOP services four times per week for a diagnosis of severe depressive bipolar disorder. Review of Patient #6’s physician initial IOP admit orders dated 01/08/2025 by S12APRN revealed in part: Psychiatric Evaluations and Treatment (including H&P) Review of Patient #6’s medical record revealed no documented neurological or cranial nerve assessment. On 12/04/2025 at 2:41 PM, an interview was conducted with S10PD during record review of Patient #6’s electronic medical record. S10PD stated the local nursing home where Patient #6 resided had the copy of his most recent H&P which likely included the neurological/cranial nerve assessment. S10PD confirmed the hospital did not have a neurological/cranial nerve assessment for Patient #6’s in his medical record.”

“Psych Eval - Medical History CFR(s): [Each patient must receive a psychiatric evaluation that must--] Include a medical history; This Standard is not met as evidenced by: 48537 Based on record review, hospital policy review and interview, the hospital failed to ensure on admission to the IOP, a medical history & physical (H&P) was obtained for 2 (#5 & #6) of 3 IOP patients sampled. Findings: Review of the hospital’s policy #OP-202 titled “Admission Procedures” revised 04/03/2020, revealed in part: “Purpose: To establish guidelines for the completions of the admission process. The following shall be instituted following admission orders being given by the admitting physician. Procedure: Psychiatrist - 1. The psychiatrist performs a psychiatric evaluation to include evaluation of the following: Psychiatric and medical history, mental status exam, risk assessment as well as vocational, pastoral, educational and legal issues.” Patient #5 Review of Patient #5’s medical record revealed she was admitted to the facility on 01/15/2025 for IOP services four times per week for a diagnosis of severe recurrent major depressive disorder without psychotic features. Review of Patient #5’s physician initial IOP admit orders dated 01/15/2025 by S12APRN revealed in part: Psychiatric Evaluations and Treatment (including H&P) Review of Patient #5’s medical record revealed no documented H&P. On 12/04/2025 at 1:56 PM, an interview was conducted with S10PD during record review of Patient #5’s electronic medical record. S10PD stated Patient #5 had an established PCP who had the copy of her most recent H&P and was in charge of managing all of Patient #5’s medical concerns/issues. S10PD confirmed the hospital did not have a copy of Patient #5’s most recent H&P in her medical record. Patient #6 Review of Patient #6’s medical record revealed he was admitted to the facility from a local nursing home on 01/08/2025 for IOP services four times per week for a diagnosis of severe depressive bipolar disorder. Review of Patient #6’s physician initial IOP admit orders dated 01/08/2025 by S12APRN revealed in part: Psychiatric Evaluations and Treatment (including H&P) Review of Patient #6’s medical record revealed no documented H&P. On 12/04/2025 at 2:41 PM, an interview was conducted with S10PD during record review of Patient #6’s electronic medical record. S10PD stated the local nursing home where Patient #6 resided had the copy of his most recent H&P and they were in charge of managing all of Patient #6’s medical concerns/issues. S10PD confirmed the hospital did not have a copy of Patient #6’s most recent H&P in his medical record.”

“Psych Eval - Attitudes and Behavior CFR(s): [Each patient must receive a psychiatric evaluation that must--] Describe attitudes and behavior; This Standard is not met as evidenced by: 48537 Based on record review, hospital policy review, and interview, the hospital failed to ensure suicide assessments were completed upon admission to the IOP program for 2 (#5 & #6) of 3 IOP patients reviewed. Findings: Review of the hospital’s policy #OP-202 titled “Admission Procedures” revised 04/03/2020, reveled in part: “Purpose: To establish guidelines for the completion of the admission process. The following shall be instituted following admission orders being given by the admitting physician. Procedure: Counselor/Social Worker - 1. The counselor or social worker performs psychosocial assessment to include evaluation of the following: Current behavior/emotional functioning, use of alcohol/drugs and need for treatment, maladaptive or problem behaviors, learning needs and barriers to treatment, identification of community resources and extent of family involvement.” Review of the hospital’s policy #OP-204 titled “Screening Procedures” revised 07/2022, revealed in part: “Policy: It is policy to perform appropriate screenings using standardized tools or instruments on patients admitted to the facility in order to develop a comprehensive treatment plan. These tools are also used at regular intervals to monitor the individual’s progress in achieving his/her care, treatment, or service goals as well as to assess readiness for discharge. Procedure: The following screenings are available to be self-administered or administered by a trained or licensed staff member (as indicated below): - Columbia-Suicide Severity Rating Scale (C-SSRS) - To be completed on all patients upon admission. Can be administered by any trained staff member.” Patient #5 Review of Patient #5’s medical record revealed she was admitted to the facility on 01/15/2025 for IOP services four times per week for a diagnosis of severe recurrent major depressive disorder without psychotic features. Review of Patient #5’s medical record revealed no suicide assessment had been completed on admission or at any point throughout her time in the IOP program from 01/15/2025 - 02/13/2025. On 12/04/2025 at 2:03 PM, an interview was conducted with S10PD during record review of Patient #5’s electronic medical record. S10PD stated the C-SSRS is completed on admit by the social worker for every patient. After review of Patient #5’s medical record, S10PD confirmed no C-SSRS had been completed and/or documented in Patient #6 medical record during her IOP program admission from 01/15/2025-02/13/2025 and should have been. Patient #6 Review of Patient #6’s medical record revealed he was admitted to the facility from a local nursing home on 01/08/2025 for IOP services four times per week for a diagnosis of severe depressive bipolar disorder. Review of Patient #6’s medical record revealed no suicide assessment had been completed on admission or at any point throughout his time in the IOP program from 01/08/2025 - 02/17/2025. On 12/04/2025 at 2:03 PM, an interview was conducted with S10PD during record review of Patient #6’s electronic medical record. S10PD stated the C-SSRS is completed on admit by the social worker for every patient. After review of Patient #6’s medical record, S10PD confirmed no C-SSRS had been completed and/or documented in Patient #6’s medical record during his IOP program admission from 01/08/2025-02/17/2025 and should have been.”

“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, record review and interview, the psychiatric hospital failed to ensure the patient right to receive care in a safe setting. This deficient practice is evidenced by: 1) Failure to ensure the patient care area was free of ligature risks; and 2) Failure to ensure unattended rooms in the patient care area were locked and secured from unauthorized entry by patients. Findings: 1) Failure to ensure the patient care area was free of ligature risks Observations during a walk-through of the psychiatric hospital on 09/23/2025 from 1:00 PM to 1:35 PM revealed the toilet seats in Rooms “c” - “j” restrooms being loosely secured. Also, the front edge of each toilet seat was bowed upwards and away from underlying edge of the toilet bowl rim, which created a pass through space for an object such as a sheet or towel. Further, it appeared there was a metal L-bracket mounted to the inner front edge of the toilet bowl rim and just under each of the toilet seats. This metal bracket could enhance the strength of this area as a potential ligature risk, as this bracket would prevent any object passed under the toilet seat from slipping off the front edge of the toilet rim. The pass through space of each toilet was as follows: Room “c” was approximately ¼ inch; Room “d” was approximately ½ inch; Room “e” was approximately ¼ inch; Room “f” was approximately ½ inch; Room “g” was approximately 1 inch; Room “h” was approximately ½ inch; Room “i” was approximately ½ inch; and Room “j” was approximately ½ inch. In an interview on 09/23/2025 and present during the psychiatric hospital walk-through, S1CEO and S4CNO confirmed the above mentioned findings. 2) Failure to ensure unattended rooms in the patient care area were locked and secured from unauthorized entry by patients A review of hospital self-report received by Louisiana Department of Health - Health Standards Section (LDH HSS) on 09/03/2025 revealed an incident of alleged patient to patient sexual assault taking place on 08/26/2025 at approximately 10:23 AM, with the date of discovery of the alleged event being 09/02/2025 at 11:36 AM. This hospital self-report revealed in part, S1CEO being informed by Patient #1’s guardian that Patient #1 and Patient #2 had engaged in sex on 08/26/2025 between breakfast and lunch and this had reportedly taken place in a bathroom. The hospital self-report also revealed the review by S1CEO of recorded video from 08/26/2025. S1CEO’s notes revealed Patient #2 entering Room “a” at 10:22:23 AM, Patient #1 entering Room “a” at 10:23:40 AM and closing the door, Patient #1 exiting Room “a” at 10:25:04 AM and Patient #2 exiting Room “a” at 10:25:28 AM. Observations of recorded video, with S1CEO navigating the computer and identifying patients and rooms, revealed the before mentioned incident on 08/26/2025. The recorded video was captured by Camera 7 and it provided a view of the hospital’s main hallway leading to Rooms “a” - “j”. The observed video revealed the same before mentioned sequence of events and timeframes. Further observations of the recorded video revealed the door of Room “a” unlocked and completely open with no staff member present. In an interview on 09/23/2025 and present during the review of recorded video, S1CEO confirmed the above mentioned findings. He further confirmed the door of Room “a” should be closed and locked when not in use and a staff member should be present when the room is being utilized by any patient regardless of the patient’s ordered observation level.”

“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: 48051 Based on observations, record review and interview, the psychiatric hospital failed to measure, analyze and track all adverse patient events. The deficient practice is evidenced by the failure to ensure documentation of preventative actions that were implemented to educate staff related to observations of patients per provider orders and the securing of areas the patients are not allowed to enter unsupervised in the patient care area. Findings: A review of the psychiatric hospital policy, “PC-1013: Levels of Patient Observation,” with an effective date of 07/10/2012 and last revised 01/08/2025, revealed in part: “POLICY All patients are monitored as to their location and activity at regular intervals. The degree of this monitoring is dependent upon the individual patient’s assessed psychiatric condition. PROCEDURE The charge RN, in conjunction with the staff providing direct patient care, is responsible for assessing the observation status of all patients and increasing the level of observation when required, until Physician’s Orders can be obtained. Any decrease in observation status requires a physician’s order prior to decrease in status. All patients admitted to the hospital will be assigned routine level of observation unless the physician orders a special level of observation. A) Routine levels of Observation 1) All patient are monitored a minimum of every 15 minutes. 2) Location of patients is monitored at each change of shift by a staff member from the off-going shift together with a member of the on-coming shift. Location is noted on observation sheet for appropriate shift. 3) Staff assigned to the charting on patients will include documentation in the Nursing Progress Notes as to the location and frequency of checks. B) Special Levels of Observation An increased degree of monitoring is applied to patients whose psychiatric conditions is assessed as needing more intense external controls and/or increased frequency of staff contract for patients to be able to maintain their internal controls. Patients assessed as needing any of the following increased levels of observation are to be maintained in the hospital. Special Levels of Observation are as follows: 1) Constant Observation - may be referred to as “Line of Sight” or “Close Observation” a. A patient is maintained in community areas where their entire body can be observed at all times. b. Staff must be able to maintain a “line-of-sight” to the patient at all times. c. Staff shall accompany the patient on constant observation at any time they leave community areas, e.g., to the bathroom or to change clothes. d. Documentation of constant observation will be completed on the Q15 Observation sheet. 2) One-to-One Observation a. This is an extreme level of observation reserved for patients whose psychiatric, medical, and/or cognitive stats is such that control/safety cannot be maintained otherwise. b. A staff member is assigned to this patient and remains in physical proximity at all times, within 4 feet of a non-violent patient, within 8 feet of a violent patient, or as specified by the ordering provider. c. Documentation in Nursing Progress Notes must state that one-to-one supervision was provided throughout the shift. The staff member providing on-to-one supervision shall give report to the on-coming shift.” A review of hospital self-report received by Louisiana Department of Health - Health Standards Section (LDH HSS) on 09/03/2025 revealed an incident of alleged patient to patient sexual assault taking place on 08/26/2025 at approximately 10:23 AM, with the date of discovery of the alleged event being 09/02/2025 at 11:36 AM. This hospital self-report revealed in part, S1CEO being informed by Patient #1’s guardian that Patient #1 and Patient #2 had engaged in sex on 08/26/2025 between breakfast and lunch and this had reportedly taken place in a bathroom. The hospital self-report also revealed the review by S1CEO of recorded video from 08/26/2025. S1CEO’s notes revealed Patient #2 entering Room “a” at 10:22:23 AM, Patient #1 entering Room “a” at 10:23:40 AM and closing the door, Patient #1 exiting Room “a” at 10:25:04 AM and Patient #2 exiting Room “a” at 10:25:28 AM. Observations of recorded video, with S1CEO navigating the computer and identifying patients and rooms, revealed the before mentioned incident on 08/26/2025. The recorded video was captured by Camera 7 and it provided a view of the hospital’s main hallway leading to Rooms “a” - “j”. The observed video revealed the same before mentioned sequence of events and timeframes. Further observations of the recorded video revealed the door of Room “a” unlocked and completely open with no staff member present. A review of the hospital’s daily census sheet and staffing sheet for 08/26/2025 revealed Patient #2 and #R1 as being observed as a Line of Sight and Patient #1 and #R2 - #R11 as being observed as Routine level of observation (q15min). A review the hospital’s daily staffing sheet for 08/26/2025 day shift revealed S7RN, S8LPN, S5MHT and S6MHT on duty. A review of Patient #2’s medical record revealed provider observation orders for Line of Sight during the before mentioned timeframe. A review of Patient #2’s Patient Observation Record dated 08/26/2025 revealed S6MHT as the staff member performing observations on Patient #2 from 10:00 AM to 10:45 AM which would include the time frame of the before mentioned event. A review Patient #R1’s medical record revealed provider observation orders for Line of Sight during the before mentioned timeframe. A review of Patient #R1’s Patient Observation Record dated 08/26/2025 revealed S6MHT as the staff member performing observations on Patient #R1 from 10:00 AM to 10:45 AM which would include the time frame of the before mentioned event. A review of Patients #R4 - #R7 observation sheets from 08/26/2025 revealed S6MHT performing observations from 10:00 AM to 10:45 AM which would include the time frame of the before mentioned event. A request was initiated with S1CEO and S2DON for documentation of educational in-services performed with staff since 08/26/2025 related to a review of the levels of observations and what each level would encompass and a review of which rooms should be locked and secured in the patient care areas to prevent a patient to gain access while unattended or being monitored. In an interview on 09/23/2025 at 11:10 AM, S1CEO confirmed the above mentioned findings. S1CEO confirmed it would be impossible to watch 2 Line of Sight patients at one time if the patients were mobile and moving around the unit and further confirmed S6MHT should not have been assigned other patients while being assigned to a Line of Sight patient. S1CEO confirmed S6MHT was not maintaining a Line of Sight on Patient #2 while he was located in Room “a” and S6MHT was located in Room “k” while Patients #1 and #2 were in Room “a” per video he had reviewed but is now unavailable. S1CEO confirmed the door of Room “a” should have been closed and locked when not in use and a staff member should be present when the room is being utilized by any patient regardless of the patient’s ordered observation level. In an interview on 09/23/2025 at 1:15 PM, S2DON confirmed the hospital had no documentation of educational in-services being performed related to a review of the levels of observations and the securing of doors in the patient care areas since 08/26/2025.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48051 Based on record review and interview, the psychiatric hospital failed to ensure nursing services have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. This deficient practice is evidenced by the failure to ensure adequate staffing was on duty to provide nursing care to all patients. Findings: A review of the psychiatric hospital policy, “PC-114: Staffing Patterns, Variances and Acuity,” with an effective date of 07/10/2012 and last revised 12/19/2024, revealed in part: “Scope The staffing pattern for the program is based on aspects of care and services provided to facilitate a ratio of staff to patients that is conducive to providing high quality, safe, efficient and compassionate care. Responsible Party Director of Nursing and Assistant Director of Nursing is responsible for ensuring that these patterns are communicated to department staff. Staff Patterns 1. There will be a minimum of 1 RN on all shifts. 2. A nursing staff to patient ratio of no less that 1:5 will be maintained at all times. 3. Additional staff may be called in at the discretion of the charge RN or to maintain a staffing ratio of no less than 1:5. 4. The charge nurse on duty will notify on-call nurse if additional staffing is needed. Daily Clinical Staffing and Management Report The night charge nurse will complete the Daily Clinical Staffing and Management Report for the day. The day, evening, and night shifts will document any changes/updates to the report. In the event that the census or acuity increases, additional staff members may be called in to ensure high quality, individualized care for every patient. If any patient’s score reach Level 3, additional staff may be needed. The charge nurse on duty will notify the on-call nurse for the need for additional staff.” A review of the psychiatric hospital policy, “PC-1013: Levels of Patient Observation,” with an effective date of 07/10/2012 and last revised 01/08/2025, revealed in part: “POLICY All patients are monitored as to their location and activity at regular intervals. The degree of this monitoring is dependent upon the individual patient’s assessed psychiatric condition. PROCEDURE The charge RN, in conjunction with the staff providing direct patient care, is responsible for assessing the observation status of all patients and increasing the level of observation when required, until Physician’s Orders can be obtained. Any decrease in observation status requires a physician’s order prior to decrease in status. All patients admitted to the hospital will be assigned routine level of observation unless the physician orders a special level of observation. A) Routine levels of Observation 1) All patient are monitored a minimum of every 15 minutes. 2) Location of patients is monitored at each change of shift by a staff member from the off-going shift together with a member of the on-coming shift. Location is noted on observation sheet for appropriate shift. 3) Staff assigned to the charting on patients will include documentation in the Nursing Progress Notes as to the location and frequency of checks. B) Special Levels of Observation An increased degree of monitoring is applied to patients whose psychiatric conditions is assessed as needing more intense external controls and/or increased frequency of staff contract for patients to be able to maintain their internal controls. Patients assessed as needing any of the following increased levels of observation are to be maintained in the hospital. Special Levels of Observation are as follows: 1) Constant Observation - may be referred to as “Line of Sight” or “Close Observation” a. A patient is maintained in community areas where their entire body can be observed at all times. b. Staff must be able to maintain a “line-of-sight” to the patient at all times. c. Staff shall accompany the patient on constant observation at any time they leave community areas, e.g., to the bathroom or to change clothes. d. Documentation of constant observation will be completed on the Q15 Observation sheet. 2) One-to-One Observation a. This is an extreme level of observation reserved for patients whose psychiatric, medical, and/or cognitive stats is such that control/safety cannot be maintained otherwise. b. A staff member is assigned to this patient and remains in physical proximity at all times, within 4 feet of a non-violent patient, within 8 feet of a violent patient, or as specified by the ordering provider. c. Documentation in Nursing Progress Notes must state that one-to-one supervision was provided throughout the shift. The staff member providing on-to-one supervision shall give report to the on-coming shift.” A review of the psychiatric hospital’s staffing matrix revealed a day shift census of 13 patients would indicated a need for 1 RN, 1 LPN and 3 MHTs. A review of the hospital’s daily census sheet for 08/26/2025 revealed Patient #2 and #R1 as being observed as a Line of Sight and Patient #1 and #R2 - #R11 being observed as Routine Q15min observations. A review the hospital’s daily staffing sheet for 08/26/2025 day shift revealed S7RN, S8LPN, S5MHT and S6MHT on duty. Per staffing matrix, there was not an adequate number of staff on duty. Additionally, each MHT would not be able to maintain a constant Line of Sight on a patient and/or have the ability to perform routine monitoring and observations on other patients whom have the opportunity to constantly move around the unit. In a telephone interview on 09/24/2025 at 10:22 AM, S5MHT confirmed he remembered the day of 08/26/2025 and confirmed there were 2 MHTs on duty that day, himself and S6MHT. S5MHT indicated he was assigned to Patient #R1 and S6MHT was assigned to Patient #2. S5MHTconfirmed he was assisting with treatment team meeting on this day and he handed off Patient #R1 to S6MHT. S5MHT further confirmed during the time he was assisting with treatment team, S6MHT had the responsibility to monitor 2 Line of Sight patients (#2 and #R1) and perform routine observations on the other patients which included Patients #1 and #R2 - #R11. In an interview on 09/24/2025 at 10:35 AM, S1CEO and S2DON confirmed the above mentioned findings and further confirmed that shift was short at minimum 1 MHT.”

“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 observation, record review and interview, the psychiatric hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice was evidenced by the failure to properly observe and monitor patients per provider orders. Findings: A review of the psychiatric hospital policy, “PC-1013: Levels of Patient Observation,” with an effective date of 07/10/2012 and last revised 01/08/2025, revealed in part: “POLICY All patients are monitored as to their location and activity at regular intervals. The degree of this monitoring is dependent upon the individual patient’s assessed psychiatric condition. PROCEDURE The charge RN, in conjunction with the staff providing direct patient care, is responsible for assessing the observation status of all patients and increasing the level of observation when required, until Physician’s Orders can be obtained. Any decrease in observation status requires a physician’s order prior to decrease in status. All patients admitted to the hospital will be assigned routine level of observation unless the physician orders a special level of observation. A) Routine Levels of Observation 1) All patient are monitored a minimum of every 15 minutes. 2) Location of patients is monitored at each change of shift by a staff member from the off-going shift together with a member of the on-coming shift. Location is noted on observation sheet for appropriate shift. 3) Staff assigned to the charting on patients will include documentation in the Nursing Progress Notes as to the location and frequency of checks. B) Special Levels of Observation An increased degree of monitoring is applied to patients whose psychiatric conditions is assessed as needing more intense external controls and/or increased frequency of staff contract for patients to be able to maintain their internal controls. Patients assessed as needing any of the following increased levels of observation are to be maintained in the hospital. Special Levels of Observation are as follows: 1) Constant Observation - may be referred to as “Line of Sight” or “Close Observation” a. A patient is maintained in community areas where their entire body can be observed at all times. b. Staff must be able to maintain a “line-of-sight” to the patient at all times. c. Staff shall accompany the patient on constant observation at any time they leave community areas, e.g., to the bathroom or to change clothes. d. Documentation of constant observation will be completed on the Q15 Observation sheet. 2) One-to-One Observation a. This is an extreme level of observation reserved for patients whose psychiatric, medical, and/or cognitive stats is such that control/safety cannot be maintained otherwise. b. A staff member is assigned to this patient and remains in physical proximity at all times, within 4 feet of a non-violent patient, within 8 feet of a violent patient, or as specified by the ordering provider. c. Documentation in Nursing Progress Notes must state that one-to-one supervision was provided throughout the shift. The staff member providing on-to-one supervision shall give report to the on-coming shift.” A review of hospital self-report received by Louisiana Department of Health - Health Standards Section (LDH HSS) on 09/03/2025 revealed an incident of alleged patient to patient sexual assault taking place on 08/26/2025 at approximately 10:23 AM, with the date of discovery of the alleged event being 09/02/2025 at 11:36 AM. This hospital self-report revealed in part, S1CEO being informed by Patient #1’s guardian that Patient #1 and Patient #2 had engaged in sex on 08/26/2025 between breakfast and lunch and this had reportedly taken place in a bathroom. The hospital self-report also revealed the review by S1CEO of recorded video from 08/26/2025. S1CEO’s notes revealed Patient #2 entering Room “a” at 10:22:23 AM, Patient #1 entering Room “a” at 10:23:40 AM and closing the door, Patient #1 exiting Room “a” at 10:25:04 AM and Patient #2 exiting Room “a” at 10:25:28 AM. Observations of recorded video, with S1CEO navigating the computer and identifying patients and rooms, revealed the before mentioned incident on 08/26/2025. The recorded video was captured by Camera 7 and it provided a view of the hospital’s main hallway leading to Rooms “a” - “j”. The observed video revealed the same before mentioned sequence of events and timeframes. Further observations of the recorded video revealed the door of Room “a” unlocked and completely open with no staff member present. A review of the hospital’s daily census sheet and staffing sheet for 08/26/2025 revealed Patient #2 and #R1 as being observed as a Line of Sight and Patient #1 and #R2 - #R11 as being observed as Routine level of observation (q15min). A review the hospital’s daily staffing sheet for 08/26/2025 day shift revealed S7RN, S8LPN, S5MHT and S6MHT on duty. A review of Patient #1, #2, and #R1- #R11 revealed the following provider observation orders and the MHT whom performed the observation on 08/26/2025 from 10:00 AM to 10:45 AM: Provider observation orders for Line of Sight on the following patients: --Patient #2: 10:00 AM-S6MHT, 10:15 AM-S6MHT, 10:30 AM-S6MHT, 10:45 AM-S6MHT; and --Patient #R1: 10:00 AM-S6MHT, 10:15 AM-S6MHT, 10:30 AM-S6MHT, 10:45 AM-S6MHT. Provider orders for Routine level of observation (q15min) on the following patients: --Patient #1: 10:00 AM-S5MHT, 10:15 AM-S5MHT, 10:30 AM-S5MHT, 10:45 AM-S5MHT; --Patient #R2: 10:00 AM-S5MHT, 10:15 AM-S5MHT, 10:30 AM-S5MHT, 10:45 AM-S5MHT; --Patient #R3: 10:00 AM-S5MHT, 10:15 AM-S5MHT, 10:30 AM-S5MHT, 10:45 AM-S5MHT; --Patient #R4: 10:00 AM-S6MHT, 10:15 AM-S6MHT, 10:30 AM-S6MHT, 10:45 AM-S6MHT; --Patient #R5: 10:00 AM-S6MHT, 10:15 AM-S6MHT, 10:30 AM-S6MHT, 10:45 AM-S6MHT; --Patient #R6: 10:00 AM-S6MHT, 10:15 AM-S6MHT, 10:30 AM-S6MHT, 10:45 AM-S6MHT; --Patient #R7: 10:00 AM-S6MHT, 10:15 AM-S6MHT, 10:30 AM-S6MHT, 10:45 AM-S6MHT; --Patient #R8: 10:00 AM-S5MHT, 10:15 AM-S5MHT, 10:30 AM-S5MHT, 10:45 AM-S5MHT; --Patient #R9: 10:00 AM-S5MHT, 10:15 AM-S5MHT, 10:30 AM-S5MHT, 10:45 AM-S5MHT; --Patient #R10: 10:00 AM-S5MHT, 10:15 AM-S5MHT, 10:30 AM-S5MHT, 10:45 AM-S5MHT; and --Patient #R11: 10:00 AM-S5MHT, 10:15 AM-S5MHT, 10:30 AM-S5MHT, 10:45 AM-S5MHT. The review of observation sheet revealed S6MHT maintaining a Line of Sight on 2 (#2, #R1) and patients maintaining routine observation on 4 (#R4- #R7) patients during the before mentioned event. The review of recorded video failed to reveal S6MHT or any staff member around Room “a” with the door open. In a telephone interview on 09/24/2025 at 10:22 AM, S5MHT confirmed he remembered the day of 08/26/2025 and confirmed there were 2 MHTs on duty that day, himself and S6MHT. S5MHT indicated he was assigned to Patient #R1 and S6MHT was assigned to Patient #2. S5MHTconfirmed he was assisting with treatment team meeting on this day and he handed off Patient #R1 to S6MHT. S5MHT further confirmed during the time he was assisting with treatment team, S6MHT had the responsibility to monitor 2 Line of Sight patients (#2 and #R1) and perform routine observations on the other patients which included Patients #1 and #R2 - #R11. In an interview on 09/23/2025 at 11:10 AM, S1CEO confirmed the above mentioned findings. S1CEO confirmed it would be impossible to watch 2 Line of Sight patients at one time if the patients were mobile and moving around the unit and further confirmed S6MHT should not have been assigned other patients while being assigned to a Line of Sight patient. S1CEO confirmed S6MHT was not maintaining a Line of Sight on Patient #2 while he was located in Room “a” and S6MHT was located in Room “k” while Patients #1 and #2 were in Room “a” per video he had reviewed but is now unavailable. S1CEO confirmed the door of Room “a” should have been closed and locked when not in use and a staff member should be present when the room is being utilized by any patient regardless of the patient’s ordered observation level.”

“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: 48051 Based on record review and interview, the psychiatric hospital failed to ensure all licensed nurses who provide services in the hospital adhere to the policies and procedures of the hospital and 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. This deficient practice is evidenced by the failure to ensure the documentation of all agency nurses completing the same orientation a staff RN would complete upon hire and prior to performing unsupervised patient care. Findings: A review of the psychiatric hospital policy, “HR-603: Temporary Service Agencies,” with an effective date of 1998 and last revised 10/2022, revealed in part: “POLICY Temporary Services are used on an as-needed basis only and require that they be coordinated through Administration to ensure control of such services. All contract employees shall receive training and orientation prior to performing his/her assigned duties. In addition, records on all contract employees shall be maintained in accordance with current regulations, standards and law. PROCEDURE Prior to performing any duties, the contract employee shall complete training and orientation. Training and orientation shall be facilitated by the facility.” A review of S9RNA personnel file failed to reveal documentation of this staff member completing hospital orientation which would include hospital policies and procedures as they relate to hospital’s emergency procedures, nursing services policies and procedures, and safety policies and procedures. The personnel file further failed to reveal documentation of competencies as this would relate to the performance of clinical activities. A review of staffing schedules revealed S9RNA had already worked as the charge nurse on the night shifts of 09/20/2025. In an interview on 09/24/2025 at 2:35 PM, S2DON confirmed the above mentioned findings and further confirmed S9RNA had worked as the charge nurse with no supervision on the nights of 09/15/2025, 09/16/2025, 09/20/2025, and 09/21/2025.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48051 Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation (CoP) of Patient Rights. The hospital failed to protect and promote each patient’s rights as evidenced by: 1) failure to properly observe 1 (#1) of 9 (#1, #R9 - #R16) patients during exterior, courtyard time (See Findings Tag A0144); 2) failure to properly observe 3 (#2, #R1, #R2) of 9 (#2, #R1-#R3) patients on 1:1 observation status (See Findings Tag A0144); 3) failure to ensure 1 (#2) of 3 (#1 - #3) patient’s plan of care included written modification for the use of restraints (See Findings Tag A0166); 4) failure to ensure 1 (#2) of 3 (#1 - #3) patients were properly monitored per hospital policy while being restrained (See Findings Tag A0175); 5) failure to properly restrain 1 (#2) of 3 (#1 - #3) patients (See Findings Tag A0194); and 6) failure to ensure documented completion of competency education in restraint chair usage by 3 (S7RN, S8LPN, S10MHT) of 5 (S6MHT, S7RN, S8LPN, S9MHT, S10MHT) staff members. (See Findings Tag A0196).”

“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, record review, and interview the hospital failed to ensure the patient’s right to receive care in a safe setting. This deficient practice was evidenced by: 1) failure to properly observe 1 (#1) of 9 (#1, #R9 - #R16) patients during exterior, courtyard time; and 2) failure to properly observe 3 (#2, #R1, #R2) of 9 (#2, #R1-#R3) patients on 1:1 observation status. Findings: 1) Failure to properly observe 1 (#1) of 9 (#1, #R9 - #R16) patients during exterior, courtyard time A review of hospital policy, “HR-201: Behavior of Employees,” with an effective date of 1998 and last revised/reviewed on 02/2025, revealed in part, “Purpose: To ensure efficient operation of the company and safety of employees by defining certain rules and regulations regarding employee behavior. Policy: Conduct that interferes with operations, discredits the company or is offensive to guests or fellow employees will not be tolerated. Procedure: Employees are expected at all times to conduct themselves in a positive manner so as to promote the best interests of the company. Such conduct includes: Refraining from behavior or conduct deemed offensive or undesirable, or which is contrary to the company’s best interests; Performing assigned tasks efficiently and in accordance with established quality standards. The Following conduct is prohibited and will subject the individual involved to disciplinary action, up to and including termination: Unauthorized use of personal computers, cell phones, or personal electronic devices while working.” Observations during a walk though of the hospital on 04/14/2025 from 2:10 PM to 2:40 PM, with S1CEO and S2DON present, revealed the exterior courtyard being enclosed by a wooden fence approximately 10 feet tall. There were two, secured exit gates that would lead to unsecured areas of the facility’s grounds. Gate #1 would open to the yard at the rear of the building. Gate #2 would open to the right side of the building and the parking lot with the fronting highway in immediate view. Both of these gates are approximately 8 foot in height and made of the same wood material as the fence. Above the gated areas, the wooden fence continued upwards to the height of the continuous 10 feet stationary, wood fencing. Where the top of each gate met the stationary fencing, there was an approximate 1 - 2 inch space/gap between the gate fencing and the stationary fencing. Gate #2 was not in the line of site of the building entry door. This surveyor stood within 5 feet of the entry door of the building and was unable to visualize Gate #2. An MHT that would stand at the entry door monitoring patients exiting and entering the building would not be able to visualize Gate #2 or the immediate area around Gate #2 if they remained stationary at the entry door. Observations of video recorded on 03/24/2025 from 12:25 PM to 12:36 PM with S1CEO navigating the computer and S2DON available to assist with the identification of staff and patients revealed simultaneous camera angles on the exterior courtyard. Camera 20 was angled to capture Gate #2 and Camera 21 was angled to capture the courtyard at the entry door of the building. S6MHT was observed standing in a stationary position within reach of the entry door to the building and remained in this area until courtyard time was completed. Camera 20 captured Patient #1 pacing the area close to Gate #2, continuously looking towards the area where S6MHT was standing and back towards Gate #2. It appeared Patient #1 was analyzing the gate and fence. Patient #1 was seen in this area for approximately 5 minutes prior to him scaling the fence. At approximately 12:35:35 PM, Patient #1 is seen approaching the gate, standing on his toes and reaching both hands up to the space between the gate and wood fence, pulling himself up to a level that he could hold his body with one hand and use his other arm/hand to grab the top of the wood fence and continued to pull himself up and over the fence. Beginning at approximately 12:33 PM, S6MHT appeared to be looking at his clipboard and remained looking down at his clipboard until approximately 12:38:26 PM. This would include the time Patient #1 scaled the wood fence and eloped. The camera angle capturing S6MHT allowed a zoom-in feature, which identified a cell phone laid upon the top of the clipboard in S6MHT’s hands. It also appeared S6MHT’s left thumb was moving in a continuous scroll-like movement/pattern of the telephone’s screen during this time frame. S6MHT was observed walking the area that was not in the line of sight of his continuous location after all the patients had re-entered the building at approximately 12:40:45 PM. In an interview on 04/14/2025 and during the review of recorded video, S1CEO and S2DON confirmed the above mentioned findings, confirmed S6MHT had his cell phone present and staff had been instructed against personal belongings being in patient care areas. Both further confirmed the staff should be observing and monitoring the entire exterior courtyard while patients were present. In an interview on 04/16/2025 at 12:41 PM, S6MHT confirmed he first recognized Patient #1’s disappearance when the patient’s reentry head count was not correct. 2) Failure to properly observe 3 (#2, #R1, #R2) of 9 (#2, #R1-#R3) patients on 1:1 observation status A review of hospital policy, “PC-1013: Levels of Patient Observation,” with an effective date of 07/10/2012 and a revised date of 07/31/2012, revealed in part: “Policy: All patients are monitored as to their location and activity at regular intervals. The degree of this monitoring is dependent upon the individual patient’s assessed psychiatric condition. Procedure: A) Routine Levels of Observation: 1) All patients are monitored a minimum of every 15 minutes. B) Special Levels of Observation: An increased degree of monitoring is applied to patients whose psychiatric condition is assessed as needing more intense external controls and/or increased frequency of staff contact for patients to be able to maintain their internal controls. Patients assessed as needing any other following increased levels of observations are to be maintained in the hospital. Special Levels of Observation are as follows: 2) One-to-One (1:1) Supervision: a. This is an extreme level of observation reserved for patient who are an imminent suicide risk or whose psychiatric state is that control/safety cannot be maintained otherwise. b. A staff member is assigned to this patient and remains in physical proximity at all times.” A review the hospital’s staff for 03/15/2025 day shift revealed in part, S7RN, S8LPN, S6MHT, S9MHT and S10MHT. A review of assignments revealed S6MHT assigned to Patients #2, #R3 -#R8 (all routine levels of observation). S9MHT was assigned to Patient #R1 (1:1). S10MHT was assigned to Patient #R2 (1:1). A review of the hospital’s bed board for 03/15/2025 revealed a total of 9 (#2, #R1 - #R8) patients. Patient #R1 and #R2 were identified on this bed board as 1:1 level of observation. A review of Patient #R1’s medical record revealed a provider order on 3/14/2025 for 1:1 level of observation for active suicidal ideations. A review of Patient #R2’s medical record revealed a provider order from 03/14/2025 for 1:1 level of observation for the level of medical care needed. A review of the hospitals incident logs revealed an incident occurring on 03/15/2025, at an unknown time involving Patient #2. Patient #2 alleged she had been sexually assaulted while restrained. A review of recorded video from 03/15/2025 from approximately 8:03 AM to 8:25 AM with S1CEO navigating the computer and S2DON assisting with identification of employees revealed in part, a situation involving Patient #2 being restrained and removed from Room “c”. During the time of Patient #2 being restrained and transferred to Room “a”, the remaining 8 (#R1 -#R8) patients were in Room “c”. The situation required all staff to control and move Patient #2 to Room “a”. Also, during the time Patient #2 was moved to Room “a” (8:06 AM to 8:07 AM) and during a subsequent interval in which Patient #2 was able to free herself from the restraint chair and the need of all staff to return her to the restraint chair (8:17 AM to 8:20 AM), 2 (#R1, #R2) of 8 (#R1 - #R8) patients were not properly observed per provider orders. Recorded video failed to reveal hospital staff within physical proximity of Patient #R1 or R#2 during the before mention times of Patient #2’s need of all staff assistance. Further, from 8:11 AM to 8:16 AM, S9MHT began outdoor smoke break for patients and did not remain within physical proximity of Patient #R1. Other observations of recorded video from 03/15/2025 failed to reveal assigned hospital staff within physical proximity of Patient #R1 during the following time frames: 8:02 AM to 8:10 AM (approximately 8 minutes), 8:11 AM to 8:40 AM (approximately 29 minutes), 8:40 AM to 8:43 AM (approximately 3 minutes), 8:53 AM to 8:56 AM (approximately 3 minutes), 9:06 AM to 9:14 AM (approximately 8 minutes) and 9:16 AM to 9:23 AM (approximately 7 minutes). Further review of recorded video from 03/15/2025 from approximately 8:03 AM to 9:40 AM with S1CEO navigating the computer and S2DON assisting with identification of employees revealed in part, the following times Patient #2 was left unobserved in Rooms “a” and “b” while restrained in the restraint chair: 8:06:34 AM Patient #2’s arrival to Room “a” in the restraint chair; 8:06:52 AM to 8:11:46 AM left unobserved (approximately 4 min 54 seconds); 8:22 AM, Patient #2 moved in the restraint chair to Room “b” and remained restrained; 8:22 AM to 8:28 AM (approximately 6 minutes) left unobserved in Room “b”; 8:33 AM to 8:49 AM (approximately 16 minutes) left unobserved in Room “b”; 8:49 AM to 8:52 AM (approximately 3 minutes) left unobserved in Room “b”; 8:53 AM to 9:01 AM (approximately 8 minutes) left unobserved in Room “b”; 9:03 AM to 9:06 AM (approximately 3 minutes) left unobserved in Room “b”; and 9:18 AM to 9:40 AM (approximately 22 minutes) left unobserved in Room “b”. Patient #2 was left unobserved for approximately 54 of the 97 minutes of recorded video reviewed. Per staffing sheet and Patient Observation Record from 03/15/2025, S6MHT was assigned to Patient #2 and was identified on video as the MHT that was partially monitoring Patient #2. A review of Patient Observation Records for Patient #2 and #R1 - #R8 revealed documentation of S6MHT performing patient observations from 8:00 AM to 11:30 AM and being assigned to 1:1 observation of Patient #2 as follows: Patient #2 (1:1): 8:15 AM to 11:30 AM; Patient #R1 (1:1): 8:00 AM to 8:30 AM; Patient #R2 (1:1): 9:30 AM; Patient #R3: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; Patient #R4: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; Patient #R5: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; Patient #R6: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; Patient #R7: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; and Patient #R8: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM. In an interview on 04/15/2025 at 11:30 AM, S1CEO and S2DON confirmed the above mentioned findings, confirmed staffing was not appropriate on 03/15/2025, and confirmed S6MHT (assigned to Patient #2) and S9MHT (assigned to Patient #R1) failed to remain within physical proximity of their assigned patient at all times.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure a written modification to the patient’s plan of care for the use of restraints or seclusion. This deficient practice was evidenced by the failure to ensure 1 (#2) of 3 (#1 - #3) patients’ plan of care included written modification for the use of restraints. Findings: A review of hospital policy, “PC-1502: Restraints and Seclusion Use,” with an effective date of 07/16/2013 and no revisions revealed in part: “Monitoring: (G) When restraint or seclusion is used, there must be documentation in the patient’s medical record of the following: h. revisions to the plan of care.” A review of Patient #2’s medical record revealed the use of restraints and the restraint chair on 03/15/2025 from approximately 8:10 AM to 10:30 AM. A review Patient #2’s treatment plan titled, “Compass Health Treatment Plan,” failed to reveal documentation related to use of restraints and the restraint chair. This had the potential to negatively affect patient care related to the communication of restraint use to the entire treatment team. In an interview on 04/15/2025 at 10:00 AM, S1CEO and S2DON confirmed the above mentioned findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 48051 Based on observation, record review and interview, the hospital failed to ensure the patient who is restrained or secluded is monitored by a physician, other licensed practitioner or trained staff that have completed training criteria per hospital policy. This deficient practice was evidenced by the failure to ensure 1 (#2) of 3 (#1 - #3) patients were properly monitored per hospital policy while being restrained. Findings: A review of hospital policy, “PC-1502: Restraints and Seclusion Use,” with an effective date of 07/16/2013 and no revisions revealed in part: “Purpose: The hospital uses restraint and seclusion only to protect the immediate physical safety of the patient, staff, or others. Policy: It is the Policy of the hospital to use the least restrictive form of restraint or seclusion only to protect the immediate physical safety of the patient, staff, or others. The hospital does not use restraint or seclusion as a means of coercion, discipline, convenience, or staff retaliation. The hospital uses restrain or seclusion only when less restrictive interventions are ineffective. The hospital discontinues restraint or seclusion at the earliest possible time, regardless of the scheduled expirations of orders. Definitions: Restraint is (A) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. A Physical Hold is considered a restraint and requires adherence to the restraint policy and procedure. Monitoring: (A) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed independent practitioner, or trained staff that have completed the training criteria specified under Staff Training Requirements in this policy. (D) Simultaneous restraint and seclusion use is only permitted if the patient is continually monitored: a. Face-to-face by an assigned, trained staff member; or b. By trained staff using both video and audio equipment. This monitoring must be in close proximity to the patient. Staff Training Requirements: (A) Training Intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraints or seclusion- a. Training will occur as part of initial employee orientation, annually, and before staff perform restraint or seclusion interventions. (B) Staff education and training will include: d. The safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia); f. Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1 hour face-to-face evaluation.” A request for a hospital policy related to restraint chair use was initiated, however the hospital was unable to provide. A review of video recorded on 03/15/2025 from approximately 8:03 AM to 9:40 AM with S1CEO navigating the computer and S2DON assisting with the identification of employees revealed in part, the following times Patient #2 was left unobserved in Rooms “a” and “b” while restrained in the restraint chair: 8:06:34 AM Patient #2’s arrival to Room “a” in the restraint chair; 8:06:52 AM to 8:11:46 AM left un unobserved (approximately 4 min 54 seconds); 8:22 AM, Patient #2 moved in the restraint chair to Room “b” and remained restrained; 8:22 AM to 8:28 AM (approximately 6 minutes) left unobserved in Room “b”; 8:33 AM to 8:49 AM (approximately 16 minutes) left unmonitored in Room “b”; 8:49 AM to 8:52 AM (approximately 3 minutes) left unobserved in Room “b”; 8:53 AM to 9:01 AM (approximately 8 minutes) left unobserved in Room “b”; 9:03 AM to 9:06 AM (approximately 3 minutes) left unobserved in Room “b”; and 9:18 AM to 9:40 AM (approximately 22 minutes) left unobserved in Room “b”. Patient #2 was left unobserved for approximately 54 of the 97 minutes of recorded video reviewed. Per staffing sheet and Patient Observation Record from 03/15/2025, S6MHT was assigned to Patient #2 and was identified on video as the MHT that was partially observing this patient during the before mentioned recorded video review. A review of a nursing note from 03/15/2025 and submitted at 11:38 AM by S7RN revealed, in part: “10AM - Pt placed in restraint chair, for her safety and safety of others, fighting the entire time, scratching staff member. Dr. notified, order written. Pt give B52, placed in front of nurses station where she could be observed entire time.” Review of the recorded video of the event above did show Patient #2 being placed within the nurses’ station view, however, this view was outside the nurses’ station’s closed doors and across the hall in Room “b”. Although Patient #2 was within eyesight of the nurses, a staff member was not within physical proximity of the patient and there was no auditory device in use to be able to hear Patient #2 within Room “b”. In an interview on 04/15/2025 at 11:30 AM, S1CEO and S2DON confirmed the above mentioned findings and further confirmed Patient #2 was not being properly observed and monitored during the time of restraint use. S1CEO also confirmed the hospital did not have a policy related to restraint chair use. In an interview on 04/16/2025 at 12:41 PM, S6MHT confirmed he was assigned to Patient #2 during the time of the above mentioned restraint use. He further confirmed when a patient is placed in restraints, the patient becomes a 1:1 level of observation and the MHT should “remain within arms-reach of the patient and not left alone or unmonitored.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f) Restraint or Seclusion: Staff Training Requirements. The patient has the right to safe implementation of restraint or seclusion by trained staff. This Standard is not met as evidenced by: 48051 Based on observation, record review, and interview the hospital failed to ensure the patient’s right to the safe implementation of restraint or seclusion by trained staff. This deficient practice was evidenced by the failure to properly restrain 1 (#2) of 3 (#1 - #3) patients. Findings: A review of hospital policy, “PC-1502: Restraints and Seclusion Use,” with an effective date of 07/16/2013 and no revisions revealed in part: “Purpose: The hospital uses restraint and seclusion only to protect the immediate physical safety of the patient, staff, or others. Policy: It is the Policy of the hospital to use the least restrictive form of restraint or seclusion only to protect the immediate physical safety of the patient, staff, or others. The hospital does not use restraint or seclusion as a means of coercion, discipline, convenience, or staff retaliation. The hospital uses restrain or seclusion only when less restrictive interventions are ineffective. The hospital discontinues restraint or seclusion at the earliest possible time, regardless of the scheduled expirations of orders. Definitions: Restraint is (A) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. A Physical Hold is considered a restraint and requires adherence to the restraint policy and procedure. Monitoring: (A) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed independent practitioner, or trained staff that have completed the training criteria specified under Staff Training Requirements in this policy. (D) Simultaneous restraint and seclusion use is only permitted if the patient is continually monitored: a. Face-to-face by an assigned, trained staff member; or b. By trained staff using both video and audio equipment. This monitoring must be in close proximity to the patient. Staff Training Requirements: (A) Training Intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraints or seclusion- a. Training will occur as part of initial employee orientation, annually, and before staff perform restraint or seclusion interventions. (B) Staff education and training will include: d. The safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia); f. Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1 hour face-to-face evaluation.” A request for a hospital policy related to restraint chair use was initiated, however the hospital was unable to provide. A review of video recorded on 03/15/2025 from approximately 8:03 AM to 8:15 AM with S1CEO navigating the computer and S2DON assisting with identification of employees revealed in part, 8:03 AM S6MHT approach Patient #2 standing in the doorway of exterior exit door of Room “c”. 8:03:51 AM S6MHT, S8LPN, S9MHT and S10MHT attempt to place Patient #2 in the restraint chair in Room “c”. Patient #2 was fighting the 4 staff and kicking legs. The staff manage to restrain Patient #2’s bilateral arms at the wrist/forearm area. Her bilateral legs were not properly secured to the chair, however they were secured enough to prohibit her from kicking staff. Patient #2 appeared to be secured to the chair by 8:05:53 AM and immediately rolled via the restraint chair to Room “a” with arrival by 8:06:34 AM. Patient #2 was alone in Room “a” with live video capture from the nurses’ station, however the room is not equipped with auditory capability. At approximately 8:11:27 AM, simultaneous recorded video review revealed Patient #2 in Room “a” removing left arm and bilateral legs from the restraints and recorded video of the nurses’ station camera revealed S6MHT identifying Patient #2 becoming unrestrained via the nurses’ station live video feed of Room “a”. S6MHT responded to Room “a” and appeared to attempt to reapply the restraint to Patient #2’s left arm, however Patient #2 was able to escape S6MHT’s hold and stand up. Patient #2’s right wrist/forearm remained attached to the restraint chair, with S6MHT attempted to hold and move the patient back to the restraint chair. S6MHT was unsuccessful at redirecting Patient #2’s return to the restraint chair and he holds Patient #2 until S7RN and S8LPN enter Room “a” at 8:15:05 AM. S7RN and S8LPN attempted to assist with returning Patient #2 to the restraint chair and were unsuccessful. S7RN requested help from S9MHT and S10MHT. All staff converge to Room “a” and successfully return and properly secure Patient #2 to the restraint chair with all restraints in place. In an interview on 04/15/2025 at 11:30 AM, S1CEO and S2DON confirmed the above mentioned findings and further confirmed Patient #2 was not properly restrained in the restraint chair. S1CEO also confirmed the hospital did not have a policy related to restraint chair use. In an interview on 04/16/2025 at 12:41 PM, S6MHT confirmed he was assigned to Patient #2 during the time of the above mentioned restraint use. He further confirmed Patient #2 was not properly restrained in the restraint chair and this was the first time the staff had used the restraint chair after being in-serviced on its use.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(1) Training intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion- (i) Before performing any of the actions specified in this paragraph; (ii) As part of orientation; and (iii) Subsequently on a periodic basis consistent with hospital policy. This Standard is not met as evidenced by: 48051 Based on observation, record review, and interview the hospital failed to ensure staff were trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion. This deficient practice was evidenced by the failure to ensure documented completion of competency education in restraint chair usage by 3 (S7RN, S8LPN, S10MHT) of 5 (S6MHT, S7RN, S8LPN, S9MHT, S10MHT) staff members. Findings: A review of hospital policy, “PC-1502: Restraints and Seclusion Use,” with an effective date of 07/16/2013 and no revisions revealed in part: “Purpose: The hospital uses restraint and seclusion only to protect the immediate physical safety of the patient, staff, or others. Policy: It is the Policy of the hospital to use the least restrictive form of restraint or seclusion only to protect the immediate physical safety of the patient, staff, or others. The hospital does not use restraint or seclusion as a means of coercion, discipline, convenience, or staff retaliation. The hospital uses restrain or seclusion only when less restrictive interventions are ineffective. The hospital discontinues restraint or seclusion at the earliest possible time, regardless of the scheduled expirations of orders. Definitions: Restraint is (A) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. A Physical Hold is considered a restraint and requires adherence to the restraint policy and procedure. Monitoring: (A) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed independent practitioner, or trained staff that have completed the training criteria specified under Staff Training Requirements in this policy. (D) Simultaneous restraint and seclusion use is only permitted if the patient is continually monitored: a. Face-to-face by an assigned, trained staff member; or b. By trained staff using both video and audio equipment. This monitoring must be in close proximity to the patient. Staff Training Requirements: (A) Training Intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraints or seclusion- a. Training will occur as part of initial employee orientation, annually, and before staff perform restraint or seclusion interventions. (B) Staff education and training will include: d. The safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia); f. Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1 hour face-to-face evaluation.” A request for a hospital policy related to restraint chair use was initiated, however the hospital was unable to provide. A review of video recorded on 03/15/2025 from approximately 8:03 AM to 8:15 AM with S1CEO navigating the computer and S2DON assisting with identification of employees revealed in part, 8:03 AM S6MHT approach Patient #2 standing in the doorway of exterior exit door of Room “c”. 8:03:51 AM S6MHT, S8LPN, S9MHT and S10MHT attempted to place Patient #2 in the restraint chair in Room “c”. Patient #2 was fighting the 4 staff and kicking her legs. The staff manage to place Patient #2 in the restraint chair and restrain her bilateral arms at the wrist/forearm area. Her bilateral legs were not properly secured to the chair, however they were secured enough to prohibit her from kicking staff. Patient #2 appeared to be secured to the restraint chair by 8:05:53 AM and immediately rolled via the restraint chair to Room “a” with arrival by 8:06:34 AM. Patient #2 was alone in Room “a” with live video capture at the nurses’ station, however the room was not equipped with auditory capability. At approximately 8:11:27 AM, simultaneous recorded video review revealed Patient #2 in Room “a” removing left arm and bilateral legs from the restraints and recorded video of the nurses’ station camera revealed S6MHT identifying Patient #2 becoming unrestrained via the nurses’ station live video feed of Room “a”. S6MHT responded to Room “a” and appeared to attempt to reapply the restraint to Patient #2’s left arm, however Patient #2 was able to escape S6MHT’s hold and stand up. Patient #2’s right wrist/forearm remained attached to the restraint chair, with S6MHT attempting to hold and move the patient back to the chair. S6MHT was unsuccessful at redirecting Patient #2’s return to the restraint chair and he holds Patient #2 until S7RN and S8LPN enter Room “a” at 8:15:05 AM. S7RN and S8LPN attempted to assist with returning Patient #2 to the restraint chair and were unsuccessful. S7RN requested help from S9MHT and S10MHT. All staff converge to Room “a” and successfully return and properly secure Patient #2 to the restraint chair with all restraints in place. A review hospital assigned educational modules revealed the course titled, “Compass Health: S & R Restraint Chair” being assigned on 01/07/2025 and having a due on date of 01/12/2025. A review of 3 (S7RN, S8LPN, S10MHT) of 5 (S6MHT, S7RN, S8LPN, S9MHT, S10MHT) staff’s assigned educational module transcripts failed to reveal a completion date for this course. In an interview on 04/15/2025 at 11:30 AM, S1CEO and S2DON confirmed the above mentioned findings and further confirmed Patient #2 was not properly restrained in the restraint chair, the hospital did not have a policy related to restraint chair use and the above mentioned staff had not completed the assigned educational module on restraint chair use. In an interview on 04/16/2025 at 12:41 PM, S6MHT confirmed he was assigned to Patient #2 during the time of the above mentioned restraint chair use. He further confirmed Patient #2 was not properly restrained in the restraint chair and this was the first time the staff had used the restraint chair after being in-serviced on its use.”

“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: 48051 Based on record review and interview, the hospital failed to ensure the QAPI program analyzed adverse patient events that impacted patient safety and quality of care. This deficient practice was evidenced by: 1) failure to conduct a thorough investigation involving the observation of 2 (#R1, #R2) of 8 (#2, #R1 - #R8) patients identified on recorded video of an unrelated incident; and 2) failure to conduct a thorough investigation involving the elopement of Patient #1. Findings: 1) failure to conduct a thorough investigation involving the observation of 2 (#R1, #R2) of 8 (#2, #R1 - #R8) patients identified on recorded video of an unrelated incident A review of hospital policy, “PC-1013: Levels of Patient Observation,” with an effective date of 07/10/2012 and a revised date of 07/31/2012, revealed in part: “Policy: All patients are monitored as to their location and activity at regular intervals. The degree of this monitoring is dependent upon the individual patient’s assessed psychiatric condition. Procedure: A) Routine Levels of Observation: 1) All patients are monitored a minimum of every 15 minutes. B) Special Levels of Observation: An increased degree of monitoring is applied to patients whose psychiatric condition is assessed as needing more intense external controls and/or increased frequency of staff contact for patients to be able to maintain their internal controls. Patients assessed as needing any other following increased levels of observations are to be maintained in the hospital. Special Levels of Observation are as follows: 2) One-to-One (1:1) Supervision: a. This is an extreme level of observation reserved for patient who are an imminent suicide risk or whose psychiatric state is that control/safety cannot be maintained otherwise. b. A staff member is assigned to this patient and remains in physical proximity at all times.” A review of hospital policy, “Performance Improvement Plan,” no policy number available, an effective date of 07/2012 and last revision 01/2025, revealed in part: “Purpose: It is the responsibility of the hospital to provide quality care in an environment where patient safety is of the utmost importance. Responsibilities: The Performance Improvement Committee maintains the responsibility to: a. Ensure processes and activities (those that affect out comes, patient safety, and/or organizational functions most significantly) within the hospital are measured, assessed, and improved systematically; d. Ensure that the hospital’s established mechanism for identification, reporting, analysis and prevention of sentinel events is followed; j. Provide and/or arrange for staff training in the basic approaches to and methods of performance improvement, stressing that nay staff can express an idea for improvement that is department-specific or organizationally focused. A review of the hospital’s bed board for 03/15/2025 revealed a total of 9 (#2, #R1 - #R8) patients. Patient #R1 and #R2 were identified on this bed board as 1:1 supervision. A review of Patient #R1’s medical record revealed a provider order on 3/14/2025 for 1:1 level of observation for active suicidal ideations. A review of Patient #R2’s medical record revealed a provider order for 1:1 level of observation for the level of medical care needed. Patient #R1 was assigned to S9MHT and Patient #R2 was assigned to S10MHT. Observations of video recorded 03/15/2025 from approximately 8:03 AM to 8:25 AM with S1CEO navigating the computer and S2DON assisting with the identification of employees revealed in part, a situation involving Patient #2 being restrained and removed from Room “c”. During the time Patient #2 was being restrained and transferred to Room “a”, the remaining 8 (#R1 -#R8) patients were in Room “c”. The situation required all staff to control and move Patient #2 to Room “a”. During the time Patient #2 was moved to Room “a” (8:06 AM to 8:07 AM) and during a subsequent interval in which Patient #2 was able to free herself from the restraint chair and the need of all staff to return her to the restraint chair (8:17 AM to 8:20 AM), 2 (#R1, #R2) of 8 (#R1 - #R8) patients were not properly monitored per provider orders. Recorded video failed to reveal hospital staff within physical proximity of Patient #R1 or R#2 during the before mention times of Patient #2’s need of all staff assistance. Further, from 8:11 AM to 8:16 AM, S9MHT began outdoor smoke break for patients and did not remain within physical proximity of Patient #R1. Other observations of recorded video from 03/15/2025 failed to reveal S9MHT within physical proximity of Patient #R1 during the following time frames: 8:02 AM to 8:10 AM, 8:11 AM to 8:40 AM, 8:40 AM to 8:43 AM, 8:53 AM to 8:56 AM, 9:06 AM to 9:14 AM and 9:16 AM to 9:23 AM. A medical record review of Patient #R1’s Patient Observation Record from 03/15/2025, revealed documented observations for 7:45 AM by S9MHT (assigned MHT), 8:00 AM to 8:30 AM by S6MHT (assigned to Patient #2), 8:45 AM and 9:00 AM by S9MHT, 9:15 AM by S10MHT (assigned to Patient #R2) and 9:30 AM - 9:45 AM 2 by S9MHT. In an interview on 04/15/2025 at 11:30 AM, S1CEO and S2DON confirmed the above mentioned findings, confirmed Patient #R1 and #R2 were not being properly observed and monitored as a 1:1 level of observation and S1CEO further confirmed the above mentioned findings were not identified until the review of the recorded video with this surveyor. 2) failure to conduct a thorough investigation involving the elopement of Patient #1 A review of hospital policy, “HR-201: Behavior of Employees,” with an effective date of 1998 and last revised/reviewed on 02/2025, revealed in part, “Purpose: To ensure efficient operation of the company and safety of employees by defining certain rules and regulations regarding employee behavior. Policy: Conduct that interferes with operations, discredits the company or is offensive to guests or fellow employees will not be tolerated. Procedure: Employees are expected at all times to conduct themselves in a positive manner so as to promote the best interests of the company. Such conduct includes: Refraining from behavior or conduct deemed offensive or undesirable, or which is contrary to the company’s best interests; Performing assigned tasks efficiently and in accordance with established quality standards. The Following conduct is prohibited and will subject the individual involved to disciplinary action, up to and including termination: Unauthorized use of personal computers, cell phones, or personal electronic devices while working.” A review of hospital policy, “Performance Improvement Plan,” no policy number available, an effective date of 07/2012 and last revision 01/2025, revealed in part: “Purpose: It is the responsibility of the hospital to provide quality care in an environment where patient safety is of the utmost importance. Responsibilities: The Performance Improvement Committee maintains the responsibility to: a. Ensure processes and activities (those that affect out comes, patient safety, and/or organizational functions most significantly) within the hospital are measured, assessed, and improved systematically; d. Ensure that the hospital’s established mechanism for identification, reporting, analysis and prevention of sentinel events is followed; j. Provide and/or arrange for staff training in the basic approaches to and methods of performance improvement, stressing that nay staff can express an idea for improvement that is department-specific or organizationally focused.” Observations of video recorded on 03/24/2025 from 12:25 PM to 12:36 PM with S1CEO navigating the computer and S2DON available to assist with identification of staff and patients revealed simultaneous camera angles on the exterior courtyard. Camera 20 was angled to capture Gate #2 and Camera 21 was angled to capture the courtyard at the entry door of the building. S6MHT is observed standing in a stationary position within reach of the entry door to the building and remained in this area until courtyard time was completed. Camera 20 captured Patient #1 pacing the area close to Gate #2, continuously looking towards the area where S6MHT was standing and back towards Gate #2. It appeared Patient #1 was analyzing the gate and fence. Patient #1 was seen in this area for approximately 5 minutes prior to him scaling the fence. At approximately 12:35:35 PM, Patient #1 is seen approaching the gate, standing on his toes and reaching both hands up to the space between the gate and wood fence, pulling himself up to a level that he could hold his body with one hand and use his other arm/hand to grab the top of the wood fence and continue to pull himself up and over the fence. Beginning at approximately 12:33 PM, S6MHT appeared to be looking at his clipboard and remained looking down at his clipboard until approximately 12:38:26 PM. This would include the time of Patient #1 scaled the wood fence and eloped. The camera angle capturing S6MHT allowed a zoom-in feature, which identified a cell phone laid upon the top of the clipboard in S6MHT’s hands. It also appeared S6MHT’s left thumb was moving in a continuous scroll-like movement/pattern of the telephone’s screen during this time frame. S6MHT was observed walking the area that was not in the line of sight of his continuous location after all patients had re-entered the building at approximately 12:40:45 PM. In an interview on 04/14/2025 and during the review of recorded video, S1CEO and S2DON confirmed the above mentioned findings, confirmed S6MHT had his cell phone present and staff had been instructed against personal belongings being in patient care areas. S1CEO further confirmed the above mentioned findings were not identified until the review of the recorded video with this surveyor.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48051 Based on observation, record review, and interview the hospital failed to ensure there were adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. This deficient practice was evidenced by failure to have adequate staff to observe and monitor 9 (#2, #R1 - #R8) of 9 (#2, #R1 - #R8) patients. Findings: A review of the hospital’s staffing matrix revealed a day shift census of 9 patients, would require 1 RN, 1 LPN, and 2 MHTs. A review of hospital policy, “PC-114: Staffing Patterns, Variances and Acuity,” with an effective date of 07/10/2012 and last revised on 12/19/2024, revealed in part, “Purpose: The program is staffed in a manner to meet the various needs of the patients served. Scope: The staffing pattern for the program is based on aspects of care and services provided to facilitate a ratio of staff to patients that is conducive to providing high quality, safe, efficient and compassionate care. Responsible Party: Director of Nursing and Assistant Director of Nursing is responsible for ensuring that these patterns are communicated to department staff. Policy: It is recognized that there may always be unpredictable fluctuations in staffing needs. Therefore, it is expected that staffing be adjusted accordingly to meet patient care needs. Staff Patterns: 3. Additional staff may be called in at the discretion of the charge RN or to maintain a staffing ratio of no less than 1:5. 4. The charge nurse on duty will notify on-call nurse if additional staffing is needed. Daily Clinical Staffing and Management Report: The night charge nurse will complete the Daily Clinical Staffing and Management Report for the day. The day, evening and night shifts will document any changes/updates to the report. In the event that the census or acuity increases, additional staff members may be called in to ensure high quality, individualized care for every patient.” A review the hospital’s staff for 03/15/2025 day shift revealed in part, S7RN, S8LPN, S6MHT, S9MHT and S10MHT. A review of assignments revealed S6MHT assigned to Patients #2, #R3 -#R8 (all routine level of observation). S9MHT assigned to Patient #R1 (1:1). S10MHT assigned to Patient #R2 (1:1). A review of the hospital’s bed board for 03/15/2025 revealed a total of 9 (#2, #R1 - #R8) patients. Patient #R1 and #R2 were identified on this bed board as 1:1 level of observation. A review of Patient #R1’s medical record revealed a provider order on 3/14/2025 for 1:1 level of observation for active suicidal ideations. A review of Patient #R2’s medical record revealed a provider order from 03/14/2025 for 1:1 lever of observation for the level of medical care needed. A review of the hospitals incident logs revealed an incident occurring on 03/15/2025, at an unknown time involving Patient #2. Patient #2 alleged she was sexually assaulted while restrained. A review of video recorded on 03/15/2025 from approximately 8:03 AM to 8:25 AM with S1CEO navigating the computer and S2DON assisting with the identification of employees revealed in part, a situation involving Patient #2 being restrained and removed from Room “c”. During the time of Patient #2 being restrained and transferred to Room “a”, the remaining 8 (#R1 -#R8) patients were in Room “c”. The situation required all staff to control and move Patient #2 to Room “a”. Also, during the time Patient #2 was moved to Room “a” (8:06 AM to 8:07 AM) and during a subsequent interval in which Patient #2 was able to free herself from the restraint chair and the need of all staff to return her to the restraint chair (8:17 AM to 8:20 AM), 2 (#R1, #R2) of 8 (#R1 - #R8) patients were not appropriately observeded per provider orders. Recorded video failed to reveal hospital staff within physical proximity of Patient #R1 or R#2 during the before mention times of Patient #2’s need of all staff assistance. Further, from 8:11 AM to 8:16 AM, S9MHT began outdoor smoke break for patients and did not remain within physical proximity of Patient #R1. A review of staffing for 03/15/2025 day shift revealed 1-RN, 1-LPN and 3 MHTs. A review of Patient Observation Records for Patient #2 and #R1 - #R8 revealed documentation of S6MHT performing patient observations from 8:00 AM to 11:30 AM and being assigned to 1:1 observation of Patient #2 as follows: Patient #2 (1:1): 8:15 AM to 11:30 AM; Patient #R1 (1:1): 8:00 AM to 8:30 AM; Patient #R2 (1:1): 9:30 AM; Patient #R3: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; Patient #R4: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; Patient #R5: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; Patient #R6: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; Patient #R7: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; and Patient #R8: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM. In an interview on 04/15/2025 at 11:30 AM, S1CEO and S2DON confirmed the above mentioned findings and further confirmed staffing was not appropriate on 03/15/2025. S2DON confirmed there was a staff member out with an illness for this shift.”

“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 observation, record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice was evidenced by the failure to ensure the monitoring and observations of 9 (#2, #R1 - #R8) of 9 (#2, #R1 - #R8) patients were appropriately performed and documented. Findings: A review of hospital policy, “PC-1013: Levels of Patient Observation,” with an effective date of 07/10/2012 and a revised date of 07/31/2012, revealed in part: “Policy: All patients are monitored as to their location and activity at regular intervals. The degree of this monitoring is dependent upon the individual patient’s assessed psychiatric condition. Procedure: A) Routine Levels of Observation: 1) All patients are monitored a minimum of every 15 minutes. B) Special Levels of Observation: An increased degree of monitoring is applied to patients whose psychiatric condition is assessed as needing more intense external controls and/or increased frequency of staff contact for patients to be able to maintain their internal controls. Patients assessed as needing any other following increased levels of observations are to be maintained in the hospital. Special Levels of Observation are as follows: 2) One-to-One (1:1) Supervision: a. This is an extreme level of observation reserved for patient who are an imminent suicide risk or whose psychiatric state is that control/safety cannot be maintained otherwise. b. A staff member is assigned to this patient and remains in physical proximity at all times.” A review of the hospital’s staff for 03/15/2025 day shift revealed in part, S7RN, S8LPN, S6MHT, S9MHT and S10MHT. A review of assignments revealed S6MHT was assigned to Patients #2, #R3 -#R8 (all routine level of observation). S9MHT was assigned to Patient #R1 (1:1). S10MHT was assigned to Patient #R2 (1:1). A review of the hospital’s bed board for 03/15/2025 revealed a total of 9 (#2, #R1 - #R8) patients. Patient #R1 and #R2 were identified on this bed board as 1:1 level of observation. A review of Patient #R1’s medical record revealed a provider order on 3/14/2025 for 1:1 level of observation for active suicidal ideations. A review of Patient #R2’s medical record revealed a provider order from 03/14/2025 for 1:1 lever of observation for the level of medical care needed. A review of the hospitals incident logs revealed an incident occurring on 03/15/2025, at an unknown time involving Patient #2. Patient #2 alleged she was sexually assaulted while restrained. A review of recorded video from 03/15/2025 from approximately 8:03 AM to 8:25 AM with S1CEO navigating the computer and S2DON assisting with the identification of employees revealed in part, a situation involving Patient #2 being restrained and removed from Room “c”. During the time of Patient #2 being restrained and transferred to Room “a”, the remaining 8 (#R1 -#R8) patients were in Room “c”. The situation required all staff to control and move Patient #2 to Room “a”. Also, during the time Patient #2 was moved to Room “a” (8:06 AM to 8:07 AM) and during a subsequent interval in which Patient #2 was able to free herself from the restraint chair and the need of all staff to return her to the restraint chair (8:17 AM to 8:20 AM), 2 (#R1, #R2) of 8 (#R1 - #R8) patients were not properly observed per provider orders. Recorded video failed to reveal hospital staff within physical proximity of Patient #R1 or R#2 during the before mentioned times of Patient #2’s need of all staff assistance. Further, from 8:11 AM to 8:16 AM, S9MHT began outdoor smoke break for patients and did not remain within physical proximity of Patient #R1. Other observations of recorded video from 03/15/2025 failed to reveal assigned hospital staff within physical proximity of Patient #R1 during the following time frames: 8:02 AM to 8:10 AM (approximately 8 minutes), 8:11 AM to 8:40 AM (approximately 29 minutes), 8:40 AM to 8:43 AM (approximately 3 minutes), 8:53 AM to 8:56 AM (approximately 3 minutes), 9:06 AM to 9:14 AM (approximately 8 minutes) and 9:16 AM to 9:23 AM (approximately 7 minutes). A review of video recorded on 03/15/2025 from approximately 8:03 AM to 9:40 AM with S1CEO navigating the computer and S2DON assisting with the identification of employees revealed in part, the following times Patient #2 was left unobserved in Rooms “a” and “b” while restrained in the restraint chair: 8:06:34 AM Patient #2’s arrival to Room “a” in the restraint chair; 8:06:52 AM to 8:11:46 AM left un unobserved (approximately 4 min 54 seconds); 8:22 AM, Patient #2 moved in the restraint chair to Room “b” and remained restrained; 8:22 AM to 8:28 AM (approximately 6 minutes) left unobserved in Room “b”; 8:33 AM to 8:49 AM (approximately 16 minutes) left unmonitored in Room “b”; 8:49 AM to 8:52 AM (approximately 3 minutes) left unobserved in Room “b”; 8:53 AM to 9:01 AM (approximately 8 minutes) left unobserved in Room “b”; 9:03 AM to 9:06 AM (approximately 3 minutes) left unobserved in Room “b”; and 9:18 AM to 9:40 AM (approximately 22 minutes) left unobserved in Room “b”. Patient #2 was left unobserved for approximately 54 of the 97 minutes of recorded video reviewed. Per staffing sheet and Patient Observation Record from 03/15/2025, S6MHT was assigned to Patient #2 and was identified on video as the MHT that was partially observing this patient during the before mentioned recorded video review. A review of Patient Observation Records for Patient #2 and #R1 - #R8 revealed the documentation of S6MHT performing patient observations from 8:00 AM to 11:30 AM and being assigned to 1:1 observation of Patient #2 as follows: Patient #2 (1:1): 8:15 AM to 11:30 AM; Patient #R1 (1:1): 8:00 AM to 8:30 AM; Patient #R2 (1:1): 9:30 AM; Patient #R3: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; Patient #R4: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; Patient #R5: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; Patient #R6: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; Patient #R7: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; and Patient #R8: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM. In an interview on 04/15/2025 at 11:30 AM, S1CEO and S2DON confirmed the above mentioned findings, confirmed staffing was not appropriate on 03/15/2025, and confirmed S6MHT (assigned to Patient #2) and S9MHT (assigned to Patient #R1) failed to remain within physical proximity of their assigned patient at all times.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48051 Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by: 1) Failure to ensure there was adequate staff to effectively manage physically aggressive patients (See Findings Tag A0144); 2) Failure to ensure patients did not have access to the nurse’s station and unsecured areas of the building (See Findings Tag A0144); 3) Failure to ensure the patient care area was free of ligature risks (See Findings Tag A0144); 4) Failure to ensure the nurse call system was functioning in 9 (a - j) of 9 (a - j) patient bedrooms and Room “o” (See Findings Tag A0144); and 5) Failure to ensure patients were being monitored per provider order (See Findings Tag A0144).”

“Special Medical Record Requirements CFR(s): Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals The medical records maintained by a psychiatric hospital must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution. This Condition is not met as evidenced by: 48051 Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by: 1) Failure to have documentation of a Master Treatment Plan in 1 (#2) of 3 (#1 - #3) patient medical records reviewed (See Findings Tag A1640); 2) Failure to address a change in condition in 1 (#3) of 3 (#1 - #3) patient’s Master Treatment Plans reviewed (See Findings Tag A1640); and 3) Failure to address the findings of each contributing discipline on 1 (#3) of 3 (#1 - #3) patient’s Master Treatment Plans reviewed (See Findings Tag A1640).”

“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, record review and interview, the hospital failed to ensure the patient received care in a safe setting. The deficient practice was evidenced by: 1) Failure to ensure there was adequate staff to effectively manage physically aggressive patients; 2) Failure to ensure patients did not have access to the nurses’ station and unsecured areas of the building; 3) Failure to ensure the patient care area was free of ligature risks; 4) Failure to ensure the nurse call system was functioning in 9 (a - j) of 9 (a - j) patient bedrooms and Room “o”; and 5) Failure to ensure patients were being monitored per provider order. Findings: 1) Failure to ensure there was adequate staff to effectively manage physically aggressive patients The facility was unable to produce a policy related to a timeframe of when a “Stat” or as soon as possible medication order for an as needed medication should be administered or a policy related to a timeframe of medication administration to assist with patient de-escalation. The facility was also unable to produce a policy related to the procedure to follow when a patient is unable to be physically controlled. A review of hospital policy, “PC-1012: Police/Law Enforcement Assistance & Patients in Custody of Law Enforcement,” with an effective date of 07/10/2012 and no revisions, revealed in part: “Policy: Law enforcement officials will be provided with the opportunity to place his/her weapons in a lock box in an effort to maintain a weapon’s free environment. Procedure: Use of Assistance from Law Enforcement: 1. Upon arrival at the facility, law enforcement officials will be advised of the hospital’s no weapons policy. 2. Law enforcement officials will have the option to place his/her weapons in a provided lock box or retain as part of his/her uniform while on the unit. a. If the law enforcement official chooses to relinquish his or her weapon, the weapon will be placed in the lock box and the officer will retain the key to box while on the unit. b. Law Enforcement Officials electing to exercise the right to retain their weapon on part of their uniform: i. Acknowledge that they understand the hospital maintains a weapons free environment and they choose to retain their uniform weapon despite the hospitals “No Weapon Policy.” ii. Assert that they have been trained in the use and care of their weapon(s) and they choose not to relinquish their uniform weapons while on the psychiatric unit. Instead, they may enter the unit in full uniform (uniform weapons included) in order to assist staff in keeping a patient from causing harm to him/herself or others. iii. The law enforcement department which employs law enforcement officials takes full responsibility for training law enforcement officials in the proper use and care of weapons on a psychiatric unit. 3. In the event law enforcement officials make the decision to use their uniform weapons to ensure safety, staff will not assist law enforcement officials with the use of the weapons. At the time weapon use is required law enforcement will notify staff to leave the area. Staff will step out of room and will re-enter as soon as law enforcement notifies staff it is safe to return to the area.” Observations of recorded video from 11/21/2024 6:51 PM to 7:25 PM revealed Patient #1 standing at the nurses’ station and looking into the window. Patient #1 remains at the window looking through the glass until Sheriff Officer (SO) 1 enters the unit from the nurses’ station door at 6:57:36 PM. SO1 appears to speak with Patient #1 as 4 MHT’s and 1 LPN also approach and surround the patient. At 6:59:57 PM, SO2 enters the unit from the nurses’ station door and begins to speak with the patient. Hospital staff remain within 5-8 feet of the patient. At 7:02:17 PM, SO2 appears to reach for Patient #1 and an ensuing altercation begins. Over the next several minutes the video revealed the interaction of the 2 sheriff officers and hospital staff attempting to hold the patient on the floor as S3LPN administered an injection. After the injection was administered, and while Patient #1 continued to be held on the floor, Patient #1 was able to grab hold of SO1’s weapon while it appeared to remain holstered and pull the trigger. SO1 was struck in the leg by the bullet. The hospital staff immediately ran away from the altercation and left the 2 officers attempting to gain control of Patient #1. SO2 was able to pull the patient’s arms and hands away from SO1’s weapon and restrain Patient #1 in a position that allowed SO2 to retrieve his weapon, place it against Patient #1’s left upper chest and fire his weapon. Patient #1 continues to resist the officers for another 60 seconds until SO2 was able to completely maneuver Patient #1’s hands away from SO1, position Patient #1 face down with his hands behind his back and place handcuffs on the patient. In an interview on 11/26/2024 at 11:20 AM, S3LPN confirmed she was the medication nurse on duty on the night of the above mention incident. She described the situation as she arrived at work on 11/21/2024 at approximately 5:50 PM, Patient #1 was pacing the unit, walking in and out of his assigned room, staring in the nurses station and saying inappropriate things to the staff. She received report of an injection being ordered by S10APRN at 2:15 PM for escalating behaviors, however it was reported the injection had not been administered due to the daytime staff not feeling as if they had an adequate amount of staff to assist with holding the patient to administer the injection. The combined day and night shift staff decided to attempt to administer the injection together. Patient #1 was escorted to his assigned room and the staff attempted to approach Patient #1 and he begin to physically push staff away and assault them. S3LPN indicated Patient #1 pushed her against the wall with his back and begin elbowing her in the chest and head. As he was elbowing S3LPN, Patient #1 also had hold of S9MHT’s hair and was pulling her around by her hair. S3LPN indicated she was eventually able to free herself and S9MHT was able to escape the patient’s hand grip after he pushed her on to the bed. After all staff were able to exit the room, they retreated to the nurses station. SLPN indicated at this point, she made the decision to contact the Sheriff’s Office. S33LPN called the Sheriff’s Office at 6:10 PM. S3LPN indicated S1CEO was contacted and updated, S1CEO instructed the staff to use their de-escalation training to gain control of the patient and administer the injection. S3LPN indicated the staff did not feel comfortable with attempting to gain control of the patient after they had been physically assaulted. At 6:37 PM, S3LPN indicated she made a second attempt to contact law enforcement for assistance and this assistance arrived around 7:00 PM. S3LPN further confirmed upon the Sheriff Officers arrival to the hospital, she made a request to the officers to lock their weapons up and not bring the weapons on the unit, however she indicated the request was not answered or acknowledged. In an interview on 11/27/2024 at 8:15 AM, S1CEO confirmed he was contacted on 11/21/2024 at approximately 6:10 PM regarding Patient #1’s escalating behaviors. He further confirmed he was aware of the patient’s behaviors throughout the day, but he was unaware the medication ordered at 2:15 PM had not been administered. S1CEO confirmed the current staff on duty was not able to effectively manage or physically control Patient #1 and law enforcement was contacted to assist with the physical hold of Patient #1 for medication injection. S1CEO confirmed the hospital had contacted law enforcement in the past to assist with a physical hold of a patient, but S1CEO was unable to provide a date(s) or the actual number of occurrences law enforcement has been contacted for assistance in holding a patient to receive an injection. S1CEO confirmed it is the responsibility of the hospital to provide the necessary staff to effectively control, monitor and/or physically hold their patients. S1CEO confirmed the facility had enough staff on duty according to staffing policy, however it was not enough staff to effectively control, monitor and/or physically hold Patient #1. The nursing staff on the day shift of 11/21/2024 were not available for interview. 2) Failure to ensure patients did not have access to the nurses’ station and unsecured areas of the building Observations during a hospital walk-thru on 11/24/2024 from 1:30 PM to 2:30 PM revealed Rooms “c,” “f,” “j,” “k,” and “m” entry doors were unlocked and unsecured which could allow patients to access these rooms without being monitored and/or observed for safety. In an interview on 11/24/2024 and present during the hospital walk-thru, S1CEO confirmed the above mentioned findings and further confirmed the doors should be locked. Observations of video recorded on 11/21/2024 from 11:20 AM to 11:35 AM revealed the camera view of the interior of the nurses’ station. Patient #3 was standing outside the nurses’ station and appeared to be asking S5LPN a question. The S5LPN retrieves a medical record and allowed the patient to observe a document in the medical record. Then S5LPN opens the door to the nurses station to allow the patient to observe the document and remains in the open doorway while the patient observes the medical record. At 11:24:25 AM, S5LPN and Patient #3 appeared to be conversing as the patient attempts to lunge towards the nurse and enter the nurses’ station. S5LPN was able to prevent the patient from entering and the patient retreats back slightly. S6RN was working at a nearby desk in the nurses station and begins to assist by helping to block the doorway as the conversation continues. S4MHT entered the nurses station and stood behind the 2 nurses. Approximately 6 minutes elapsed with the nurses’ station door in the open position, S5LPN and S6RN standing in the doorway and the patient approximately 1-2 feet in front of them. During this time frame, the video did not appear to physically show any attempt by S5LPN or S6RN to move the conversation away from the open nurses station doorway. At 11:30:01 AM, Patient #3 is observed pushing her way through S5LPN and S6RN. S4MHT attempted to assist however Patient #3 overpowers all 3 staff and made her way to the exit door of the nurses’ station leading the main entrance of the building. Another camera recorded Patient #3 exiting the building at 11:30:18 AM with S4MHT in pursuit. During the before mentioned time frame of the video reviewed, there were no other observable staff seen on video. In an interview on 11/24/2028 at 4:00 PM, S1CEO and S2DON confirmed the recorded video did not appear to physically show any attempt by S5LPN or S6RN to move the conversation away from the open nurse’s station doorway. Further they confirmed the staff have been instructed to not allow the nurses station door to remain open. 3) Failure to ensure the patient care area was free of ligature risks Observations during a hospital walk-thru on 11/24/2024 from 1:30 PM to 2:30 PM revealed loosely secured toilet seats in the restrooms of 9 (a - j) of 9 (a - j) patient bedrooms. This style toilet seat, even when properly secured, created a ligature risk where as an item such as a bed sheet could be passed between the toilet bowl and the toilet seat and used for potential injurious behaviors. Further observations revealed sleigh bed style bed frames (plastic head board and foot board touch the floor and are connected via an above floor plastic platform for mattress placement) in 4 (b, c, e, g) of 9 (a - j) patient bedrooms. This style frame creates multiple ligature risk points that an item such as a bed sheet could be wrap around and used for potential injurious behaviors. In an interview on 11/24/2024 and present during the hospital walk-thru, S1CEO and S2DON confirmed the above mentioned findings. 4) Failure to ensure the nurse call system was functioning in 9 (a - j) of 9 (a - j) patient bedrooms and Room “o” Observations during a hospital walk-thru on 11/24/2024 from 1:30 PM to 2:30 PM revealed the nurse call system not alerting the nurses station when activated in 9 (a - j) of 9 (a - j) patient bedrooms and Room “o.” In an interview on 11/24/2024 and present during the hospital walk-thru, S1CEO and S2DON confirmed the above mentioned findings. 5) Failure to ensure patients were being monitored per provider order A review of hospital policy, “PC-1013: Levels of Patient Observation,” with an effective date of 07/10/2012 and last revised 07/31/2012 revealed in part: “Policy: All patients are monitored as to their location and activity at regular intervals. Procedures: A) Routine Levels of Observation: 1) All patients are monitored a minimum of once every 15 minutes. B) Special Levels of Observation are as follows: 1) Constant Observation: a. a patient is maintained in community areas where they can be observed at all times when the patient’sconditionrequires a more intense levelof observation and contact. b. Patients on a constant observation status must be accompanied if leaving the community area, e.g. to bathroom or to change clothes. c. Documentation of constant observation will be completed on observation sheets.” A review of hospital policy, “PC-1014: Patient Observation Record (15 Minute Check Sheet),” with an effective date of 07/10/2012 and last reviewed 12/27/2021 revealed in part: “Purpose: a designated MHT or other assigned staff will note and document patients’ location and behavior every fifteen minutes on the Patient Observation Record.” Observations of video recorded on 11/21/2024 from 11:20 AM to 11:35 AM revealed the camera view of the interior of the nurses’ station. Patient #3 was standing outside the nurses’ station and appeared to be asking S5LPN a question. The S5LPN retrieves a medical record and allowed the patient to observe a document in the medical record. Then S5LPN opens the door to the nurses’ station to allow the patient to observe the document and remains in the open doorway while the patient observes the medical record. At 11:24:25 AM, S5LPN and Patient #3 appeared to be conversing as the patient attempts to lunge towards the nurse and enter the nurses’ station. S5LPN was able to prevent the patient from entering and the patient retreats back slightly. S6RN was working at a nearby desk in the nurses’ station and begins to assist by helping to block the doorway as the conversation continues. S4MHT entered the nurses’ station and stood behind the 2 nurses. Approximately 6 minutes elapsed with the nurses station door in the open position, S5LPN and S6RN standing in the doorway and the patient approximately 1-2 feet in front of them. During this time frame, the video did not appear to physically show any attempt by S5LPN or S6RN to move the conversation away from the open nurses’ station doorway. At 11:30:01 AM, Patient #3 is observed pushing her way through S5LPN and S6RN. S4MHT attempted to assist however Patient #3 overpowers all 3 staff and made her way to the exit door of the nurses’ station leading the main entrance of the building. Another camera recorded Patient #3 exiting the building at 11:30:18 AM with S4MHT in pursuit. During the before mentioned time frame of the video reviewed, there were no other observable staff seen on video. A review of the hospital records revealed the following staff scheduled at the time of the elopement: S4MHT, S5LPN, S6RN, S7MHT, and S8MHT. A review of the hospital census at the time of the above mentioned elopement revealed 10 patients with the current level of observations: 2 patients on line of sight (LOS) and 8 patients on every 15 minutes. A review of Patients #1 - #10 medical record revealed: Patient #1: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S4MHT; Patient #2: Level of observation ordered: Line of Sight Observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S8MHT; Patient #3: Patient eloped; Patient #4: Level of observation ordered: Line of Sight Observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S7MHT; Patient #5: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S7MHT; Patient #6: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S4MHT; Patient #7: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S8MHT; Patient #8: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S4MHT; Patient #9: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S7MHT; and Patient #10: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S8MHT. The above mentioned observations of recorded video included the timeframe of the above mentioned observation checks on 11/21/2024 at 11:30 AM. S4MHT was observed on video being involved with Patient #3 prior to an elopement and leaving the building in pursuit of Patient #3 at 11:30 AM. The Patient Observation Logs revealed S4MHT initials indicating an observation on 3 (#1, #6, #8) of 10 (#1 - #10) patients at 11:30 AM. This surveyor did not observe any recorded video of S8MHT or S9MHT on the unit during the above mentioned time frame. The Patient Observation Logs revealed S7MHT initials indicating an observation on 3 (#4, #5, #9) of 10 (#1 - #10) patients at 11:30 AM and Patient #4 was a LOS. The Patient Observation Logs revealed S8MHT initials indicating an observation on 3 (#2, #7, #10) of 10 (#1 - #10) patients at 11:30 AM and Patient #2 was a LOS. In an interview on 11/27/2024 at 10:35 AM, S1CEO confirmed the above mentioned observations checks were not performed. S1CEO indicated video review by himself, confirmed S7MHT and S8MHT had left the building at 11:09 AM. S1CEO further confirmed the other 9 patients were not being monitored per physician orders.”

“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 hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by: 1) Failure to document a nursing shift assessment on 2 (#2, #3) of 3 (#1 - #3) patient’s medical record reviewed; 2) Failure to accurately document observation check performance by the mental health techs (MHTs) on 9 (#1, #2, #4 - #10) of 10 (#1 - #10) patients. Findings: 1) Failure to document a nursing shift assessment on 2 (#1, #2) of 3 (#1 - #3) patient’s medical record reviewed A review of hospital policy, “PC-62: Charting-Nursing,” with an effective date of 07/10/2012 and no revisions, revealed in part: “Policy: It is the policy of the nursing department to regularly and accurately record pertinent information on all patients. Procedure: 1) The nurse’s documentation should include the following: a) a chart entry shall be made every shift on every patient.” A medical record review revealed the following: Patient #1: An admission on 11/19/2024 at 3:30 AM and a discharge on 11/21/2024 at 7:32 PM. A review of nursing shift assessments revealed no documentation of a shift assessment being performed on the day shifts of 11/20/2024 and 11/21/2024. Patient #2: An admission on 11/16/2024 at 4:15 AM and a discharge on 11/22/2024 at 12:30 PM. A review of nursing shift assessments revealed no documentation of a shift assessment being performed on the day shifts of 11/16/2024, 11/17/2024, 11/20/2024 and 11/21/2024. In an interview on 11/27/2024 at 1:00 PM, S2DON confirmed the above mentioned findings. 2) Failure to accurately document observation check performance by the mental health techs (MHTs) on 9 (#1, #2, #4 - #10) of 10 (#1 - #10) patients. A review of hospital policy, “PC-1013: Levels of Patient Observation,” with an effective date of 07/10/2012 and last revised 07/31/2012 revealed in part: “Policy: All patients are monitored as to their location and activity at regular intervals. Procedure: A) Routine Levels of Observation: 1) all patients are monitored a minimum of once every 15 minutes. B) Special Levels of Observation: 1) Constant Observation: a. A patient is maintained in community areas where they can be observed at all times when the patient’s condition requires a more intense level of ovservation and contact. b. Patients on a constant observation status must be accompanied if leaving the community area, e.g. to bathroom or to change clothes. c. Documentation of constant observation will be completed on observation sheets.” A review of hospital policy, “PC-1014: Patient Observation Record (15 Minute Check Sheet),” with an effective date of 07/10/2012 and last reviewed 12/27/2021 revealed in part: “Purpose: A designated MHT or other assigned staff will note and document patient’s location and behavior every fifteen minutes on the Patient Observation Record.” Observations of video recorded on 11/21/2024 from 11:20 AM to 11:35 AM revealed the camera view of the interior of the nurses’ station. Patient #3 was standing outside the nurses station and appeared to be asking S5LPN a question. The S5LPN retrieves a medical record and allowed the patient to observe a document in the medical record. Then S5LPN opens the door to the nurses’ station to allow the patient to observe the document and remains in the open doorway while the patient observes the medical record. At 11:24:25 AM, S5LPN and Patient #3 appeared to be conversing as the patient attempts to lunge towards the nurse and enter the nurses’ station. S5LPN was able to prevent the patient from entering and the patient retreats back slightly. S6RN was working at a nearby desk in the nurses station and begins to assist by helping to block the doorway as the conversation continues. S4MHT entered the nurses’ station and stood behind the 2 nurses. Approximately 6 minutes elapsed with the nurses’ station door in the open position, S5LPN and S6RN standing in the doorway and the patient approximately 1-2 feet in front of them. During this time frame, the video did not appear to physically show any attempt by S5LPN or S6RN to move the conversation away from the open nurses’ station doorway. At 11:30:01 AM, Patient #3 is observed pushing her way through S5LPN and S6RN. S4MHT attempted to assist however Patient #3 overpowers all 3 staff and made her way to the exit door of the nurse’s station leading the main entrance of the building. Another camera recorded Patient #3 exiting the building at 11:30:18 AM with S4MHT in pursuit. During the before mentioned time frame of the video reviewed, there were no other observable staff seen on video. A review of the hospital records revealed the following staff scheduled at the time of the above mentioned elopement: S4MHT, S5LPN, S6RN, S7MHT, and S8MHT. A review of the hospital census at the time of the above mentioned elopement revealed 10 patients with the current level of observations: 2 patients on line of sight (LOS) and 8 patients on every 15 minutes. A review of Patients #1 - #10 medical record revealed: Patient #1: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S4MHT; Patient #2: Level of observation ordered: Line of Sight Observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S8MHT; Patient #3: Patient eloped; Patient #4: Level of observation ordered: Line of Sight Observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S7MHT; Patient #5: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S7MHT; Patient #6: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S4MHT; Patient #7: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S8MHT; Patient #8: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S4MHT; Patient #9: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S7MHT; and Patient #10: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S8MHT. The above mentioned observations of recorded video included the timeframe of the above mentioned observation checks on 11/21/2024 at 11:30 AM. S4MHT was observed on video being involved with Patient #3 prior to an elopement and leaving the building in pursuit of Patient #3 at 11:30 AM. The Patient Observation Logs revealed S4MHT initials indicating an observation on 3 (#1, #6, #8) of 10 (#1 - #10) patients at 11:30 AM. This surveyor did not observe any recorded video of S8MHT or S9MHT on the unit during the above mentioned time frame. The Patient Observation Logs revealed S7MHT initials indicating an observation on 3 (#4, #5, #9) of 10 (#1 - #10) patients at 11:30 AM and Patient #4 was a LOS. The Patient Observation Logs revealed S8MHT initials indicating an observation on 3 (#2, #7, #10) of 10 (#1 - #10) patients at 11:30 AM and Patient #2 was a LOS. In an interview on 11/27/2024 at 10:35 AM, S1CEO confirmed the above mentioned observations checks were not performed. S1CEO indicated a video review by himself, confirmed S7MHT and S8MHT had left the building at 11:09 AM. S1CEO further confirmed the other 9 patients were not being monitored per physician orders.”

“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 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: 1) Brown stained ceiling tiles above the entry door of Room “i”; 2) Failure to clean the ventilation system’s return and exit vents of a grey, fuzzy substance resembling dust. Findings: 1) Brown stained ceiling tiles above the entry door of Room “i” Observations during a hospital walk-thru on 11/24/2024 from 1:30 PM to 2:30 PM revealed brown staining of 2 ceiling tiles above the entry door of Room “i.” In an interview on 11/24/2024 and present during the hospital walk-thru, S1CEO confirmed the above mentioned findings. 2) Failure to clean the ventilation system return and exit vents of a grey, fuzzy substance resembling dust. Observations during a hospital walk-thru on 11/24/2024 from 1:30 PM to 2:30 PM revealed the hospital’s ventilation system having a grey, fuzzy substance resembling dust accumulated on the vents located at the sky light of the unit’s main hallway and at the entrance of Rooms “g,” “m” and “p.” In an interview on 11/24/2024 and present during the hospital walk-thru, S1CEO confirmed the above mentioned findings.”

“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: 48051 Based on medical record review and interview, the hospital failed to ensure social services records, including reports of interviews with patients, family members, and others, provided an assessment of home plans and family attitudes, and community resource contacts as well as a social history, were completed according to hospital policy. This deficient practice was evidenced by 2 (#2, #3) of 3 (#1 - #3) patient medical records reviewed having a psychosocial assessment being completed greater than 72 hours after admissions. Findings: A review of hospital policy, “PC-104: Assessments of Patients,” with an effective date of 07/10/2012 and last revised on 12/27/2021, revealed in part, Procedure: The Department specific time frames for assessments are as follows: Psychosocial Assessment, SW (Social Worker), Within 72 hours of admission.” A review of hospital policy, “PC-405: Psychosocial Assessment,” with an effective date of 07/10/2012 and no revisions, revealed in part: “Procedure: 1) A social work will conduct the psychosocial assessment within 72 hours of admission.” A review of medical records revealed the following completion times of the psychosocial assessment: Patient #2 was admitted on 11/16/2024 at 4:15 AM. The psychosocial assessment was submitted on 11/20/2024 at 12:43 PM or approximately 104 hours after admissions. Patient #3 was admitted on 11/21/2024 at 2:15 AM. The psychosocial assessment was submitted on 11/25/2024 at 3:26 PM or approximately 108 hours after admissions. In an interview on 11/27/2024 at 11:15 AM, S2DON confirmed the above mentioned information.”

“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 hospital failed to ensure each patient had an individualized, comprehensive treatment plan based on the inventory of the patient’s strengths and disabilities. This deficient practice was evidenced by: 1) Failure to have documentation of a Master Treatment Plan in 1 (#2) of 3 (#1 - #3) patient medical records reviewed; 2) Failure to address a change in condition in 1 (#3) of 3 (#1 - #3) patient’s Master Treatment Plans reviewed; and 3) Failure to address the findings of each contributing discipline on 1 (#3) of 3 (#1 - #3) patient’s Master Treatment Plans reviewed. Findings: 1) Failure to have documentation of a Master Treatment Plan in 1 (#2) of 3 (#1 - #3) patient medical records reviewed A review of hospital policy, “PC-501: Treatment Plans,” with an effective date of 07/10/2012 and no revisions, revealed in part: “Policy: Each patient will have an individualized inter-disciplinary treatment plan developed under the direction of the psychiatrist. The comprehensive plan is initiated upon admission following assessments by various disciplines and will reflect the individual’s clinical needs, condition, functional strengths and limitations. The treatment plan will be revised throughout the patient’s hospitalization to reflect progress towards the treatment goals. Procedure: A) Problem List: Within 8 hours of admission, a problem list is initiated based on initial assessments. B) Initial Treatment Plan: 1) Within 24 hours of admission, a nurse completes an initial treatment plan that is based on an assessment of presenting problems, physical health emotional and behavioral status. C) Master Treatment Plan: 2) The Master Treatment Plan is based on the findings of each contributing discipline, which describe the patient’s problems, strengths, clinical needs, and the patients goals for treatment. 3) The Master Treatment Plan contains: a) the patient’s diagnosis; b) estimated length of stay; c) the problems to be addressed; d) the strengths to be utilized; e) Long-term goal of treatment for each problem; f) short term goals (objectives) of treatment for each problem, written in objective, and measurable terms with expected dates of achievement stated; g) staff interventions; h) discharged criteria. 7) The Master Treatment Plan includes planning specifically aimed at achieving the patient’s goal(s) of treatment. 8) Each problem of the treatment plan is addressed, updated, revised, or resolved, and documented weekly during treatment team. 10) All newly identified patient problems or diagnosis will be incorporated into the plan of care and the treatment plan will be modified to reflect these changes.” A review of hospital policy, “PC-1201: Master List of Standards-NIMH,” with an effective date of 07/10/2012 and no revisions, revealed in part: “Policy: C) Each patient must have an individual comprehensive treatment plan that must be based on an inventory of the individual patient’s strengths and disabilities. 1) The written treatment plan must include: g) The plan should state: who is responsible for carrying out the plans by name and discipline; k) Interdisciplinary participation in treatment planning.” A medical record review of Patient #2 revealed an admission of 11/16/2024 through 11/22/2024. A form titled, “Master Treatment Plan Cover Sheet” was signed and dated by Patient #2 on 11/16/2024. The attending physician signed on 11/19/2024 indicating the Problem List, Treatment Plans, and Master Treatment Plan were reviewed. The other Participants included the signature of 2 RN’s. There was no signature related to social services participation on this form. A form titled, “Treatment Team Plan Review,” signed by the physician and nurse on 11/19/2024, but no social services signature indicating participation. The Psychosocial Assessment was submitted on 11/20/2024 (day after treatment team meeting). The medical record did not reveal the documentation of a Problem List or Master Treatment Plan. In an interview on 11/27/2024 at 11:00 AM, S2DON confirmed the above mentioned information and further confirmed she contacted Social Services regarding the above mentioned information and S11DSS confirmed there was no documentation of a Problem List or a Master Treatment Plan being completed for Patient #2. 2) Failure to address a change in condition in 1 (#3) of 3 (#1 - #3) patient’s Master Treatment Plan reviewed A review of hospital policy, “PC-1-15: Elopement Risk Assessment and Precautions,” with an effective date of 07/10/2012 and revised 08/25/2021, revealed in part: “Procedure: All protocols and precautions implemented for a patient at risk for elopement or escape shall be documented in the patient’s treatment plan.” A medical record review of Patient #3 revealed an elopement occurring on 11/21/2024 at approximately 11:30 AM. A review of Patient #3 Master Treatment Plan did not reveal any documentation of the patient’s change in condition or protocols and precautions implemented for a patient at risk for elopement or escape. In an interview on 11/27/2024 at 10:30 AM, S2DON confirmed the above mentioned information. 3) Failure to address the findings of each contributing discipline on 1 (#3) of 3 (#1 - #3) patient’s Master Treatment Plans reviewed A review of hospital policy, “PC-1201: Master List of Standards-NIMH,” with an effective date of 07/10/2012 and no revisions, revealed in part: “Policy: C) Each patient must have an individual comprehensive treatment plan that must be based on an inventory of the individual patient’s strengths and disabilities. 1) The written treatment plan must include: a) a substantiated diagnosis; b) the responsibilities of each member of the treatment team; g) The plan should state: who is responsible for carrying out the plans by name and discipline; k) Interdisciplinary participation in treatment planning.” A medical record review of Patient #3 revealed an admission on 11/21/2024 at 2:15 AM. Patient #3 was admitted for a primary diagnosis of unspecified schizophrenia spectrum and other psychotic disorder and a secondary diagnosis of methamphetamine use disorder, moderate. The Master Treatment Plan was initiated on 11/21/2024 at 4:21 AM by S12RN and included: Problem #1: Mild Cognitive Impairment and Problem #2: At risk for increased anxiety. The Master Treatment Plan was not inclusive of the current diagnosis and did not reflect social services involvement after social services assessments. In an interview on 11/27/2024 at 10:30 AM, S2DON confirmed the above mentioned information.”