Kalamazoo Behavioral Health Hospital

“Special Staff Requirements CFR(s): Condition of Participation: Special Staff Requirements for Psychiatric Hospitals The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning. This Condition is not met as evidenced by: 53399 Based on interview and record review, the facility failed to allow for staffing adjustments in accordance of Federal Regulation §482.62 “Special Staff Requirements for Psychiatric Hospitals” and facility policy “Clinical Staff (Nurse) Staffing Plan” in relation to volume and acuity of patients resulting in the increased likelihood of negative outcomes for all patients. Findings include: On 05/20/2026 at 1012 Registered Nurse Staff K was queried about facility staffing, the admission process and weather staffing is ever adjusted based on the acuity of the units. Staff K stated, “We are not involved in the admission process, sometimes we will get a report, but patients usually just show up.” “Staffing is good while you guys are here, but that is not even close to normal.” Staff K further stated, “We strive to put new patients with patients we think will work well together and be safe, but we cannot do that because the admitting people, who are from another state, just send them to us and we never know what’s going on.” Staff K was asked if the Director of Nursing ever adjusts staffing based on higher acuity situations. Staff K stated well I was shown an “acuity tracking thing”, but I was told that they were not allowed to use it, the CEO is the only person who can block a room or bed. “Corporate just disregards any processes management tries to implement for us here.” On 05/20/2026 at 1215 Nurse Practitioner Staff G was queried about the admission process. Staff G stated, “I never get called about an admission, about 75% of the time, I get notified by a Teams provider message.” “Our Medical Director Staff E, has told the admissions team that a patient was not appropriate for here, but the admissions team sends the patient anyways.” Staff G stated, “I do not feel safe here as a provider.” “I recently has a patient I had made a 1:1 and someone took him off 1:1, I assume because of staffing, and the patient urinated on a female patients face while she was asleep in bed and they had him arrested and I guess he is in jail now.” “ I didn’t even want to come to work because I don ’ t feel safe here.” 05/21/2026 at 1400 Director of Nursing Staff B was queried about the admission process and if patient acuity was a factor in staffing numbers. Staff G stated. “According to our policy patient acuity is supposed to be a factor in staffing, and as the Director of Nursing, I am ultimately responsible for staffing in the facility. I created an acuity tool that addresses acuity for adjusting staffing, but corporate leadership will not allow me to use the tool.” Staff G was further queried, are you involved in evaluating patient acuity on admissions and are you allowed to adjust staffing based on admitting acuity? Staff G stated, “I am not really involved in admissions.” “Corporate administration has not allowed me to adjust staffing based on acuity.” Policy: “Clinical Staff (Nurse) Staffing Plan” identified the following: “The Hospital recognizes that each patient is a unique human being and is to be evaluated for acuity and treated on an individual basis.” “Patient acuity will be reviewed based on the ability to complete activities of daily living (ADLs), risk assessments, and the behaviors and needs of the medical/psychiatric patient.” “Staffing will be based on a Core Staffing matrix and augmented when the patient acuity is high, based on the decision of hospital administration.” “Acuity that deviates from the projected needs is assessed and accommodated in the shift-to-shift allocation of staff. In addition to acuity, including patient diagnosis, age, functioning of the patients, co-occurring conditions, physical care, equipment, technology, emotional support, education for self-care, social needs, discharge planning and patient safety are considered.” 53475 On 5/20/2026 at 1021, Registered Nurse (RN) Staff N expressed concern about ongoing staffing shortages, noting that one RN assigned to up to 16 patients could not adequately address the needs of patients who may be at risk for falls, behavior issues or other acuity related challenges. Staff N stated, “staffing was low in the last 2 weeks” on a unit accepting patients who are geriatric and have medical complex needs. On 5/20/2026 at 1225, Nurse Practitioner (NP) Staff G was asked about fall prevention strategies and corresponding interventions. Staff G stated, “No fall risk precautions were observed out there;” staff is not educated to these. Staff G further reported that the Intake Department does not notify providers of new admissions prior to their arrival on the unit. According to Staff G, “patients just come,” without prior interdisciplinary communication or preparatory collaboration, limiting the ability of the facility staff to appropriately plan for adequate staffing levels or proactively address patient acuity needs, including implementation of fall prevention strategies and interventions. On 5/21/2026 at 1214, the Director of Nursing Staff B was queried about staffing ratios. Staff B stated that staffing ratios were determined solely by the number of patients on the unit, not by medical complexity or acuity, per corporate direction. Staff B explained that staffing required one staff member, either a Registered Nurse (RN) or a Behavioral Health Tech (BHT), for every four patients during the day and every eight patients at night, with at least one RN assigned to each unit at all times. When asked whether staffing could be adjusted based on patient acuity, such as for individuals with elevated fall risk scores, Staff B reported that corporate leadership did not permit for such adjustments. Staff B stated that an acuity tool had been developed but corporate leadership did not allow the use of the tool. Staff B was asked whether they participated in evaluating patient acuity upon admission and whether staffing could be adjusted in response to that acuity. Staff B stated they were “not really involved in admissions” and reported that “corporate leadership will not allow me to increase staffing based on acuity.” Staff B also expressed concern that one- to-one observations for high risk patients were frequently discontinued prematurely to maintain minimum staffing levels on the unit. At 1613, Staff B shared that the facility had experienced a nursing turnover rate of 288 percent over the past year due to challenging working conditions at the facility. On 05/21/2026 at 1005, during an interview with the Director of Quality & Compliance Staff A and the Director of Nursing Staff B, the facilities’ fall data trends were reviewed and revealed the following: Month Unit Unit Unit Unit Total (2026) 100 200 300 400 January 4 4 8 February 1 7 3 1 12 March 1 6 2 4 13 April 1 7 8 12 28 through 1 14 6 21 May 16 Total 4 38 13 27 82 The monthly fall data for Units 100 through 400 from January 2026 through May 16, 2026, demonstrated a progressive increase in falls over time, rising from 8 in January 2026 to a peak of 28 falls in April 2026. The consistently elevated fall trends on Unit 200 designed for geriatric and medical patients, and the significant spikes observed on Unit 400 in April 2026, indicated unit specific increases in falls and Staff A and Staff B confirmed these findings. On 5/21/2026 at 1005, a review of 10 patients (P-8, P-9, P-10, P-11, P-12, P-13, P-14, P-15, P-16, P-17) revealed also that P-8, P-9, P-14 and P-17 had falls with varying degrees of injury. P-17 also had a broken hip after an unwitnessed fall. Review of the facility’s policy “Clinical Staff (Nurse) Staffing Plan” effective 08/2022, states: “PURPOSE: This policy is to establish guidelines for providing sufficient numbers and mix of staff necessary to provide multi-disciplinary patient care that is consistent with the assessed needs of the population served and associated plan of care. The Hospital recognizes that each patient is a unique human being and is to be evaluated for acuity and treated on an individual basis. The ability to predict nurse staffing requirements based on projected patient care needs is not an exact science. POLICY: A. A minimum staffing level system is used at the hospital to appropriately staff in compliance with federal, state and regulatory requirements. The Director of Nursing (DON) shall ensure that a staffing plan is established, implemented, documented and annually reviewed and revised as needed. B. Patient acuity will be reviewed based on the ability to complete activities of daily living (ADLs), risk assessments, and the behaviors and needs of the medical/psychiatric patient. C. Staffing will be based on a Core Staffing matrix and augmented when the patient acuity is high, based on the decision of hospital administration. D. The DON is accountable to ensure a sufficient number of qualified staff members are on duty at all times to provide patients with quality care. The DON has the final responsibility and accountability of approving usage of supplemental nursing staff. E. All patient care personnel are expected to remain on duty until adequate relief is available. F. The DON maintains 24-hour accountability for adequate staffing with responsibility for each shift delegated to a member of the Nursing Leadership Team. Specific staffing for the facility will be commensurate with the care requirements, staff expertise, availability of support services, and method of patient care delivery.””

“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: 53399 Based on interview and record review, the facility failed to provide a prescribed medical device (BIPAP) for 1 (P-3) of 1 patient reviewed for BIPAP use, and failed to implement fall risk interventions for 2 (P-8, P-9) of 3 patients reviewed for falls, resulting in the potential for physical harm. Findings include: On 02/20/2026 a preadmission physical assessment from the acute care setting was identified in P-3’s medical record findings included Chronic Obstructive Pulmonary Disease (COPD), History of Pulmonary Embolism, and Obstructive Sleep Apnea (OSA) on BiPAP. On 02/28/2026 at 2300 identified documentation in the “Daily Nursing Assessment” “Per report, patient is BIPAP dependent. This night as an alternative, patient placed on 2 liters per minute (LPM) oxygen via nasal canula.” 03/01/2026 at 1114 Registered Nurse Staff Q documented in the “Daily Nursing Narrative”, “Patient returned from (Acute ED) at 0934. (P-3) is insistent she is on a BIPAP at home for nights and she is concerned about not having her BIPAP, she states she gets confused when she is without it.” On 03/03/2026 at 1530 a handwritten letter by P-3, included in the medical record stated, “I am requesting discharge from (Facility) so that I can pay my rent, and get back into the community. I am not a threat to others or myself. I would like to go home so I can use my BiPAP. I get headaches when I don ’ t use it.” On 03/07/2026 A review of P-3’s medical record revealed that an oxygen concentrator and BIPAP machine with carrying case was added to P-3’s Patient Personal Effects Inventory and then signed out by the discharging staff on 03/11/2026 upon discharge. P-3 which was not provided for P-3. 03/08/2026 at 2011 Nurse Practitioner Staff W documented, “Nursing staff report that she has been profane, yelling, and demanding on the unit, largely focused on frustration regarding the inability to use a BiPAP device at this facility. She continues to demonstrate irritability and limited capacity for redirection when discussing this issue. The patient also reports chest congestion and difficulty breathing at night, which appears to be contributing to her distress and agitation.” On 05/21/2026 at 1100 a Teams (Electronic messaging platform) interview was conducted with Medical Director Staff E. Staff E was queried if they were aware of the concerns related to P-3 and the inability to accommodate their BIPAP needs? Staff E stated that he was unaware of the situation with P-3. Staff E was provided with a brief clinical overview of P-3 including past medical history and was asked, in his medical opinion, was placing a patient on oxygen at 2 liters per minute in lieu of BIPAP appropriate. Staff E stated, “No that would not be appropriate and just wouldn’t make sense, it’s not the same thing.” Staff E stated that he is not aware of any quality tracking being done to evaluate patients needing to be transferred to the acute care setting related to not meeting a patient’s medical needs but identified that they would begin monitoring going forward.” Policy: “CPAP (BiPAP) policy” Indications: Patients who use CPAP device at home, Patients with Obstructive Sleep Apnea, Patients without artificial airways who exhibit medically unacceptable or worsening hypoxemia despite administration of supplemental oxygen. Addendum: Patients who bring their CPAP device from home will be monitored and provided with supplemental oxygen as prescribed by a physician. Patients with a home CPAP device will need to have appropriate orders written by their assigned inpatient physician. Full face mask may only be worn on the unit if it is part of the patient’s home equipment is already setup. 53475 For P-8: On 05/20/2026 at 1400, a targeted review of P-8’s medical record revealed: P-8, an 88 year old female, presented to the facility on 04/12/2026 with bipolar disorder (mental health condition marked by significant fluctuations in mood, energy, and activity), anxiety, mania (a distinct period of abnormally elevated, expansive, or irritable mood), and dementia. According to the admitting hospital, P-8 lacked insight and demonstrated poor judgment. P-8 also presented with multiple chronic medical concerns, including but not limited to a history of coronary artery disease (heart problem), restless leg syndrome, and frequent falls. On 4/29/2026 at 1355, P-8 was found in their room following an unwitnessed fall. P-8 was transported to the ED and diagnosed with a right sided hip fracture. P-8 did not return to the facility following this incident. On 04/12/2026 at 0818, the Pre Admission Assessment for P-8, generated by the facility’s Intake Department, showed that P-8 required “Stand by Assist” (a person readily available to assist), was ambulatory, was identified as a low fall risk, and indicated that no assistive devices were required. No “Stand-by Assist” documentation could be located in the medical record. On 4/12/2026 at 1750, the Admission Nurse to Nurse Report identified P-8 under precautions/observations as a “fall risk” assigned to the 200 Unit, a medical unit. On 04/12/2026 at 2000, the Unit Registered Nurse (RN) documented that P-8 reported using a walker at home but had not brought it to the facility. A walker was ordered on 04/13/2026. On 04/12/2026 at 2010, the Admission Nurse scored P-8 as a “high fall risk” on the Morse Fall Scale (tool used to assess a patient’s risk of falling). The Nurse Practitioner Notes for the time frame 04/13/2026 through 04/29/2026 showed: o “Mental Status: Poor insight/judgement o Family/Internal Medicine Assessment Plan and Past Medical History: Frequent falls” The Daily Nursing Assessments from 4/12/2026 through 4/29/2026 showed fluctuating fall risk scores and inconsistent documentation of constant assessment factors that should remain stable, including history of prior falls, secondary diagnoses, use of ambulatory aids. P-8 should have always been a High Fall Risk based on: History of falling (25 points (pts)) and secondary diagnosis (15 pts) and ambulatory aid (walker) (15pts) = 55 pts/high fall risk. Date: 1st Shift Assessment: 2nd Shift Assessment: 4/27/2026 Low /Mod Risk No Risk 4/26/2026 High Risk High Risk 4/25/2026 High Risk High Risk 4/24/2026 High Risk High Risk 4/23/2026 No assessment found No assessment found 4/22/2026 High Risk High Risk 4/21/2026 High Risk Low/Mod Risk 4/20/2026 High Risk High Risk 4/19/2026 Low /Mod Risk Low /Mod Risk 4/18/2026 High Risk High Risk 4/17/2026 High Risk High Risk 4/16/2026 High Risk High Risk 4/15/2026 High Risk High Risk 4/14/2026 High Risk No Risk 4/13/2026 Low Risk No Risk On 05/21/2026 at 1005, during an interview with the Director of Quality & Compliance Staff A and the Director of Nursing Staff B, the Safety Event Report for P-8 was reviewed, which described the patient’s condition as “lost balance while using walker.” Review of the Behavioral Health - Patient Observation Sheet for 4/29/2026 indicated that no fall risk precautions were implemented despite P-8 consistently receiving “High Risk” scores on the Morse Fall Scale for the stay at the facility. On 5/21/2026 at 1444, RN Staff I was interviewed regarding P-8’s fall. Staff I recalled the patient and confirmed that the event was an unwitnessed fall. Staff I was responsible for 15 or 16 patients that day, supported by three Behavioral Health Techs (BHT’s). Staff I stated that the medical and psychological patient acuity on the 200 Unit was high and that “we could have used another nurse on the unit.” Staff I noted that not all BHTs were adequately trained to handle complex patients, and reported that given the level of behavioral issues and patient complexity/acuity on the unit, conditions could have been “better managed” with an additional RN to support patients. Staff I described the unit environment as “very stressful” and was glad that P-8 was transferred to another facility to address the medical needs caused by the fall. For P-9: On 05/20/2026 at 1500, a targeted review of P-9’s the medical record revealed: P-9, a 79 year old female, was admitted to the facility on 04/29/2026 at 1640 from a local Emergency Department (ED). P-9 arrived using a wheeled walker and experienced confusion, hallucinations and had documented diagnoses of dementia, depression, schizophrenia (mental disorder that affects a person’s thoughts, emotions, and behaviors), suicidal ideations and a wide variety of other chronic medical conditions. On 5/2/206, P-9 had a witnessed fall where P-9 “just buckled and fell right on her bottom” and was sent to the acute care hospital. Upon survey exit, P-9 had not returned to the facility. On 04/12/2026 at 0818, P-9’s Pre Admission Assessment, generated by the facility’s Intake Department, showed P-9 as independent, ambulatory; a moderate fall risk using an assistive device (walker). The Daily Nursing Assessments from 4/29/2026 through 5/4/2026 showed fluctuating fall risk scores and inconsistent documentation of constant assessment factors that should remain stable, including history of prior falls, secondary diagnoses, use of ambulatory aids. P-9 should have always been a High Fall Risk based on: History of falling (25 points (pts)) and secondary diagnosis (15 pts) and ambulatory aid (walker) (15pts) = 55 pts/high fall risk. Date: 1st Shift Assessment: 2nd Shift Assessment: 4/29/2026 N/A Low/Mod Risk 4/30/2026 No Risk Low/Mod Risk 5/1/2026 High Risk High Risk 5/2/2026 High Risk No assessment Had an unanticipated fall 5/4/2026 No assessment No assessment The Behavioral Health - Patient Observation Sheets from 4/29/2026 through 5/2/2026 showed that P-9 was never placed on fall precautions despite shift assessments indicating that fall prevention and interventions were warranted. On 5/21/2026 at 1000, during an interview with The Director of Quality & Compliance Staff A and the Director of Nursing Staff B, the Safety Event Report for P-9 was reviewed. P-9’s condition was described as “fall with sendout (sic), concern for stroke due to neurological stroke-like symptoms (facial drooping, difficulty talking, lessened movement on one side.” According to the documentation, P-9 was “known as fall risk with 2 falls same day, patient with stroke-like symptoms” on 5/2/2026. Only one fall was documented. P-8 and P-9: During unit observations on 5/20/2026 from 0906 to 1030, with the Director of Quality & Compliance Staff A and the Director of Nursing Staff B, several staff members were asked about the Morse Fall Risk Score (score that determined the likelihood of a fall), including their understanding of its rating categories and the required interventions associated with each score. The Morse Fall Scale includes the following rating levels: No Risk 0-24 Points Low/Mod Risk 25-45 Points High Risk >45 Points On 5/20/2026 at 1021, RN Staff N was queried about fall risk prevention strategies and interventions and accurately explained the general components of the Morse Fall Risk Score. Staff N identified that patients assessed as “High Risk” were assigned a red wristband and provided non-slip socks. Staff N was unable to distinguish between “No Risk, Low/Moderate Risk, and High Risk” categories in terms of required follow up interventions. Staff N was not able to articulate fall prevention strategies outside of providing a wrist band and socks. Staff N did not know how to locate the facility’s Fall Prevention policy. On 05/20/2026 at 1027, Behavioral Health Tech (BHT) Staff L was queried about fall prevention strategies and interventions, similar to Staff N, Staff L was not able to articulate the required fall prevention strategies and interventions and reported that no training had been provided. Staff L also stated that no training had been received on how to enter an incident report for a patient who experienced a fall. On 5/20/2026 at 1225, Nurse Practitioner (NP) Staff G was asked about fall prevention strategies and interventions. Staff G stated that “No fall risk precautions were observed out there.” Staff G also reported that the Intake Department did not notify providers of new admissions prior to unit arrival. According to Staff G, “patients just come,” without prior collaboration or advanced notice to allow facility staff to prepare for staffing and patient needs, including necessary fall prevention strategies or interventions. Staff G expressed safety concerns for staff and patients. On 5/21/2026 at 1214, the Director of Nursing Staff B was asked whether RNs and BHTs received training in Fall Prevention (strategies and interventions) including aspects such as gait instability challenges, transfer safety, the use of assistive devices (such as crutches and walkers), delirium and cognitive changes, and gait related precautions (such as braces and boots). Staff B stated that RNs learned some of these skills in nursing school and that the facility had certain competencies in place to support the care of gait impaired or medically complex patients. Staff B further clarified that BHTs, the non-licensed personnel, were “not trained” in these areas. On 5/21/2026 at 1000, a review of the Fall Log with the Director of Quality and Compliance Staff A revealed that the facility recorded 82 falls from 1/1/2026 through 5/16/2026. These included 4 falls on the 100 Unit, 38 on the 200 Unit, 13 on the 300 Unit, and 27 on the 400 Unit. The 200 and 400 Units were identified as units serving patients with psychological and medical conditions. Year 2026 Unit 100 Unit 200 Unit 300 Unit 400 Total January 4 4 8 February 1 7 3 1 12 March 1 6 2 4 13 April 1 7 8 12 28 May 16 1 14 6 21 Total 4 38 13 27 82 Review of the facility’s policy “Fall Prevention Program” effective 04/2023, states: “It is the policy of the Hospital to assess and appropriately identify patients who are at risk for possible falls while hospitalized. A Fall Prevention Program will be implemented and maintained to assure the safety of all patients admitted to the facility. The program will be inclusive of measures which determine the individual needs of each patient by assessing the risk of falls, and implementation of appropriate staff interventions to assure a safe environment is maintained, adequate supervision is provided, and assistive devices are utilized when necessary. All falls occurring during hospitalization will be evaluated to determine the potential causative factors and discern appropriate interventions ... 3. Patients who score a low risk for falls (scoring ? 24 on the Morse Fall Scale) will be monitored. Will be wearing green socks or their own socks and shoes.4. Patients who score a moderate risk for falls (scoring 25-44 on the Morse Fall Scale) and high risk for falls (scoring 45 and higher on the Morse Fall Scale) will receive red colored non-skid socks, as well as any other potential interventions. 5. Fall precautions will be added to the Admission Orders.6. All patients who are on seizure precautions will automatically be placed on fall precautions at the high-risk level. 7. Non-licensed nursing staff will ensure all interventions are in place each shift.” The policy did not specify what additional fall-risk interventions were expected or available for different levels of fall severity.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 53399 Based on interview and record review, the facility failed to prevent the use of an improper restraint resulting in injury for 1 (P-1) of 7 patients reviewed resulting in the increased likelihood of negative outcomes for P-1. Findings include: On 05/20/2026 at 0800 Registered Nurse Staff Q was queried about an allegation of abuse related to P-1 on 02/23/2026 at 1700. Staff Q stated, “P-1 was having some behavioral issues and two nurses, and a behavioral health tech were having trouble getting them into isolation because (P-1) was fighting them.” “One of the BHA’s pulled P-1’s shirt over their head to prevent P-1 from hitting staff, then one of the nurses put P-1 into a chokehold that left bruises.” On 02/23/2026 at 1720 a Physician order was documented in the medical record, “Restraint Order for Seclusion and Emergency Medications” signed by Nurse Practitioner Staff KK for seclusion and Zyprexa 10mg administered Intramuscularly (IM). Restraint in time was 1720 and restraint out time was documented as 1820. On 02/25/2026 at 0831 Behavioral Health Technician documented in their “Shower/Care Sheet” “Skin issues (Bruising) related to patient self-harming and placed into physical management to seclusion on 02/23/2026, providers aware day of incident.” On 05/21/2026 at 1400 the investigation file was reviewed with Director of Nursing Staff B. The original closed-circuit file used for the investigation was not retained by the facility and the Recipient Rights representative involved in the investigation Staff U is no longer employed with facility. Staff B acknowledged that counseling for improper restraint type was provided for Registered Nurse Staff R. Director of Quality Staff A “discussed what is acceptable and what is not with regards to Handle with Care, and how it is not acceptable to put a shirt over the top of a patient’s face. In the investigation file, Behavioral Health Technician Staff V identified “I was on 300 Hall, a code green went off on 100 so I went to the 100 Hall to help. We were short staffed that day and I stayed over to help.” Staff V was asked by Director of Nursing Staff B and Director of Quality Staff A if they recalled a code green debriefing being held after the event. Staff V was further quoted as stating, “yes, I was wondering why they pulled a shirt over (P-1’s) head, and I remember trying to snatch it off and I thought it was a bit much.” On 05/21/2026 at 1400 Director of Nursing (DON) Staff B was queried about the incident involving P-1. Staff B stated that a full investigation was conducted, and 3 staff members were suspended pending the outcome of an investigation. Staff B identified that all 3 staff members were allowed to return to work, and that no disciplinary action was added to their files. Staff B stated that the suspension letters were included in their employee files. Staff B was asked, do you believe that the actions of the staff in the “Code green” (Deescalating and/or restraint / Seclusion) of an aggressive Patient constituted patient abuse. Staff B stated, “Yes, I do believe that it was patient abuse.” Staff B was further queried, if you believed their actions rose to the severity of patient abuse, why were no official disciplinary actions rendered and their actions not reported to the State licensing board. Staff B stated that “it was the decision of Human Resources and the Corporate leadership team that the suspended staff all be brought back without disciplinary action.” “I was overruled on the decision.””

“DIETS CFR(s): 482.28(b)(2) All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to order a specialty diet for a patient with dietary restrictions for 1 (P-4) of 4 patients reviewed with dietary restrictions resulting in the increased likelihood of negative outcomes for the patient. Findings include: On 5/21/2026 at 1010, Nurse Practitioner Staff W was queried as a provider, for new admissions from another facility, were they expected to review the transport information in the documentation provided from the other facility, Staff W said “yes.” On 5/20/2026 at 1445, P-4’s medical record was reviewed. P-4 was admitted on 12/13/2025 with an origin of admission “Transfer from a (Facility) (Different Facility).” A review of P-4’s transport information revealed that P-4 had past medical diagnoses including: - Bipolar 1 disorder - No known health problems - Phenylketonuria - Schizophrenia On 12/14/2025 at 0530, P-4’s admission orders revealed that for “Nutrition/Diet,” P-4 had a “Regular Diet” with “Thin” liquids ordered. There were no additional orders to change or modify P-4’s diet during P-4’s admission. A review of P-4’s Patient Daily Care Forms revealed on: - 12/14/2025 P-4 ate 100% breakfast, 100% lunch, 100% dinner, and 100% snack - 12/15/2025 P-4 ate 100% breakfast, 75% of lunch, 100% dinner, and 100% snack. - 12/16/2025 P-4 ate 100% breakfast, 100% lunch, 100% dinner, and 100% snack - 12/17/2025 P-4 ate 100% breakfast, 100% lunch, 100% dinner, and 100% snack - 12/18/2025 P-4 ate 100% breakfast, 100% lunch, 100% dinner, and 100% snack - 12/19/2025 P-4 ate 80% lunch and 80% dinner - 12/20/2025 P-4 ate 100% breakfast and 100% dinner On 12/21/2025 at 1900 P-4’s Internal Medicine note revealed “patient d/c (discharge) due to being admitted to (facility). Unknown at this time what caused admission.” On 12/21/2025 at 1932, P-4’s Daily Nursing Assessment revealed “At 1615 patient was assisted onto the toilet. At the next check 1630, patient was found to have a change in mentation and was drooling and was breathing heavily and quickly.” The note also revealed “provider contacted and patient transported to (another facility) at 1710.” On 5/21/2026 at 1500, Director of Quality Staff A was queried if they expected that a dietary order to address P-4’s dietary restriction for PKU (Phenylketonuria) be ordered rather than a regular diet order, Staff A said “yes” and confirmed the facility identified that P-4 had specific dietary restrictions “during an audit” after P-4 was discharged. On 5/19/2026 at 0840, a policy on Dietary Specialty diets was requested at entrance and the facility failed to upload the policy at the time of exit.”

“Treatment Plan - Team Responsibilities CFR(s): [The written plan must include] The responsibilities of each member of the treatment team; and This Standard is not met as evidenced by: 53475 Based on interview and record review, the facility failed to document and ensure that treatment team meetings were conducted with the team members primarily responsible for patient care to support compliance with individualized fall prevention strategies and interventions for 2 (P 8, P 9) of 2 patients reviewed, resulting in the facility’s inability to re- evaluate care needs and prevent harm from falls. Findings include: For P-8: On 05/20/2026 at 1400, a targeted review of P-8’s the medical record revealed: P-8, an 88 year old female, presented to the facility on 04/12/2026 with bipolar disorder (mental health condition marked by significant fluctuations in mood, energy, and activity), anxiety, mania (a distinct period of abnormally elevated, expansive, or irritable mood), and dementia. According to the admitting hospital, P-8 lacked insight and demonstrated poor judgment. P-8 also presented with multiple chronic medical concerns, including but not limited to a history of coronary artery disease (heart problem), restless leg syndrome, and frequent falls. On 4/29/2026 at 1355, P-8 was found in their room on the 200 Unit following an unwitnessed fall. P 8 was transported to the ED and diagnosed with a right sided hip fracture. P-8 did not return to the facility following this incident. On 4/12/2026, the Initial Treatment Plan, completed by the Admission Nurse, showed that P-8 was identified as a “Fall Risk” by nursing and would require the use of a walker due to a “weak gate.” On 04/18/2026 at 0809, P-8’s interdisciplinary Master Treatment Plan, which was signed and dated, showed a review of identified problems by Social Services and the Physician. A Registered Nurse (RN) did not attend the interdisciplinary meeting, nor was documentation of the patient’s fall risk status evident in the Master Treatment Plan. This meeting was intended to support coordinated care by addressing “physical health, emotional status, and behavioral status” (Facility Policy: Patient Treatment effective 09/2022) through collaboration among Nursing, Social Services, Recreational Therapy, the Physician, and other relevant care team members. The Interdisciplinary Master Treatment Plan was signed by the Physician, the Social Worker but not the RN. For P-9: On 05/20/2026 at 1500, a targeted review of P-9’s the medical record revealed: P-9, a 79 year old female, was admitted to the facility on 04/29/2026 at 1640 from a local Emergency Department (ED). P-9 arrived using a wheeled walker. P-9 experienced confusion, hallucinations, and had documented diagnoses of dementia, depression, schizophrenia (mental disorder that affects a person’s thoughts, emotions, and behaviors), suicidal ideations and a wide variety of other chronic medical conditions. On 5/2/206, Nurse Practitioner Staff CC stated in the Internal Medicine Assessment that P-9 had a witnessed fall where P-9 “just buckled and fell right on her bottom.” Upon exit from the facility, P-9 had not returned to the facility. On 4/29/2026, P-9’s Initial Treatment Plan was not completed by the Admission Nurse. The fall risk was not addressed nor was it carried forward for interdisciplinary collaboration with the remaining Treatment Team (Social Work, Physician, and other pertinent care team members). Additionally, no Master Treatment Plan was created; no interdisciplinary collaboration regarding fall prevention strategies and interventions occurred. For P-8 and P-9: On 05/21/2026 at 1225, the Director of Nursing, Staff B, was queried regarding RN attendance at Interdisciplinary Treatment Plan meetings. Staff B reported that RNs completed the Initial Treatment Plan at admission but were unable to attend subsequent Master Treatment Plan meetings to provide updates and adjustments due to low RN staffing on the unit. On 5/21/2026 at 1444, RN Staff I was interviewed and stated that due to low RN staffing, Staff I has not attended Treatment Team Meetings. Staff I recognized the importance of having treatment team meeting input to support individualized fall prevention strategies and interventions. Review of the facility’s policy “Patient Treatment” effective 09/2022, states: “Each patient shall have a written, comprehensive, individualized treatment plan that is based on assessment of his/her medical, clinical and nursing needs. Individualized treatment planning shall be based on patient need. A. Patients have the right to ongoing participation in their treatment plan. B. Patients have the right to a reasonable explanation of their treatment plan. C. The treatment plan reflects a multidisciplinary, comprehensive, holistic, culturally sensitive approach to evaluating and treating each patient. D. Overall development, implementation, and supervision of the treatment plan is the responsibility of the patient’s providers. Responsibility for ensuring that the treatment plan is accurate, up-to-date, and reviewed regularly is the responsibility of the interdisciplinary care team. E. The treatment plan is individualized to the needs of the patient ... PROCEDURE: Preliminary Treatment Plan: Interdisciplinary Treatment Plan 1. Upon completion of evaluation/assessment of the patient, the provider and social services team member will add treatment interventions on their assessment of patient needs. 2. Under the direction of the provider, existing and any additional problems will be addressed and documented at the interdisciplinary treatment planning meeting. Information from the interdisciplinary assessments will be utilized to develop an individualized, comprehensive treatment plan which meets the patient’s specific needs. The patient’s presenting problems, physical health, emotional status and behavioral status will be included. The interdisciplinary treatment planning meetings are one mechanism to ensure that there is interdisciplinary communication, collaboration, and consistency in the treatment planning and implementation process. 3. Short, and long term goals, will be identified and documented for each problem on the treatment plan. Expected measurable target/achievement dates for attainment of a given goal will be included. 4. Interventions will include the individual/and discipline responsible for implementation and the frequency of Upon admission, the nurse shall initiate the Interdisciplinary Treatment Plan for the patient’s identified nursing care needs as part of the admission assessment. This plan will be based on the patient assessment and an evaluation of the patient’s presenting problems, physical health, emotional status and behavior and provider input. An initial discharge plan will be completed along with the admission assessment. Once the treatment plan has been developed, a staff person shall review the treatment plan with the patient. This participation shall be noted by the staff’s signature on the treatment plan. services and shall be documented by the discipline responsible for implementing the service or treatment. 5. The patient goals and progress reassessment shall be documented by an interdisciplinary team member on the “Treatment Plan Update” form during treatment planning or rounds, or more frequently as required by the patients’ condition. Identified new problems will be listed with identified goals and target dates on the “Treatment Plan Update” form.””

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 47415 Based on interview, and record review, the facility failed to ensure adequate numbers of registered nurses (RNs) and behavioral health associates (BHAs) were available to provide nursing care based on the acuity of patients, resulting in the likelihood that all patients at the facility would experience decreased supervision, and be at increased risk for adverse events. Findings include: Review of facility incident data for 5/1/26 through 5/20/26, revealed 83 events were reported in this time frame. Falls accounted for 26 events and behavioral incidents accounted for 36 events. Approximately 36 percent of all reported events occurred during weekend shifts. Units 200 and 400 accounted for 56 events, representing approximately 66 percent of all incidents reported during the review period. During an interview on 5/21/26 at 1045, the Director of Nursing (Staff B) stated staffing schedules for May met the facility’s minimum staffing ratios of 1 staff member for every 4 patients during day shift and 1 staff member for every 8 patients during night shift (excluding sitters). Current staffing assignments were based on staffing numbers and did not adequately account for patient acuity, and units 200 and 400 routinely experienced the highest acuity levels within the facility (based on higher medical and psychiatric care needs). Staff B stated she requested core staffing levels of two RNs and two BHAs on these units due to patient acuity and medical complexity but was unable to obtain approval. Staff B further stated that requests for additional staffing based on acuity discussed during daily safety meetings were frequently denied. Staff B reported being instructed to maintain staffing within budget expectations, and stated she has been asked to get one-to-one observation orders discontinued before the weekend. Nursing staff frequently prioritizes direct patient care over ancillary duties, including answering facility phones, due to inadequate staffing resources. Staff B acknowledged receiving complaints from family members and guardians regarding unanswered telephone calls. Staff B stated authority to increase staffing levels based upon patient acuity was controlled by corporate leadership despite ongoing concerns reported regarding patient safety and medical care needs. During interview on 5/21/26 at approximately 12:30 PM, the Corporate Director of Quality and Compliance (Staff EE) stated he was aware of quality-of-care concerns, including falls, restraint use, and behavioral incidents occurring within the facility. Staff EE further stated the facility’s staffing ratios represented minimum baseline staffing levels and should be adjusted based upon patient needs and acuity. Staff EE stated the Director of Nursing possessed authority under facility policy to increase staffing levels when necessary. Record review of policy titled, “Clinical Staff (Nurse) Staffing Plan, dated last revised 09/2024, revealed, “Patient acuity will be reviewed based on the ability to complete activities of daily living assessments, and the behaviors and needs of the medical/psychiatric patient...A DON is accountable to ensure a sufficient number of qualified staff members provide patients with quality care. The DON has the final responsibility and of approving usage of supplemental nursing staff”.”

“Therapeutic Activities - Staffing CFR(s): The number of qualified therapists, support personnel, and consultants must be adequate to provide comprehensive therapeutic activities consistent with each patient’s active treatment program. This Standard is not met as evidenced by: 47415 Based on observation, interview, and record review, the facility failed to ensure adequate numbers of therapeutic staff were available to provide therapeutic activities consistent with the patient’s treatment plan, and policy requirements, resulting in the likelihood that patients will have decreased access to therapeutic services, and the potential of increased behavioral events and longer hospitalizations. Findings include: Review of the facility incident data for 5/1/26 through 5/20/26, revealed 83 events were reported in this time frame. Behavioral incidents accounted for 36 events. Record review of patient records for P-1 and P-8 revealed no documentation that therapeutic coping-skill groups, were provided by social work. On 5/20/26 at 9:45 AM, an interview with Recreation Therapy Aide Staff M revealed he was the currently the facility’s only recreational therapy staff member and was able to provide three group sessions daily (the facility has four inpatient units). Observation confirmed recreational activities were occurring on Unit 100; however, therapeutic coverage for all units could not be provided by a single staff member on a daily basis. During interview on 5/21/26 at 1210, the Director of Clinical Services and Therapeutic Activities Program Director (Staff FF) stated the one full time recreational therapist position is currently vacant, and social work staffing has been down 1 full time employee since January 2026. Staff FF confirmed social work headed therapeutic coping groups had not been conducted since January due to staffing shortages. Staff FF stated these groups were intended to occur daily and were designed to teach coping strategies and assist patients in preparing for discharge. Staff FF acknowledged no quality monitoring process existed to ensure required therapeutic groups were occurring. On 5/21/26 at 1030, an interview with Utilization Review Manager/CFO Staff D revealed audits are done to obtain stay coverage from the insurance companies for all patients. A review for the presence of daily provider psychiatric rounding notes, medication changes, and laboratory levels is conducted for all patients. Staff D asked if therapeutic groups notes and participation were monitored, and the reply was “it depends on the insurance company”. Record review of policy titled, “Therapy Services” dated last approved 9/2025, revealed that, “Group therapy will be offered to each patient by the Therapy Services team...One-to one therapy will be offered to those patients that are not physical or emotionally able to tolerate group therapy. Therapeutic group activities will include... Exercise program...Coping skills”.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 47415 Based on interview and record review the leadership failed to follow its grievance policy and procedure by failing to consistently log, investigate, track, and resolve patient grievances, resulting in resulting in the loss of patient rights and the potential for poor patient outcomes for all patients submitting grievances/complaints to the facility. Findings include: The hospital experienced a two-week gap in grievance oversight during April 2026 while a newly assigned Recipient Rights Officer was in training. During this period, grievance forms were not consistently retrieved or processed, and no effective backup process was implemented. On 5/21/26, a review of the facility’s grievance log revealed no entries were made for 6 written grievance forms submitted to the Office of Recipient Rights (ORR) in May 2026. Forms were in a file, without documentation that: an acknowledgement of the complaint and a copy of the complaint were sent to the complainant within 5 business days, that an investigation was initiated, conducted, or in progress, or that the complainant was notified an investigation was not warranted. Additional documentation was requested and not provided during survey. On 5/21/26 at 0945, an interview with the facility CEO Staff A revealed the recipient rights advisor (appointed in April) was terminated on Friday, May 15, 2026, for failing to meet the training requirements, and failure to pass the state examination. The position was offered to and accepted by an internal staff member (Staff E) who has some prior training and who is to complete the full training for the position. A plan is in place for the CEO Staff A to complete training and be a backup to the recipient rights advisor. Review of policy titled, “Patient Grievance Procedure” dated last approved 4/23 revealed, “A written complaint is always considered a grievance ...All verbal or written complaints regarding abuse, neglect, patient harm ...are to be considered a grievance that requires immediate redress ...After thorough research has been conducted ...All efforts will be made to effectively and expeditious resolve the ...grievance ...All complaints and grievances will be addressed ...within 7 days ...if ...not resolved ...the hospital shall send a response to the patient stating that the hospital continues to work to resolve the complaint/grievance ...All ...complaints and grievance will be logged into a reporting system.” Review of policy titled, “Complaint and Appeal” dated last reviewed 10/25, revealed, “Each Recipient Rights Complaint is recorded upon receipt in the KBHH Rights Complaint Module ...Acknowledgement of the complaint ... is sent along with a copy of the complaint to the complainant within 5 business days ...Investigation will be immediately initiated in cases involving alleged abuse, neglect ...The Chief Executive Officer shall ensure adequate Recipient Rights coverage”.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 47415 Based on interview and record review, the governing body failed to ensure an effective governing structure and failed to provide oversight of hospital operations and policies for the facility, resulting in less than optimal outcomes for all patients served by the facility. Findings include: Review of “Governing Board Bylaws for Kalamazoo Behavioral Health” dated adopted 6/2024, provided during survey, documents, “Kalamazoo Behavioral Health Hospital is a for-profit organization structured under the laws of the State of Indiana. The Corporation has authorized the promulgation and adoption of these Bylaws and has delegated to the Governing Board of the Hospital as established in these Bylaws, the power and authority to conduct the operations of the Hospital ... These Bylaws are adopted by the Hospital for the purpose of organizing an effective governing body for the hospital, which is legally responsible for the conduct of the Hospital as an institution...The Governing Board shall consist of 3 persons and no more than 5 ...selected to serve as Voting Directors of the Governing Board: Chairman/President; Vice President and Secretary/Treasurer ...A Quorum Two (2) Voting Directors shall constitute a quorum for the transaction of business at any meeting of the Board. On 04/23/26 during record review, it was revealed that the hospital operates under a private equity ownership structure. On 4/23/26 at 1000, interviews with hospital leadership (Staff A, B and H) indicated that Hospital decisions, were directed by “corporate” (including decisions on adequate staffing), no documentation how the corporate governing body-maintained accountability of these decisions was provided. The facility leaders could not clearly identify the local governing body or officers (President, Vice President, Secretary/Treasurer, for the facility). A Trustee/Membership list was requested during survey on 4/23/26 and not provided prior to exit. On 4/23/26 at 1045, interview with Staff B revealed leaders of the facility attend morning flash meetings and confirmed the Regional CEO attended at times and stated: Nursing leadership has requested an increase in RNs (Registered Nurses) in the staff mix, and to staff based on acuity, and was denied, despite the fact the requests were correlated with safety events, and increased care needs of patients. The corporate staffing plan is 1 (RN):4(patients) (excluding 1:1 staff). 36887 On 4/23/2026 at 0900, review of policy #10623375 titled “Transfer of Patient” effective 10/2021 indicated at the bottom of the policy the applicability was for “Indiana.” On 4/23/2026 at 1600, review of policy #13517670 titled “Patient Rights and Responsibilities” effective 4/2023 stated, “19. Per Indiana Code IC 12-27-3-3... 20. Per Indiana Code 12-27-3-4... 26... You may file a grievance or complaint with the hospital or any of the agencies listed below whether or not you use the hospital’s complaint/grievance process. Lighthouse Services... Indiana State Department of Health... The Joint Commission... Office of Civil Rights... Indiana Division) of Mental Health and Addiction... Indiana Protection and Advocacy Services...” The bottom of the policy indicated the applicability of the policy was for “Indiana.” See also tag:A - 0083 Governing Body: Contracted Services”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47415 Based on interview and record review, the facility failed to 1) prevent, monitor, investigate, and address an allegation of sexual assault for 1 (P-2) of 23 patients reviewed resulting in a known sexual aggressor (P-11) having unsupervised access to a vulnerable adult and the potential for less than optimal outcomes for all patients served by the facility. Findings include: See Tags: A-0118 Patient Rights: Grievances A-0123 Patient Rights: Notice of Grievance Decision A-0130 Patient Rights: Participation in Care Planning A-0131 Patient Rights: Informed Consent A-0145 Patient Rights: Free from Abuse A-0175 Patient Rights: Restraint or Seclusion”

“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: 36887 Based on interview and record review, the facility failed to have a complete and accurate medical record for 6 (P-2, P-4, P-5, P-6, P-22, P-23) of 23 patients reviewed resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include: On 4/21/2026 at 1023, while on the treatment floor, review of the medical record for P-5 revealed orders for seclusion and for rounding every 5 minutes while awake and every 15 minutes while asleep; however, no documentation could be found in the medical record for seclusion or for rounding. On 4/21/2026 at 1042, while on the treatment floor, review of the medical record for P-6 revealed provider orders for seclusion. No seclusion or rounding documentation could be found on the chart. On 4/21/2026 at 1058, Director of Nursing Staff H stated, “We just started keeping restraint/seclusion documentation on the chart. Observation reviews (rounding) are not printed. We can easily look them up.” On 4/21/2026 at 1202, Director of Quality Staff A stated all of the restraint and seclusion documentation was “sitting on my desk right now” as there was a “QAPI (Quality Assurance Performance Improvement) meeting tomorrow.” She stated all of the documentation “should absolutely be on the medical record.” Staff A explained the electronic system used for rounding could be printed for the record, but it was not done. In a follow-up interview on 4/21/2026 at 1544, Staff A stated, “We were told we didn’t need to have (rounding documentation) in the medical record.” On 4/24/2026 at 1100, record review revealed that rounding and/or restraint/seclusion observations were not present on all open or closed medical records reviewed. On 4/21/2026 at 1439, review of the medical record for P-4 revealed orders dated 3/8/2026 for Zyprexa 2.5 mg (milligrams) by mouth at bedtime. No further orders were found regarding Zyprexa on the provider order sheet. Review of the MAR (medication administration record) revealed Zyprexa 2.5 mg was discontinued on 3/12/2026. A new, handwritten entry on the MAR indicated Zyprexa 5 mg was started 3/12/2026 and was given until P-4 left the facility. Review of the provider notes indicated the plan was to raise the Zyprexa dose to 5 mg every night. Review of the pharmacy log revealed an order had been given 3/12/2026 for Zyprexa 5 mg by mouth at bedtime. On 4/24/2026 at 1118, review of the medical record for P-22 revealed the admitting psychiatric history and physical (H&P) dated 4/9/2026 had a section labeled “Lab Orders” and 15 labs were present. No lab results were found in the medical record. On 4/24/2026 at 1151, Director of Nursing Staff H stated, “Orders on the H&P (or other provider notes) are not orders. We have no access to the provider notes for a couple of days until it gets printed.” She indicated orders were written on the orange provider order sheet. On 4/24/2026 at 1447, review of the medical record for P-23 revealed orders for labs on the admitting psychiatric H&P. These orders were not on the provider orders sheet, and no results were found in the medical record. Facility policy #12507952 titled “Content of the Medical Record” effective 10/2022 states, “The medical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, and document the course and results accurately and facilitate continuity of care among health care providers. Each medical record contains at least the following: 1. The patient’s name, address, date of birth, legal status and the name of any legally authorized representative... Communication Needs... Care provided to the patient before arrival, if any... The record and findings of the patient’s assessment... Conclusions or impressions drawn from the medical history and physical examination... The diagnosis or diagnostic impression... The reason(s) for admission or treatment... The goals of treatment and the treatment plan of care... Evidence of known advanced directives... Evidence of informed consent, when required by hospital policy... Diagnostic and therapeutic orders, if any... All diagnostic and therapeutic procedures and test results... Progress notes made by the medical staff and other authorized individuals... All reassessments, and any revisions of the treatment plan... Clinical observations... The patient’s response to care... Consultation reports... Documentation of every medication ordered or prescribed for an inpatient... Every medication dispensed to an inpatient on discharge... Every dose of medication administered, including the strength, dose and route and any adverse drug reaction... Any access site for medication, administration devices used, and rate of administration... All relevant diagnoses established during the course of care... Any referrals and communications made to external or internal care providers and to community agencies... Discharge Plan and Discharge Planning Evaluation... Conclusions at termination of hospitalization... Discharge instructions to the patient and family... Clinical resumes and discharge summaries... Other information: In addition to the above, the hospital will define what is to be included in medical records according to departmental policies. a. Any records of communication with the patient, such as telephone calls or e-mail. b. Any patient-generated information.” See tags: A - 1621 Assessment - Diagnostice Data A - 1687 Personnel - Active Treatment”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 53475 Based on interview and record review, the governing body failed to provide oversight of contracted laboratory services needed to provide care for 1 (P-3 ) of 23 patients resulting in unrecognized, unmet patient needs and the potential for poor patient outcomes. Findings include: Review of P-3’s medication administration record (MAR) provided by Pharmacist Staff Z on 4/23/2026 at 1245 showed that P-3 was prescribed medications requiring STAT (Latin - “STATim” means “immediately”) and routine laboratory (lab) blood draws. The following lab orders were either delayed or not completed on the specified dates: Date: Lab Order: Outcome: 1/16/2026 Clozaril (anti-psychotic medication) No lab draw initiated 1/20/2026 Clozaril Stat (sic) STAT, 3 lab draws were delayed until 1/24/2026 (4 days later) despite the Clozaril STAT order Complete Blood Count (CBC), Absolute Neutrophil Count (ANC) 1/29/2026 Clozaril Lab draw was delayed until 1/31/2026; results could not be located. 2/16/2026 CBC, Clozaril Labs were to be obtained before next dose; no lab draws were initiated. 2/17/2026 CBC, Clozaril State Of Michigan No lab draws were initiated. 3/17/2026 Weekly ANC and Clozapine Levels Order was documented, no lab draws were initiated. During an interview with Physician Staff S on 4/24/2026 at 0838, Staff S stated lab requests were “not processed in a timely manner” at the facility due to the lack of STAT lab services. Staff S also noted that “not all nurses knew how to draw labs.” Director of Nursing (DON) Staff H and unit staff were queried about the meaning and timing of STAT labs on 4/24/2026 on 300 unit between 1353-1414 as follows: Time: Staff: Response: 1353 DON Staff H STAT meant “immediately” 1400 RN Staff HH STAT meant “done asap (as soon as possible). I think within an hour.” 1403 RN Staff DD STAT meant “within 2 hours” 1412 RN Staff II STAT meant “do it now.” 1415 LPN Staff EE STAT meant “right now” DON Staff H also shared during interview on 4/24/2026 at 1154 that there was one-time per day when labs were picked up from the contracted lab service, and that was at 1700. It did not matter if there were STAT labs that needed to be done, there was only one pick-up daily because the lab company was located approximately 45 minutes away. She then stated when they first opened, that they worked with the local acute care hospital lab who would make multiple pick-ups daily and STAT labs were never an issue. DON Staff H also stated since “corporate” had denied the PT/INR machine, patients were being sent to the ED that needed STAT labs. Physician Staff S stated during interview on 4/22/2026 at 1336 obtaining lab results has been an issue “for a long time.” She stated certain labs are necessary to determine if a patient was having a mental health issue versus having a medical issue which needed to be addressed. Other times, it was for evaluation of medications in the system. “For example, a patient on 200 Hall was ordered a lab draw for Depakote on Monday (4/20/2026) and it is still not drawn.” Some patients needing labs were sent to the Emergency Department (ED) to get them so the providers could properly treat them. She was unable to recall a specific patient that had occurred with. Staff S further stated it did not matter if orders for labs were STAT or not, either way most of the time it was not done or not resulted. On 4/28/2026 at 1300, review of the lab contract revealed it was dated 10/1/2018-9/30/2023 (expired) and appeared to have business information present; however, no specific data was present stating what labs would/could be done, storage until pick-up, how many pick-ups per day were to be expected, or defining acceptable time frames for regular and STAT results. Facility policy titled “Laboratory Process” effective 08/2022 states: “PROCEDURE: 1. Provider orders lab. 2. Nurse transcribes order onto patient lab sheet, which is with the patient ’ s MAR. 3. Nurses place order for laboratory tests on lab website. 1. For a STAT order, the STAT box is noted on the on-line order. 2. STAT lab pick up is requested. 4. Nurses and/or phlebotomist obtains specimen for ordered tests. 5. Specimen is processed as needed, and placed in lab fridge/freezer or stored at room temperature if indicated. 6. Printed requisition is placed in lab bag with specimens. 7. Lab courier picks up the specimen. 8. Nurses/Unit Clerks obtain laboratory results from lab website and print results. 1. Nurse updates provider of abnormal results as needed, including obtaining any new orders. 9. Nurses/Unit Clerks place printed results in the patient ’ s medical record for the provider to review. 10. Lab Refusals shall be documented on the lab sheet in the patient ’ s MAR and/or in the Nursing narrative.” No STAT lab timing expectations were articulated in the policy.”

“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: 48030 Based on interview and record review, the facility failed to investigate and report findings to the patient/patient representative for 1 (P-2) of 1 patients reviewed for an alleged assault allegation, resulting in the loss of patient rights and the potential for poor patient outcomes for all patients submitting grievances/complaints to the facility. Findings include: P-2 was a 25-year-old who had a Past Psychiatric History of Bipolar Disorder, Autism Spectrum Disorder, Intermittent Explosive Disorder and intellectual disability with functioning at a 4-year-old level. P-2 was admitted to the facility from an Emergency Department (ED) on 3/2/2026 at 2038 for engaging in aggressive behaviors including punching holes in walls and pulling a toilet from the wall. During record review for P-2 a Social Services Progress Note dated 3/8/2026 at 0940 signed by Staff K, a clinical social worker for the facility revealed, “Patient ’ s mom told the SW (social worker) that she got a call from her son saying his butt/penis,[sic] She said he also, told her his throat. [sic] She said she let [Staff P, social worker] know, she said she told [Staff Q, registered nurse] that she didn ’ t want him to be with anyone. [Staff Q] told her that BHA ’ s (behavioral health associates) [sic], she told [Staff Q] that they are being very vague.” Review of note from 3/8/2026 at 1023 reveals, “[Staff L, psychiatric nurse practitioner] told her that it [sic] was too many issues with the roommate. Monday to Tuesday he was with a roommate. She stated what happens if he is bleeding internally, he said his stomach is hurting him. She said she asked [Staff P] to check him thoroughly on 3/7/2026.” On 4/22/2026 at 1602 Staff K explained that P-2’s mother had called the social work office and left a voicemail “to make a complaint”. Staff K revealed she called P-2’s mother back and she reported that P-2 was “saying unusual things that he doesn’t normally say that were alarming to her about pain in his butt, penis, stomach and mouth”. When queried if she had reported the complaint to anyone else at the facility, Staff K revealed she went to the 400 Unit to talk with the nurses taking care of P-2 and someone that was sitting with him as a 1:1 explained to her that they thought the pain was related to an intramuscular (IM) injection in his butt. Staff K revealed she reported the complaint to the Director of Social Work (Staff R) who told her to document the complaint in the patient ’ s record. When queried if an incident report was completed or a complaint/grievance report was filed, Staff K revealed, “no”. An interview with the Director of Social Work (Staff R) was conducted on 4/22/2026 at 1619 and revealed she was familiar with P-2, and she did review Staff K ’ s note. Staff R revealed that she was unaware whether Staff K notified the CEO, the Medical Director or the Office of Recipient Rights. Staff R added that if Staff K took the complaint from P-2’s mother, “she should have done an incident report. Staff gets trained on incident reports.” During an interview with Staff O (Behavior Health Analyst assigned to P-2) on 4/22/2026 at 0930 it was revealed she remembered P-2. Staff O explained that she also remembered that she observed a Sheriff Deputy in the main lobby of the facility when she was walking in one day and she was told by the Sheriff that he was there because P-2’s mother had made a report that her son was complaining of rectal pain. When queried if she reported this to anyone at the facility, Staff O explained she notified the Director of Nursing (Staff H) who was reportedly going to notify the Chief Executive Officer (Staff B). An interview with the Director of Nursing (Staff H) was conducted on 4/22/2026 at 1046. Staff H explained that she recalled P-2 and that it was reported to her from one of the floor nurses that “his mother called and said he was being sexually assaulted because he was constipated”. Staff H recalled that she asked the floor nurse if the provider had been notified and whether P-2 had been assessed and at that time, at which time neither had occurred. Staff H revealed that she recalled asking the floor nurse how he was acting and was told that he had been constipated and given stool softeners. When queried how sexual assault allegations are investigated at the facility, Staff H explained that “It depends on who is making the allegation. If we don ’ t have a date, it is hard to follow-up.”. When queried if she ever spoke with P-2’s mother to confirm the allegations, Staff H revealed she did not call her but she was unaware of the allegations that he had pain in his penis and mouth and only knew about the rectal pain which they attributed to constipation. During an interview with the Director of Quality, Compliance and Risk Management (Staff A) and the Office of Recipient Rights (Staff E) representative on 4/22/2026 at 1503 it was revealed that Staff A was aware that the Sheriff was at the facility but she was never told why and was unaware of the complaints about possible assault with P-2. Staff E revealed she was unaware of the alleged assault related to P-2. On 4/23/2026 at 1234 an interview with the Chief Executive Officer (Staff B) was conducted. When queried what is the facilities policy for staff that receive a complaint from a patient or family member, Staff B explained that an incident report should be made so it can be investigated. There was no evidence of the facility following their grievance procedure related to the allegations of P-2 being sexually assaulted Review of facility policy titled, Patient Grievance Procedure, policy #13517667, last revised 01/2020, section titled Procedure, paragraph 8 reveals, “The hospital will investigate the grievance, reviewing any documentation, obtaining statements if needed, and reviewing patient records (as needed). All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are to be considered a grievance that requires immediate redress. After thorough research has been conducted, the CEO or designee will work in tandem with the Compliance Officer and any staff identified as key individuals critical to problem resolution for the specific identified concern. All efforts will be made to effectively and expeditiously resolve the patient’s grievance. A complaint is considered resolved when the patient is satisfied with the actions taken on his/her behalf.””

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 47415 Based on interviews and record review, the facility failed to follow policy and procedure and notify the guardian of a significant safety incident occurring during the discharge process, resulting in the denial of the guardian’s right to participate in P-1’s plan of care. Record review revealed the guardian was not notified by the facility that P-1 eloped from the transportation service arranged by the facility on 1/15/26 at 1740. Review of the incident investigation, documentation and medical record notes by social work revealed the police were notified immediately; however, the guardian notification was delayed until the next day, 1/16/26 at 1438. On 4/23/26 at 0930, interview with Social Worker Staff K revealed that the guardian (wife) was contacted by phone on 1/16/26 at 1438, to follow up on the patient. Noting on 1/15/26 the facility was aware P-1 was taken (by unknown person) to the daughter’s house. The facility initiated an investigation on 1/16/26 and identified transport vendor issues (with corrective actions) but did not identify or address internal system failures with communication to the guardian. Review of policy titled, “Patient Rights and Responsibilities”, dated last revised 9/2021, revealed, “A POA/Guardian will be identified for discussion of the patient’s condition ...5. Receive information about your health status, course of treatment ...including unanticipated outcomes ...8. Be informed of continuing health care requirements following discharge from the hospital and the right to receive reasonable continuity of care ...” Review of policy titled, “Elopement”, dated last revised 6/2021, revealed, “Purpose: To ensure that patients are provided with follow-up care and that they are not in imminent danger to themselves or others and ensure that all safety measures are taken ...If the patient is on a conservator ship, the police department and the conservator must be notified immediately.””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 47415 Based on interview and record review, the facility failed to obtain consent for the use of psychotropic medication for 3 (P-18, P-19, P-20) of 4 patients reviewed for medication administration, resulting in the loss of the patient’s right to make an informed decision regarding their care and treatment. Findings include: P-18 was ordered and received Risperidone 1 milligram (mg) (antipsychotic) on 4/21/26 and 4/22/26, a psychotropic medication consent was not found in the medical record. P-19 was ordered and received Namenda 10 mg (mood stabilizer) on 4/6/26, 4/7/26, 4/8/26, and 4/9/26, a psychotropic medication consent was not found in the medical record. P- 20 was ordered and received Risperidone 0.25mg twice daily (antipsychotic) and received doses on 4/16/26, 4/17/26, and 4/18/26, a psychotropic medication consent was not found in the medical record. On 4/22/26 at approximately 1030, an interview with nursing leadership Staff A and Staff H revealed the process had a recent change, nursing used to do it, now it is a responsibility of the providers. On 4/22/26 at 1335, an interview was conducted with Provider Staff S, when asked who was responsible for completing the psychotropic medication consent forms, Staff S stated the nursing staff. Review of policy titled, “Use of Psychotropic Medications” dated last reviewed 5/2024, revealed: “Informed consent ...Client (or their legally authorized representatives) must be informed about the purpose, benefits, risks, and potential side effects of psychotropic medication ...Informed consent must be obtained and documented before initiating or changing any psychotropic medication ...” Responsibility for who completes the form is not defined in the policy.”

“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: 36887 Based on interview and record review, the facility failed to screen for and implement precautions for safety and/or high risk behaviors for 2 (P-2, P-11) of 23 patients reviewed, resulting in the potential for unidentified needs and patient to patient abuse. Findings include: Review of the medical record for P-2 revealed the admitting physician was Physician Staff S. P-2 was a 24-year-old male admitted 3/2/2026 with autism and had the function of a 4-year-old per his guardian. He was verbally non-communicative; however, used an electronic tablet and pictures to communicate with others. P-2 had no precautions in place. He was placed in a room with P-11. Review of the medical record for P-11 revealed he was a 48-year-old with a history of sexual preoccupation who was placed on sexually acting out, assault, and elopement precautions on admission. Further review of the medical record for P-2 revealed a Social Services note dated 3/8/2026 at 0940 revealing P-2’s mother/guardian reported a call from P-2 complaining of buttock, penile, and throat pain and she had told the nurse she did not want her son to have a roommate. On 4/23/2026 at 1336, Physician Staff S stated during interview she had no say in what patients were admitted to the hospital or what rooms they were placed in and she was unable to refuse a patient based on acuity, staffing, medical need, or any other reason. She said her name was used on all of the documents for admission because she was the only psychiatric physician on site and nursing usually made the bed assignments after arrival to the facility. Facility policy #12508272 titled “Admission of Patients (MI)” effective 10/2022 states, “The Intake Department will notify the Interdisciplinary Team of a referral... The admitting provider will authorize the admission of the patient and give the order of admission to the Charge Nurse or his/her designee. The Reception/Admitting Department will be notified by Intake Department/Charge Nurse/or designee and will be given the following information: Name, Psychiatric diagnosis, Attending provider... Room assignment...””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48030 Based on interview and record review, the facility failed to prevent and investigate an allegation of sexual assault for 1 (P-2) of 23 patients reviewed, resulting in a known sexual aggressor (P-11) having unsupervised access to a vulnerable adult. Findings include: P-2 was a 25-year-old with a past psychiatric history of Bipolar Disorder, Autism Spectrum Disorder, Intermittent Explosive Disorder and intellectual disability with functioning at a 4-year-old level. P-2 was admitted to the facility from an Emergency Department (ED) on 3/2/2026 at 2038 for engaging in aggressive behaviors including punching holes in walls and pulling a toilet from the wall. P-2 was also engaging in self-injurious behaviors including hitting himself, striking his head against walls and sleep disturbance. During record review on 4/21/2026 at 1410 it was noted P-2 was minimally verbal and primarily communicates through yes and no responses or occasional written responses depending on the complexity of the question. Hospital course P-2 required a highly structured environment and intensive staff supervision due to persistent behavioral dysregulation associated with severe autism and intellectual development disability. P-2 demonstrated episodes of agitation, impulsivity and poor behavioral control including disrobing, leaving his room and disrupting the unit milieu, frequently requiring staff redirection with episodes of physical aggression toward staff. P-2 required seclusion and intramuscular medications on several occasions. During record review for P-2 a Social Services Progress Note dated 3/8/2026 at 0940 signed by Staff K, a clinical social worker for the facility revealed, “Patient ’ s mom told the SW (social worker) that she got a call from her son saying his butt/penis,[sic] She said he also, told her his throat. [sic] She said she let [Staff P, social worker] know, she said she told [Staff Q, registered nurse] that she didn ’ t want him to be with anyone. [Staff Q] told her that BHA ’ s (behavioral health associates) [sic], she told [Staff Q] that they are being very vague.” Staff K also documented a note dated 3/8/2026 at 1011 which reveals, “SW texted her supervisor.” Review of note from 3/8/2026 at 1023 reveals, “[Staff L, psychiatric nurse practitioner] told her that it [sic] was too many issues with the roommate. Monday to Tuesday he was with a roommate. She stated what happens if he is bleeding internally, he said his stomach is hurting him. She said she asked [Staff P] to check him thoroughly on 3/7/2026.” The final entry from Staff K from 3/8/2026 at 1040 reveals, “SW (social worker) spoke to pt ’ s (patient ’ s) nurse on unit 400.” At the time of admission on 3/2/2026 at 2038, P-2 was placed in room 107 on the 100 Unit with P-11 until he was transferred to room 401 on the 400 Unit on 3/3/2026 at 1503. Review of the electronic Behavioral Health-Patient Observation Sheets for P-2 revealed no Precaution Risk Flags were identified and every 15-minute observations during the time P-2 shared a room with P-11. Observations from 3/3/2026 reveal the following times were left blank: 0734-0804, 1019-1049, 1104-1134. There was a gap in observation times from 1449 until 1804. Staff A was queried why there was a large gap of time missing from the observation logs and she could not explain the missing data and replied, “I will need to check into this.” Review of orders for P-2 reveals 1:1 observation was ordered on 3/4/2026 at 0954, and again on 3/7/2026 at 1839, no orders to discontinue were found in the record. Review of Patient Observation Sheets reveals P-2 had 1:1 observation with every 5-minute checks beginning on 3/4/2026 at 2312 through 3/5/2026 at 0057, 3/6/2026 at 1321 through 3/7/2026 at 1933, 3/8/2026 at 0736 through 1901. Despite the order for 1:1 observation every 5-minutes, P-2’s Observation Sheets reveal he was on 15-minute observations the remainder of P-2’s hospitalization. Review of a Daily Nursing Narrative note dated 3/6/2026 at 0730 reveals, “No 1:1 aide available 11pm-0700”. Review of electronic Behavioral Health-Patient Observation Sheets for P-11 (P-2’s roommate from 3/2/2026-3/3/2026) reveals in the Precautions Risk Flags: Assault, Elopement, Sexual Acting Out. P-11 was on every 15-minute observations and during the time P-2 shared a room with him, observations were left blank during the following times: 0345-0415, 0730-0800, 1015-1045, 1115-1145, and 1330-1400. On 4/22/2026 at 1602 an interview with Staff K was conducted and revealed she did not remember the patient initially. After sharing Staff K ’ s note with her, Staff K explained that P-2’s mother had called the social work office and left a voicemail “to make a complaint”. Staff K revealed she called P-2’s mother back and she reported that P-2 was “saying unusual things that he doesn ’ t normally say that were alarming to her about pain in his butt, penis, stomach and mouth”. When queried if she had reported the complaint to anyone else at the facility, Staff K revealed she went to the 400 Unit to talk with the nurses taking care of P-2 and someone that was sitting with him as a 1:1 explained to her that they thought the pain was related to an intramuscular (IM) injection in his butt. Staff K explained that the staff member told her that P-2’s mother called the 400 Unit but never shared her concerns about the pain. Staff K explained she attempted to speak with P-2 briefly, but he did not respond. Staff K revealed after her conversation with the staff on the 400 Unit she reported the complaint to the Director of Social Work (Staff R) who told her to document the complaint in the patient ’ s record. Staff K explained that Staff R told her that she had received a couple of calls about the incident. When queried if an incident report was completed or a complaint/grievance report was filed, Staff K revealed, “no”. On 4/22/2026 at 0930 an interview was conducted with Staff Q, a staff nurse at the facility. Staff Q was familiar with P-2 and his mother. Staff Q explained that P-2 was originally assigned to a room in the 100 Unit because of availability and was moved the next day because he needed a private room. Staff Q also remembered that she was in the front lobby of the facility when a Sheriff came to ask questions about P-2 because his mother reported his rectum hurt after being on the 400 Unit a few days. Staff Q explained that she notified the Director of Nursing who was going to let the CEO know. During an interview with social worker (Staff P) on 4/22/2026 at 1255 it was revealed that she remembered P-2, but she was not his primary social worker. Staff P explained she did not remember the incident but “remembers speaking with the family about the alleged assault”. Staff P revealed she did not remember speaking with Staff K about the alleged assault but most likely it was discussed at treatment team and directed to Recipient Rights. When queried if there are minutes from the treatment team meetings and whether she was aware of any follow-up, Staff P revealed no. An interview with the Director of Social Work (Staff R) was conducted on 4/22/2026 at 1619 and reveals she was familiar with P-2, and she did review Staff K ’ s note. Staff R revealed there were reports that P-2 was constipated, which staff believed was the reason for the rectal pain. Staff R revealed that she was unaware whether Staff K notified the CEO, the Medical Director or the Office of Recipient Rights. Staff R added that if Staff K took the complaint from P-2’s mother, “she should have done an incident report. Staff gets trained on incident reports.” During an interview with Staff O (Behavior Health Analyst) on 4/22/2026 at 0930 it was revealed she remembered P-2 and that he was originally in the 100 Unit and had to be moved to the 400 Unit the next day because he needed a private room. Staff O explained that she also remembered that she observed a Sheriff Deputy in the main lobby of the facility when she was walking in one day and she was told by the Sheriff that he was there because P-2’s mother had made a report that her son was complaining of rectal pain and the Sheriff asked her some questions and then left. When queried if she reported this to anyone at the facility, Staff O explained she notified the Director of Nursing (Staff H) who was reportedly going to notify the Chief Executive Officer (Staff B). An interview with the Director of Nursing (Staff H) was conducted on 4/22/2026 at 1046. Staff H explained that she recalled P-2 and that it was reported to her from one of the floor nurses that “his mother called and said he was being sexually assaulted because he was constipated”. Staff H recalled that she asked the floor nurse if the provider had been notified and whether P-2 had been assessed and at that time, at which time neither had occurred. Staff H revealed that she recalled asking the floor nurse how he was acting and was told that he had been constipated and given stool softeners. When queried how sexual assault allegations are investigated at the facility, Staff H explained that “It depends on who is making the allegation. If we don ’ t have a date, it is hard to follow-up.”. When queried if she ever spoke with P-2’s mother to confirm the allegations, Staff H revealed she did not call her but she was unaware of the allegations that he had pain in his penis and mouth and only knew about the rectal pain which they attributed to constipation. On 4/22/2026 at 1543 an interview was conducted with the Psychiatric Nurse Practitioner (Staff L) who revealed that she remembered P-2 and that Staff O reported to her that he had complaints about his genitals. Staff L explained that she remembers discussing it with the Family Medicine Nurse Practitioner (who is unavailable for interview) possibly. Staff O revealed she thinks the complaints were discussed at the Treatment Team Meeting. When queried if she filled out an incident report, Staff L responded that Staff L would have done that because she took the complaint from the mother. During an interview with the Director of Quality, Compliance and Risk Management (Staff A) and the Office of Recipient Rights (Staff E) representative on 4/22/2026 at 1503 it was revealed that Staff A was aware that the Sheriff was at the facility but she was never told why and was unaware of the complaints about possible assault with P-2. Staff E revealed she was unaware of the alleged assault related to P-2. An interview with the Medical Director (Staff S) was conducted on 4/23/2026 at 1350. Staff S was queried whether she was aware of the assault allegations regarding P-2 and revealed she was unaware of the allegations and did not recall this being discussed at the Treatment Team Meeting. When queried if a patient that has 1:1 observation should have observations documented in the record every 5 minutes, Staff S explained “yes, observations should be documented every 5 minutes and the person doing the observation should be within an arm length away from the patient at all times.” Staff S continued and revealed, “We have had instances where there are patients in seclusion that do not have a BHA [behavioral health associate] available” for observation due to staffing. On 4/23/2026 at 1234 an interview with the Chief Executive Officer (Staff B) was conducted and revealed he was familiar with P-2 and that he had a “dramatic entry into the system because he was not responding to his meds” and he was aggressive towards staff. Staff B revealed he was not aware that a Sheriff Deputy came to the facility to investigate a complaint about P-2. When queried how room assignments are made, Staff B explained that Intake will check to see what beds are available and make the assignment, which is done outside of the facility. Staff B revealed it would be the expectation that clinical staff would look at safety precautions and assign a bed appropriately. When queried what is the facilities policy for staff that receive a complaint from a patient or family member, Staff B explained that an incident report should be made so it can be investigated. When queried what the policy for patients that require 1:1 observation, Staff B revealed that 1:1 observation requires the patient to be within arm’s length all time. Staff B was asked whether it would be acceptable to not have adequate staff to be able to provide 1:1 observations for a patient and responded that, “it may happen sometimes, I ’ m sure they feel overwhelmed, but we staff to a ratio of 4(patients):1(RN), we have to staff according to 4:1, not based on clinical judgement.” Review of facility policy titled, Patient Rights and Responsibilities, policy #13517670 last revised 09/2021, under Procedure reveals, “You have the right to: 18. Receive care in a safe setting, free from verbal or physical abuse or harassment. You have the right to access protective and advocacy services including notifying government agencies of neglect, abuse, or exploitation.” Review of facility policy titled, Patient Grievance Procedure, policy #13517667, last revised 01/2020, section titled Procedure, paragraph 8 reveals, “The hospital will investigate the grievance, reviewing any documentation, obtaining statements if needed, and reviewing patient records (as needed). All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are to be considered a grievance that requires immediate redress. After thorough research has been conducted, the CEO or designee will work in tandem with the Compliance Officer and any staff identified as key individuals critical to problem resolution for the specific identified concern. All efforts will be made to effectively and expeditiously resolve the patient’s grievance. A complaint is considered resolved when the patient is satisfied with the actions taken on his/her behalf.””

“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: 48030 Based on interview and record review, the facility failed to monitor 1 (P-2) of 1 patients reviewed for monitoring during seclusion, resulting in the loss of patient rights and the potential for poor patient outcomes. Findings include: Review of provider orders and nursing documentation for P-2: 3/4/2026 at 0902: Seclusion order 3/4/2026 at 0915: Seclusion order 3/4/2026 at 0954: 1:1 observation - agitation, aggression, impulsivity - Order not discontinued 3/4/2026 at 1355: Seclusion order 3/5/2026 at (time not documented): Review of nusing note reveals, “when he was put in seclusion”. No order found in record. 3/7/2026 at 1839: 1:1 observation while awake, every 15 minutes asleep - 2nd order 3/8/2026 at 0850: Review of nursing note reveals, “patient put into seclusion this morning due to agression and agitation. No order found in the record. 3/10/2026 at 2000: Review of nursing note reveals “patient in and out of seclusion three seperate times this shift”. No orders found in record. 3/10/2026 at 2100: Review of nursing reveals, “Pt (patient) in seclusion due to assaulting staff repeatedly”. No order found in record. Large missing gaps in observations (1:1, 5 minute, or 15 minute) documentation was noted as follows: 3/3/2026 - 1449 until 1804 3/4/2026 - 2149 until 2304 3/6/2026 - 1401 until 1431 3/6/2026 - 2346 until 3/7/2026 @ 0046 3/7/2026 - 0226 until 0441 3/7/2026 - 0511 until 0651 3/7/2026 - 1933 until 2103 3/7/2026 - 2103 until 2203 3/7/2026 - 2203 until 2348 3/9/2026 - 2017 until 2117 3/9/2026 - 2302 until 3/10/2026 @ 0032 3/10/2026 - 1432 until 1832 3/10/2026 - 1932 until 2247 Review of facility policy titled, “Restraint or Seclusion”, policy #13483128, last revised 2/2026 reveals in the section titled, “ONGOING ASSESSMENT, MONITORING AND EVALUATION DURING RESTRAINT/ SECLUSION: Patients in seclusion will be directly observed by one-to-one staff observation. A nurse shall observe and assess patients in restraint or seclusion approximately every 60 minutes including respiratory and circulatory status, skin integrity and vital signs. In some circumstances, approaching the patient may be dangerous and may increase patient agitation. Visual checks may be performed if the patient is too agitated to approach. but at a minimum, the patient must be assessed for safety and signs of injury, as well as readiness for discontinuation of restraint or seclusion. The patient’s response to the intervention or interventions used shall be documented every fifteen (15) minutes throughout the duration of the restraint or seclusion. The fifteen (15) minute monitoring must include the monitoring of the patient’s physical and psychological condition including, but not limited to: Respiratory and circulatory status; Skin integrity; Vital signs; An unlicensed trained staff member who is knowledgeable of the seclusion/restrain policy may provide this monitoring and documentation. All documentation should include date, time and staff signature/initials.””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to follow provider orders for 2 (P-3, P-4) of 23 patients reviewed resulting in unmet patient needs and the potential for poor outcomes. Findings include: Review of the medical record for P-4 revealed he was a 59-year-old male admitted 3/8/2026 for major depressive disorder and suicidal ideation. P-4 was placed on CIWA (Clinical Institute Withdrawal Assessment - a 10-item evidence-based tool used to assess and manage alcohol withdrawal severity) on admission as he was a “severe” alcoholic. Since he had been started on Librium (approved treatment for alcohol withdrawal) in the Emergency Department (ED), it was continued at the facility. Review of provider orders dated 3/8/2026 at 1411 revealed an order for Librium 25 mg po (by mouth) every 6 hours for alcohol withdrawal. Review of the pharmacy electronic MAR (Medication Administration Record) revealed Librium doses were not given according to provider orders on the following dates and times: -3/10/2026 - a dose was given at 0602 and another at 0630 (extra dose given, 28 minutes apart) -3/10/2026 - no dose given after 1755 (missed one dose) -3/11/2026 - no dose given prior to 1145 (missed one dose; total of 17 hours, 40 minutes between doses) -3/11/2026 - no dose given after 1623 (missed one dose) -3/12/2026 - no dose given prior to 1247 (missed two doses; total of 20 hours, 24 minutes between doses) -3/12/2026 - no dose given after 1641 (missed one dose) -3/13/2026 - a dose was given prior to 0539 (total of 12 hours,58 minutes between doses) -3/13/2026 - a dose was given at 0539 and another at 0824 (2 hours, 45 minutes apart) -3/13/2026 - no dose given after 1326 (1 dose missed) -3/14/2026 - no dose given prior to 1327 (3 doses missed; total of 24 hours, 1 minute between doses) -3/14-2026 - no dose given after 1740 (1 dose missed) -3/15/2026 - no dose given prior to 0525 (total 11 hours, 45 minutes between doses) -3/15/2026 - no dose given after 1747 (1 dose missed) -3/16/2026 - no dose given prior to 0610 (total 12 hours, 23 minutes between doses) Review of the MAR in the medical record revealed the Librium midnight dose was held on 3/11, 3/12, and 3/13; however, there was no documentation found as to why the medication was held and no orders were found to hold the dose at any time. Facility policy #11132380 titled “Administration of Medications” effective 2/2022 states, “Medications and biologicals are administered upon the order of a practitioner responsible for the care of the patient or another practitioner acting in accordance with State law, including scope of practice laws, hospital policy and procedures and medical staff by laws (sic) rules and regulations... When medications eligible for a scheduled dosing time are not administered within the defined time period: 1. Document the reason the dose was missed or delayed (i.e. patient refused, patient off unit, etc.) 2. Reschedule missed or delayed doses, as appropriate.” 53475 Review P-3’s MAR provided by the Pharmacist Staff Z on 4/23/2026 at 1245 showed that medications prescribed for secretion management and anxiety were not always given. Nursing staff did not document any explanations for the missed doses. Date: Order: Outcome: 1/18/2026 Glycopyrrolate (to decrease secretions); Given 1 time ordered 3 times daily 2/15/2026 Glycopyrrolate; Given 2 times ordered 3 times daily 2/21/2026 Glycopyrrolate; Given 2 times ordered 3 times daily 2/21/2026 Ativan (anti-anxiety medication); Given 2 times ordered 3 times daily 3/17/2026 Ativan; Given 2 times ordered 3 times daily Review of the facility’s policy “Medication Procedures” effective 05/2024 states: “7. This policy aims to ensure the appropriate use, administration, storage, and monitoring of medications ... Medications must be administered by trained and authorized personnel in accordance with the prescribing provider’s instructions. o The administration of medication must be documented in the Medication Administration Record (MAR), including the date, time, dosage, and initials of the person administering the medication. o Any refusal or omission of medication must be documented, along with the reason and any follow-up actions taken.””

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 53475 Based on observation, interview, and record review, the facility failed to ensure that outdated medications were removed from use for the 16 patients on the 200 unit at the time of observation, resulting in less-than-optimal outcomes for all patients admitted to this patient care area. Findings include: On 4/21/2026 at 1025, the Emergency Medication Box on 200 was observed to contain expired medications, including Epinephrine (Epi Pen- emergency medication to counteract severe allergic reactions) with an expiration date of 11/20/2025, and Diphenhydramine (antihistamine - supportive medication to treat allergy symptoms caused by histamine) with an expiration date of 03/26. On 4/21/2026 at 1028, the Director of Quality/Compliance/Risk Staff A was queried during the unit tour to review the expirations dates of the medications in the Emergency Medication Box. Staff A acknowledged that both medications were expired. Review of the facility’s policy “Expired Medications,” effective 12/2021, reveals: “Pharmacy will monitor expiration dates of medications and maintain a drug inventory that is within the expiration date indicated by the manufacturer ... 6. When a medication is outdated, consideration will be given to its formulary status and quantity on hand. 7. The pharmacy will dispose of expired medications utilizing a licensed pharmaceutical disposal company. Said company will be responsible for maintaining compliance with local, state, and federal regulations of disposal.””

“Assessment - Diagnostic Data CFR(s): Standard: Development of Assessment/Diagnostic Data Medical records must stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the patient is hospitalized. This Standard is not met as evidenced by: 47415 Based on interview and record review, the facility failed to ensure a safe transition of care for 1 (P-1) of 23 patients reviewed, resulting in the potential for endangerment of a vulnerable adult. Findings include: Record review revealed P-1 was a geriatric patient with diagnoses including bipolar disorder with severe psychotic features and dementia. P-1 was assessed by the provider on day of discharge (1/15/26) with demonstrated poor judgment, poor insight, and behavioral dysregulation. The “Interdisciplinary Discharge Plan/Order” form for P-1 was signed by the provider on 1/15/26 at 1630, however, no mode of transport was checked, and no discharge disposition was checked. On 1/15/26 at approximately 1740, P- 1 was discharged to an assisted living facility by a transportation service, (on the facilities contract list) unsupervised. At approximately 1750, P-1 got agitated during transport and exited the vehicle. The contracted transport driver failed to follow safety protocol by allowing P-1 to sit in front seat without child locks and did not remain with the patient to know his whereabouts after exiting the vehicle, police involvement was necessary. P-1 was exposed to environmental and safety risks, including (January) weather, exploitation (taken by unknown person to daughter’s house), and the potential for medical deterioration (taken for an examination in the emergency room on 1/16/26). On 4/22/26 at 1335, an interview with the medical director Staff S, revealed that the discharge plan/order forms are often signed before the transportation mode and discharge disposition is completed by the social worker. Review of policy titled, Transfer of Patient”, last reviewed 6/2023, revealed under “Purpose: To provide hospital staff with guidelines to follow to help assure continuity of care...when a patient needs to be transferred or transported to another facility for a non-emergent reason...Transport: when a patient is sent to either another healthcare institution for outpatient medical services or otherwise...Transports: Obtain physician order for transport, including method and type of personnel to accompany the patient...Type of transportation must be decided based on the patient’s condition...””

“Personnel - Active Treatment CFR(s): [The hospital must employ or undertake to provide adequate numbers of qualified professional, technical, and consultative personnel to:] Provide active treatment measures; This Standard is not met as evidenced by: 47415 Based on interview and record review, the facility failed to provide an adequate number of registered nurses (RNs), behavioral health assistants (BHAs) and other ancillary staff to consistently meet the needs of all patients, resulting in an increased risk of injury and unmet patient care needs for patients at the facility. Findings include: On 4/21/26 at 1045 an interview with floor staff RN Staff Y revealed staffing is often short, and today she was the only RN on the unit (200) with 3 BHA’s with a census of 13 patients, with 3 patients on every 5-minute checks. On 422/26 at 1115,on unit 300, an interview with Recreational Therapist (RT) Staff U revealed she is the only RT at the facility, and she works with recreational aid assistant, and has given her 2-week notice. Patients are supposed to get two group sessions per day/per unit and at the current staffing level all groups do not get done. Review of daily staffing reports dated 4/13/26, 4/14/26 and 4/20/26 (presented at the daily morning flash meeting and signed by the Director of Nursing Staff H, Chief Executive Officer Staff B, Chief Financial Officer Staff C, Director of Quality Staff A, and Human Resource Director Staff F, revealed staffing concerns on the following dates reviewed (current 2 weeks): Date Unit Census Staffing 4/13/26 300 14 staffing down 1 RN, day shift, and 1 RN evening shift 4/14/26 400 10 staffing down 1 RN night shift 4/20/26 400 13 staffing down: 2 BHA day shift, 1 BHA, evening shift, and 2 BHA night shift Review of unit acuity documentation on daily staff report revealed: 4/20/26 - Unit 300 - 4 seclusions over the weekend 4/20/26 - Unit 400 - 3 seclusions over the weekend, 1 colostomy care, 2 wound care, multiple wheelchairs and walkers. Very high acuity for patient needs and behaviors, 1 fall sent out to emergency room. On 4/22/26 at 1000, an interview session with nursing leaders (Staff A, Staff H) revealed that Hospital staffing decisions, were directed by “corporate”, and the staffing plan was a 1:4 ratio (minimum 1 RN per unit/per shift/per day, and excluding 1:1 observations) and requests for additional staff members at times of high patient acuity were not approved. On 4/23/26 at 1045, interview with Staff B revealed leaders of the facility attend a morning flash meeting and confirmed that the Regional CEO attended at times and confirmed: Nursing leadership has requested to increase staff based on acuity, and has been denied, despite the fact the requests were correlated with care needs of the patients and with safety events. Record review for P-2 revealed that nursing documented on 3/6/26 in a note timed 0730, “Twice this shift required multiple staff intervention for safety. No 1:1 aide available 11pm - 0700. 48030 Review of provider orders for P-2 revealed: 3/4/2026 at 0954: 1:1 observation - agitation, aggression, impulsivity - Order not discontinued 3/7/2026 at 1839: 1:1 observation while awake, every 15 minutes asleep - 2nd order Large missing gaps in observations (5 minute or 15 minute) documentation was noted as follows: 3/3/2026 - 1449 until 1804 3/4/2026 - 2149 until 2304 3/6/2026 - 1401 until 1431 3/6/2026 - 2346 until 3/7/2026 @ 0046 3/7/2026 - 0226 until 0441 3/7/2026 - 0511 until 0651 3/7/2026 - 1933 until 2103 3/7/2026 - 2103 until 2203 3/7/2026 - 2203 until 2348 3/9/2026 - 2017 until 2117 3/9/2026 - 2302 until 3/10/2026 @ 0032 3/10/2026 - 1432 until 1832 3/10/2026 - 1932 until 2247 Review of facility policy titled “Patient Observation”, policy #12931622, last revised 10/2024 reveals, “POLICY: On admission, patients shall be assigned an observation level. An order indicating the observation level shall be based on an assessment of the patient’s emotional, physical, cognitive, and behavioral status as determined by the nursing personnel assessing the patient for admission with specific consideration as to the risk posed to themselves or others. Patients will continue to be assessed and monitored during their treatment to ensure observation levels are appropriate.” and in the section titled, “PROCEDURE: 1. On admission, each patient will be assessed for the level of observation. The provider will order one of three observation levels. All patients will be admitted to the patient care unit with a minimum of “every 15 minutes” observation level” 3. Level III - 1:1 Observation, 1. The patient is to be under constant visual observation by an assigned staff member, regardless of other unit activities.””

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 36887 Based on observation, interview, and record review, the facility failed to 1) have contact information for making complaints to the State Agency for all patients served by the facility and failed to 2) address written complaints with requests for action for 2 (P-27, P-28) of 2 patients reviewed resulting in the potential for loss of patient rights. Findings include: 1) Upon entrance to the facility on 1/13/2026 at 0901, a large patient rights posting was observed hanging in the lobby. Under the section titled “Patient Grievance Process” which was highlighted in blue with white writing was listed contact information for the corporation that owned the facility, the US Department of Health and Human Services, the Michigan Department of Civil Rights, the Michigan Office of Recipient Rights and contact information for the accreditation organization serving the facility. The posting failed to include contact information for filing a complaint with the State Agency (SA) for CMS (Centers for Medicare and Medicaid Services) including the name of the department, physical address, and phone number. During the initial tour on 1/13/2026 at 1016, review of the on-boarding documents and consents revealed no up-to-date information for making a complaint to the SA. The above findings were shared with Director of Nursing Staff C during an interview on 1/15/2026 at 1020. Staff C stated she was unaware the information was not correct and agreed to pass the provided correct information on to Director of Quality Staff B. 2) On 1/15/2026 at 0940, review of the complaint log from 7/1/2025-present revealed multiple entries. Two entries were chosen: one for P-27 and the other for P-28. The complaint information was requested. On 1/15/2026 at 0947, review of the complaint information provided for P-27 revealed a “Recipient Rights Complaint” form, handwritten by a staff member assisting the patient and dated 1/2/2026, which stated, “Before I left unit 300 my Black (name brand) sweatshirt (with) Hoodie was missing.” Under section asking how to correct the “violation” it stated, “I would like my black hoodie or 60 dollars for my hoodie.” On 1/15/2026 at 0952, review of the complaint information provided for P-28 revealed a “Recipient Rights Complaint” form, handwritten by the patient and dated 12/29/2025. Under the section “What right was violated” P-28 wrote, “PERSONAL ARTICALS (sic) MISSING” and then described pants being given to staff to be placed with locked belongings as he did not want the string cut off of them. He stated he would like to have them replaced as they had been a gift and he had been “ASSURED THEY WERE GOING TO BE IN SAFE KEEPING.” On 1/15/2026 at 1000, Recipient Rights Officer Staff Q, who also took care of facility complaints and grievances, was queried as to if the complaints were opened or closed to which she stated she did not know. When asked for her investigation notes, Staff Q stated, “I turned the investigation over to [Staff C]. I don’t have any notes.” Staff Q then provided a “Complaint Action” showing “Steps taking [sic] by the Patient Advocate.” The narrative indicated Staff Q talked with P-27 and gave “a copy of [P-27’s name] complaint to give to DON (director of nursing) [Staff C]” on 1/5/2026. The Complaint Action for P-28 was similar to that of P-27 which referred the case to DON Staff C. Staff Q confirmed neither patient was given an acknowledgement letter and stated both cases must still be opened as she had not heard anything from Staff C. On 1/15/2026 at 1017, Director of Nursing Staff C stated there was not much she could do when it came to missing belongings. She stated the first step would be to view the inventory sheet to see if the item was present on arrival. If missing, she attempted to retrace the steps of where the patient last had the item. She admitted there was no lost/found area and that items found, that seemingly had no owner, were put in the donation area. Once there, it was very difficult to tell if an item was a patient belonging or a donation. Staff C admitted the facility “struggled” with documentation on the inventory sheets and being able to identify items patients might lose. When queried as to it she had investigative notes she stated she did not. She was also unaware of having to report back to Staff Q her findings or that there was any time-frame in which the investigation needed to occur. A policy or procedure related to patient belongings was not provided prior to exit.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to 1) obtain consent for 1 (P-22) of 5 patients reviewed for consent and 2) failed to notify guardians of a sexual encounter for 2 (P-5, P-6) of 2 patients reviewed for guardian notification, resulting in the loss of patient rights to make informed decision regarding care and treatment. Findings include: On 1/13/2026 at 1116, review of the medical record for P-22 revealed he was a 63-year-old male who was admitted involuntarily to the facility 1/7/2026 with dementia, altered mental status, and Alzheimer’s. P-22 had a guardian. The following consents, common for all patients, were found not signed: Influenza Vaccine, Conditions of Admission Authorization for Medical Care and Psychiatric Treatment Assignment of Benefits and Financial Agreement, Consent Addendum for Medications, Important Message from Medicare, Notice of Physician On-Site Availability, Release of Patient Access Code, Notification of Patient’s Admission, Notification of Seclusion and/or Restraint Episode, Non-Disclosure of Information, Permission to Release Information by Phone, Patient Visitation Rights, and Informed Consent for Telehealth Services. It was noted that attached to the first consent for Influenza Vaccine that a sticky note was presents stating, “Consents Need to be sent to Guardian/DPOA (durable power of attorney). On 1/13/2026 at 1120, the blank consents and/or acknowledgements were shown to Staff C. She stated the recipient rights officer, Staff Q, was responsible for follow-up with the guardian to obtain consents. On 1/13/2026 at 1528, Staff Q stated she had noticed approximately one month prior there were several medical records that had blank consents so she took it upon herself to try to contact the patient representatives. Then, the interim chief executive officer (CEO), Staff A, requested she continue to do it. When queried as to who was responsible for obtaining consent from a patient representative or guardian, Staff Q stated, “Reception is responsible to get guardianship paperwork but not necessarily the consent itself. I think nursing might be responsible. I’m not sure.” Staff Q further stated she was unaware of any policy on what should be done if unable to get consents signed by the patient representative/guardian. Staff Q also provided a log she was using to track contact made with patient representatives/guardians including for P-22. The log indicated the guardian for P-22 had two attempted phone calls, one on 1/9/2026 and one on 1/12/2026. Additionally, two emails had been sent on the same dates as the phone calls that were made. On 1/13/2026 at 1537, Staff A stated there “should be a process for finding the phone and email” for the patient representative/guardian. When queried as to his expectation of how often and how many times attempts with the patient representative/guardian should occur, Staff A state, “No less than 3 follow-ups on 3 consecutive days. Really it should be done daily until the consents are obtained.” Staff A further stated it was “not uncommon to have several guardian issues” and said the nurses were responsible on the front-end for getting consents; however, Staff Q was ultimately responsible.” Review of policies including “Consent for Admission and Treatment” effective 4/2024, “Informed Consent Process” effective 07/2021, “Consents” effective 10/2022, and “Legal Guardian, Power of Attorney and Admitting Procedures” effective 4/2023, revealed that all failed to give instruction on procedure for what to do when no response was obtained from the patient representative/guardian. The policies failed to identify timeframes for obtaining consent and failed to identify who was responsible for obtaining consent for patients. 53475 The review of the medical record for P-5, female, age 18, who was admitted to the facility on 10/7/2025) showed that she had a diagnosis of mild intellectual disabilities and psych symptoms. “Episodes of elopement, inappropriate engagement with strangers and assaultive behaviors,” fear by guardian that she “could be sex trafficked,” and “history of intellectual and developmental disability (IDD), post-traumatic stress disorder (PTSD), disruptive mood dysregulation (DMD), and attention-deficit hyperactive disorder (ADHD)” were listed as part of her psychosocial and medical history. The review of the medical record, history of present illness/presenting symptoms for P-6, a homeless male, age 66, who arrived at the facility on 4/4/2025 showed a diagnosis of schizophrenia, consistent symptoms of persecutory elusion, auditory hallucination, disorganization, lack of self-care, behavioral resistance, and impaired judgement. P-6 was at the facility at the time of the investigation. Record review revealed that on 11/07/2025 P-5 and P-6 were found in a room together with their pants off. Both P-5 and P-6 had court-appointed guardians: Guardian involvement and/or notification were not found in either medical record. Staff G, the Director of Quality, did was unable to confirm guardian notifications in her incident reporting on 11/8/2025 nor during the interview on 1/14/2026 at 1050. During an interview on 1/15/2026 at 0922, the Medical Director, Staff-L was asked about guardianship information for P-5 and P-6. She confirmed that both patients had legal guardians and no communication with the respective guardians about the incident on 11/7/2025 took place. The review of the policy “Legal Guardian, Power of Attorney and Admitting Procedures” effective 04/2023 states, “Guardian-granted by court. A legal guardian is a person who has the legal authority (and the corresponding duty) to care for the personal and property interests of another person, called a ward.” Under “Procedure” #7 and #9 it states: The admissions representative at the hospital will confirm that these forms are in the patient’s chart. This acts as a quality control measure to verify the correct steps have been taken during the admitting process in order for individual patients who have Power of Attorneys or legal Guardians speaking and making health care decisions for them.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to provide evidence of corrective actions related to identification of and protection from sexually acting out patients, resulting in the potential for patient abuse for all patients exposed to sexually acting out behaviors. Findings include: Review of the medical record for P-35 revealed he was admitted involuntarily to the facility 11/6/2025 with bipolar disorder current episode, mixed, severe, with psychotic features. From admission, P-35 displayed multiple concerning sexual behaviors throughout his hospitalization toward other patients and staff including: disrobing in common areas, grabbing/fondling his own genitalia in front of patients and staff, talk of sex and use of vulgar language regarding sex in common areas, attempting to touch female patients, exposing himself in common areas, masturbating in the hallway, entering other patient’s rooms, and fondling another patient’s genitalia (P-36). P-35 was discharged 1/15/2026 at 1725. On 1/15/2026 at 1000, review of the incident report revealed on 12/2/2025 at 0530, P-35, a 73-year-old male, was found by the Behavioral Health Associate (BHA) “in another female patient’s room with his hand in her pants.” The name of the female involved was not given and there was no corresponding incident report. Additionally, the name of the BHA was not provided. The nurse, who was the person filling out the incident report, was not available for interview. The incident report indicated Director of Nursing (DON) Staff C had been notified. On 1/15/2026 at 1017, Staff C stated her investigation of the incident should be included on the incident report. When queried as to what sexually acting out (SAO) precautions are, she stated it was an awareness that the person was acting out sexually. Staff C was then shown the incident report follow up area designated for the DON which stated, “Reviewed with DOQ (Director of Quality).” On 1/15/2026 at 1125 DOQ Staff G stated she could not recall the name of the female patient (P-36) involved and her investigation was also on the incident report. Staff G, reading from the DOQ follow-up section, stated, “Pt removed appropriately, pt placed on SAO precautions and increased pt observations to q5min (every 5 minute) checks. RN (registered nurse) completed exam and interview with other patient and noted no new scraps (sic), lacerations, bruising. Report to be filed to state.” Staff G admitted there was no further investigation information. Further review of the medical record for P-35 revealed provider notes dated 11/17/2025, 1:1 observation was “recommended.” One nursing note, dated 12/2/2025, broadly documented the above-mentioned incident and stated, “On call provider was notified and (P-35) was put on 5 minute (sic) checks until female resident was taken off the unit and put on another one.” On 1/15/2026 at 1135, Physician Staff L was queried as to why 1:1 monitoring was “recommended” and not ordered. She stated the facility does not have staff to be able to adequately monitor the patients as they should be for normal monitoring not to mention heightened monitoring. By stating 1:1 monitoring was recommended, the providers were attempting to show they recognized the need for the 1:1 monitoring while knowing it would not happen. On 1/14/2026 at 1050, Staff G stated SAO precaution training had been done in November 2025 during a staff meeting and staff were educated to the policy. On 1/14/2026 at 1230, review of staff meeting minutes dated November 2025 revealed an agenda for the staff meeting. The minutes did not show any educational points regarding SAO precautions present; however, did have a list of “handouts” which included SAO precautions. On 1/13/2026 at 0956, RN (Registered Nurse) Staff P stated the staff had received education during a staff meeting regarding sexually acting out precautions. When asked what sexually acting out precautions were, she stated, “It’s watching the patient more often.” When queried as to if that meant increased monitoring, she stated, “No, it doesn’t mean that, it means we just watch them more.” Facility policy #12195131 titled “Sexually Acting Out (SAO) Precautions” effective 8/2022 states, “PURPOSE: To provide appropriate guidelines and procedures for staff to follow when confronted with issues relating to the sexual behavior of hospital patients... (Name of a hospital within the corporation located in Indiana) will take precautions to protect patients from sexual abuse, and restrict sexual relations between patients... RESPONSIBILITIES: A. Responsibilities of ALL Staff: 1. To understand and follow hospital policy. 2. To ask for assistance from other appropriate supervisory or clinical staff members when faced with a difficult issue not clearly addressed by policy. 3. To attempt to protect patients who may be particularly vulnerable to being sexually abused by other patients. 4. To protect patients who may have experienced traumatic events and who are at risk for being re-traumatized. 5. To respond appropriately to questions or concerns that patients may have regarding sexual issues or behaviors. 6. To redirect or restrict patients who may be demonstrating sexual behaviors towards other patients. PROCEDURE: 1. Treatment teams will assess the newly admitted patient’s risk for sexually acting out. 2. Following this assessment the team will develop an appropriate risk management plan. 3. Master treatment plans will be updated with any behaviors 4. Staff members will take reasonable steps to prevent the opportunity for sexual contact between patients. 5. Staff will monitor patients for any sexually acting out behaviors. 6. Explicit sexual material is not allowed in the hospital.” The policy failed to define what SAO entailed, how to identify a patient in need of SAO precautions, documentation requirements, what precautions should be taken, how quickly precautions should be implemented, the type of monitoring that should occur to protect ALL patients from a SAO patient, and steps to take should any type of sexual contact be made between patients.”

“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: 53475 Based on interview and record review, the facility failed to 1) ensure that nursing staff acted on directives for reporting abnormal blood pressures for three (P-6, P-15, P-24) out of four patients reviewed, resulting in a failure to provide ongoing nursing assessments and interventions, and 2) failed to ensure that nursing services were documented in accordance with professional standards of practice for five (P-10, P-18, P-19, P-20, P-22) out of five patient records, resulting in the potential for less than optimal patient outcomes. Findings include: Review of the facility’s Daily Care Form indicated that “any vital signs out of normal range” required nurse notification. For blood pressure (BP), out of normal ranges are defined by the facility as “systolic” less than 100 and greater than 140 and “diastolic” less than 60 and greater than 80. The review of the Daily Care Forms revealed that the following abnormal BPs had no indication they were reported to the nurse. Note, the Daily Care Forms only allowed documentation of one set of vitals per shift, there was no designated area on the form to show who documented the vitals and the exact time the vitals were taken. On 1/10/2026, P-6 had a BP of 144/73 between 0700-1900. On 1/12/2026, P-15 had a BP of 143/71 documented in the 0700-1900 section. On 1/14/2026 between 0700-1900 the BP was recorded as 157/80. On 1/7/2026, P-24 had a BP of 148/96 between 0700-1900 and 152/92 between 1900-0700. On 1/8/2026, the BP was 143/93 between 0700-1900. On 1/12/2026 the BP was 173/102 between 0700-1900. On 1/13/2026, the BP was 183/119 between 0700-1900. On 1/14/2026, the BP was 152/101 between 0700-1900. On 1/14/2026 at 1240, in an interview with the Nurse Practitioner, Staff N, she stated that nursing staff did not call her regarding abnormal BPs/vital signs to ask for medications or treatment adjustments. She also stated that nurses “do not check BPs,” if required prior to giving medications requiring a blood pressure assessment. Staff N stated that most medication adjustments due to abnormal BPs were made based on her review of the medical record. On 1/14/2026 at 1425, Medical Director Staff L confirmed “that she “did not receive abnormal vital sign information” from nurses. Staff L acknowledged that vital signs abnormalities were sometimes communicated with her by Nurse Practitioners or the Nursing Director, Staff C, when they completed chart reviews When queried regarding how often charts were reviewed, Staff L was unable to provide a specific plan or timeframe for chart review. The facility policy on “Nursing Documentation,” effective 08/2022, states, “Nursing staff must complete documentation on each patient as outlined in this procedure. Based on the patient’s condition, situation, and complexity, clinical judgment and critical thinking are employed to determine the need for additional data collection and/ or more frequent monitoring and documentation. The policy did not have any specifics regarding documentation of or reporting abnormal vital signs. P-10 is a 65 year old female with a history of progressive dementia complicated by behavioral and psychological symptoms including aggression, impulsivity, wandering, and psychosis. P-10 was admitted to the facility on 11/19/25 after being found by police wandering 8 miles from home and rifling through mail boxes. A review of P-10s medical record revealed that a regular diet was ordered on admission. A review of P-10s weekly weight forms revealed that there was one instance marked as refused and no other weights were documented during P-10s hospitalization. A review of P-10s daily intake record revealed the following: 11/22/25: 30% breakfast, 5% lunch, no dinner documented 11/23/25: 0% breakfast and lunch, no dinner documented 11/24/25: No intake documented 11/25/25: Dinner 100%, snack 100%, other meals not documented 11/26/25: 0% breakfast and lunch, no documentation for dinner 11/27/25: No intake documented A nursing note dated 11/28/25 indicates that P-10 was lethargic at breakfast and required 2 people to stand, P-10s POA came to visit and requested that she be sent to the hospital for evaluation. P-10 was sent to the emergency department. A review of the emergency department records reveal that P-10 was admitted for altered mental status and acute kidney injury. Head CT was done, antibiotics and iv fluids were given and P-10 was discharged to another psychiatric hospital on 12/2/25. On 1/14/25 Nurse Practitioner, Staff N explained that staff often did not document or notify providers of inadequate intake. Staff N explained that if they had been notified or aware of concerns they could order nutritional supplements if needed and would watch the patient for weight loss or complications. Staff N explained that documentation was inconsistent, and staff did not always monitor intake. Staff N explained that patients should be weighed weekly. On 1/14/25 Registered Nurse, Staff CC explained that the behavioral health aids document the percentage of meals eaten, but snacks and small intake occurrences are not consistently logged. Staff CC explained that patients are allowed to refuse meals but if it is consistent or there is a concern, they notify the practitioner and they can order a supplement or more protein and the patients can always have an alternate meal if something is served that they don’t like. On 1/14/25 the Director of Nursing (DON) explained that the facility has not had a dietician in 6-7 months. If the staff has a nutritional concern they should reach out to the provider. The DON explained that it would be concerning if a patient missed 3 meals and that the BHAs should document the intake on the daily care forms and notify the nurses if there’s a concern. P-10s intake was reviewed with the DON who confirmed that it should have been identified as a concern and had an intervention put in place. The facility policy, “Nursing Documentation” effective 08/2022, states under “DAILY DOCUMENTATION A. Document at least once per shift, including but not limited to: 1. Physical and/or behavioral assessment and re-assessment, if needed based on patient’s condition. a. NOTE: May use “within normal limits” or “WNL”. If patient assessment findings are not within normal limits, the nurse documents the part of the assessment that is not within normal limits. 2. Vital signs and other monitored parameters; such as pain. 3. Nursing care and responses to interventions, as applicable.” 36887 On 1/13/2026 at 1011, review of the medical record for P-18 revealed he was a 59-year-old male involuntarily admitted for suicidal ideation 12/14/2025-present. Review of the “Patient Daily Care” forms revealed a form for each day since admission was lacking information regarding hygiene. On 1/13/2026 at 1026, review of the medical record for P-19 revealed he was an 18-year-old transgender male admitted 1/6/2026-present involuntarily for major depressive disorder, recurrent, severe, without psychotic features and borderline personality disorder. Review of the Patient Daily Care forms from admission forward revealed no documentation present for hygiene. On 1/13/2026 at 1042, review of the medical record for P-20 revealed he was a 23-year-old male admitted involuntarily 12/30/2025 - present for schizoaffective disorder, bipolar type. Review of the Patient Daily Care forms from admission forward revealed no documentation present for hygiene. On 1/13/2026 at 1116, review of the medical record for P-22 revealed he was a 63-year-old male admitted 1/7/2026-present for dementia, altered mental status, and Alzheimer’s disease. Review of the Patient Daily Care forms from admission forward revealed no documentation present for hygiene. On 1/15/2026 at 0935, Social Worker Staff AA stated patients were “receiving their ADL’s (activities of daily living - includes hygiene care)” but the schedule for providing the ADL’s was not always met. 50223”

“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: 53475 Based on interview and record review, the facility failed to 1) ensure that nursing staff acted on directives for reporting abnormal blood pressures for three (P-6, P-15, P-24) out of four patients reviewed, resulting in a failure to provide ongoing nursing assessments and interventions, and 2) failed to ensure that nursing services were documented in accordance with professional standards of practice for five (P-10, P-18, P-19, P-20, P-22) out of five patient records, resulting in the potential for less than optimal patient outcomes. Findings include: Review of the facility’s Daily Care Form indicated that “any vital signs out of normal range” required nurse notification. For blood pressure (BP), out of normal ranges are defined by the facility as “systolic” less than 100 and greater than 140 and “diastolic” less than 60 and greater than 80. The review of the Daily Care Forms revealed that the following abnormal BPs had no indication they were reported to the nurse. Note, the Daily Care Forms only allowed documentation of one set of vitals per shift, there was no designated area on the form to show who documented the vitals and the exact time the vitals were taken. On 1/10/2026, P-6 had a BP of 144/73 between 0700-1900. On 1/12/2026, P-15 had a BP of 143/71 documented in the 0700-1900 section. On 1/14/2026 between 0700-1900 the BP was recorded as 157/80. On 1/7/2026, P-24 had a BP of 148/96 between 0700-1900 and 152/92 between 1900-0700. On 1/8/2026, the BP was 143/93 between 0700-1900. On 1/12/2026 the BP was 173/102 between 0700-1900. On 1/13/2026, the BP was 183/119 between 0700-1900. On 1/14/2026, the BP was 152/101 between 0700-1900. On 1/14/2026 at 1240, in an interview with the Nurse Practitioner, Staff N, she stated that nursing staff did not call her regarding abnormal BPs/vital signs to ask for medications or treatment adjustments. She also stated that nurses “do not check BPs,” if required prior to giving medications requiring a blood pressure assessment. Staff N stated that most medication adjustments due to abnormal BPs were made based on her review of the medical record. On 1/14/2026 at 1425, Medical Director Staff L confirmed “that she “did not receive abnormal vital sign information” from nurses. Staff L acknowledged that vital signs abnormalities were sometimes communicated with her by Nurse Practitioners or the Nursing Director, Staff C, when they completed chart reviews When queried regarding how often charts were reviewed, Staff L was unable to provide a specific plan or timeframe for chart review. The facility policy on “Nursing Documentation,” effective 08/2022, states, “Nursing staff must complete documentation on each patient as outlined in this procedure. Based on the patient’s condition, situation, and complexity, clinical judgment and critical thinking are employed to determine the need for additional data collection and/ or more frequent monitoring and documentation. The policy did not have any specifics regarding documentation of or reporting abnormal vital signs. P-10 is a 65 year old female with a history of progressive dementia complicated by behavioral and psychological symptoms including aggression, impulsivity, wandering, and psychosis. P-10 was admitted to the facility on 11/19/25 after being found by police wandering 8 miles from home and rifling through mail boxes. A review of P-10s medical record revealed that a regular diet was ordered on admission. A review of P-10s weekly weight forms revealed that there was one instance marked as refused and no other weights were documented during P-10s hospitalization. A review of P-10s daily intake record revealed the following: 11/22/25: 30% breakfast, 5% lunch, no dinner documented 11/23/25: 0% breakfast and lunch, no dinner documented 11/24/25: No intake documented 11/25/25: Dinner 100%, snack 100%, other meals not documented 11/26/25: 0% breakfast and lunch, no documentation for dinner 11/27/25: No intake documented A nursing note dated 11/28/25 indicates that P-10 was lethargic at breakfast and required 2 people to stand, P-10s POA came to visit and requested that she be sent to the hospital for evaluation. P-10 was sent to the emergency department. A review of the emergency department records reveal that P-10 was admitted for altered mental status and acute kidney injury. Head CT was done, antibiotics and iv fluids were given and P-10 was discharged to another psychiatric hospital on 12/2/25. On 1/14/25 Nurse Practitioner, Staff N explained that staff often did not document or notify providers of inadequate intake. Staff N explained that if they had been notified or aware of concerns they could order nutritional supplements if needed and would watch the patient for weight loss or complications. Staff N explained that documentation was inconsistent, and staff did not always monitor intake. Staff N explained that patients should be weighed weekly. On 1/14/25 Registered Nurse, Staff CC explained that the behavioral health aids document the percentage of meals eaten, but snacks and small intake occurrences are not consistently logged. Staff CC explained that patients are allowed to refuse meals but if it is consistent or there is a concern, they notify the practitioner and they can order a supplement or more protein and the patients can always have an alternate meal if something is served that they don’t like. On 1/14/25 the Director of Nursing (DON) explained that the facility has not had a dietician in 6-7 months. If the staff has a nutritional concern they should reach out to the provider. The DON explained that it would be concerning if a patient missed 3 meals and that the BHAs should document the intake on the daily care forms and notify the nurses if there’s a concern. P-10s intake was reviewed with the DON who confirmed that it should have been identified as a concern and had an intervention put in place. The facility policy, “Nursing Documentation” effective 08/2022, states under “DAILY DOCUMENTATION A. Document at least once per shift, including but not limited to: 1. Physical and/or behavioral assessment and re-assessment, if needed based on patient’s condition. a. NOTE: May use “within normal limits” or “WNL”. If patient assessment findings are not within normal limits, the nurse documents the part of the assessment that is not within normal limits. 2. Vital signs and other monitored parameters; such as pain. 3. Nursing care and responses to interventions, as applicable.” 36887 On 1/13/2026 at 1011, review of the medical record for P-18 revealed he was a 59-year-old male involuntarily admitted for suicidal ideation 12/14/2025-present. Review of the “Patient Daily Care” forms revealed a form for each day since admission was lacking information regarding hygiene. On 1/13/2026 at 1026, review of the medical record for P-19 revealed he was an 18-year-old transgender male admitted 1/6/2026-present involuntarily for major depressive disorder, recurrent, severe, without psychotic features and borderline personality disorder. Review of the Patient Daily Care forms from admission forward revealed no documentation present for hygiene. On 1/13/2026 at 1042, review of the medical record for P-20 revealed he was a 23-year-old male admitted involuntarily 12/30/2025 - present for schizoaffective disorder, bipolar type. Review of the Patient Daily Care forms from admission forward revealed no documentation present for hygiene. On 1/13/2026 at 1116, review of the medical record for P-22 revealed he was a 63-year-old male admitted 1/7/2026-present for dementia, altered mental status, and Alzheimer’s disease. Review of the Patient Daily Care forms from admission forward revealed no documentation present for hygiene. On 1/15/2026 at 0935, Social Worker Staff AA stated patients were “receiving their ADL’s (activities of daily living - includes hygiene care)” but the schedule for providing the ADL’s was not always met.”

“CONTENT OF RECORD: HISTORY & PHYSICAL CFR(s): 482.24(c)(4)(i)(A) All records must document the following, as appropriate: (i) Evidence of-- (A) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(4)(i)(C) of this section. The medical history and physical examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 50585 Based on observation, interview, and record review, the facility failed to perform or have readily available in the medical record a history and physical (H&P) within 24 hours of admission for 1 (P-12) of 4 patients reviewed resulting in the increased likelihood of negative outcomes for the patient. Findings include: On 1/13/2026 at 1005, P-12’s medical record was reviewed on the unit. P-12 was admitted to the facility on 1/12/2026 and there was no history and physical note available in the P-12’s medical record. According to Director of Nursing Staff C, the facility had up to 1/13/2026 at 1840 to have the H&P note in the medical record (24 hours after admission). On 1/15/2026 at 0945, P-12’s medical record was reviewed on the unit and there was no H&P note for review in P-12’s medical record. Director of Quality Staff G confirmed the findings at the time of discovery. According to the facility’s “Rules and Regulations of the Medical Staff,” dated 08/2023, “A medical history and physical examination shall in all cases be completed within 24 hours following admission of the patient. In those cases, where the history and physical is performed by a mid-level practitioner there should be evidence that the person is credentialed by the hospital and legally authorized by the state to perform that function. A physician with appropriate privileges then must review and countersign.””

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to document vital signs according to the facility’s policy for 2 (P-9, P-11) of 2 patients reviewed for vital sign documentation and failed to ensure lab results were available for 1 (P-21) of 2 patients reviewed for labs, resulting in the increased likelihood of negative outcomes for the patients. Findings include: On 1/14/2026 at 1030, P-9’ s medical record was reviewed. On 11/20/2025 during the 1900 to 0700 shift, P-9’s Daily Nursing Assessment note in the vital sign section revealed no documentation of vital signs but contained the statement “see V/S chart.” P-9’s patent Daily Care Form for 11/20/2025 for the 1900-0700 shift (same shift) also revealed that there were no vital signs documented. On 11/21/2025 during the 0700 to 1900 shift, P-9’s vital sign documentation in the Daily Nursing Assessment revealed: - Temperature 91.6 - Pulse 44 - Respiration 14 - O2 saturation 90 - Blood pressure 80/58 On 11/21/2025 at 1031, P-9 was transferred to an outside facility for further treatment of low blood pressure and low body temperature. On 1/14/2026 at 1335, Director of Quality Staff G was queried about the P-9’s incident report dated 11/21/2025. The report revealed P-9 was transferred to a higher level of care (outside facility) for treatment of low blood pressure and low body temperature and Staff G revealed that in their investigation of the incident that even though P-9 would “refuse vitals,” Staff G expected “vitals” to be documented. A review of Nurse Staff EE email dated 11/21/2025 at 1900 to Director of Nursing Staff C revealed, “While finishing the filing for night shift paperwork, I noticed (P-9) had no vitals taken on Thursday after 0900. There were no vitals charted in his nurse narrative. I check the rest of night shift and discovered that no one had vitals taken after 0900 on Thursday.” On 1/14/2026 at 1030, P-11’ s medical record was reviewed. P-11 was admitted to the facility on 12/13/2025 and was discharged to a skilled nursing facility on 1/8/2026. According toe P-11’s Patient Daily Care Form vital sign documentation, vital signs were not documented on the following shifts: - 12/20/2025 for the 0700-1900 shift - 12/21/2025 for the 1900 - 0700 shift - 1/1/2026 for the 1900-0700 shift - 1/2/2026 for the 1900-0700 shift According to the facility’s policy “Nursing Documentation,” dated 8/2022, “Document at least once per shift, including but not limited to: Vital signs and other monitored parameters, such as pain.” 36887 On 1/13/2026 at 1056, review of the medical record for P-21 revealed she was a 57-year-old female who was admitted 1/5/2026 to present for major depressive disorder, recurrent, severe, without psychotic symptoms. Review of provider orders revealed on 1/6/2026 a laboratory test for PT/INR (prothrombin time - measures how many seconds it takes for a blood clot to form; international normalized ratio - measures how long it takes blood to form a clot) to be done STAT (needed immediately) as the patient was being started on Warfarin, a blood thinner. On 01/08/2026 the record revealed the PT/INR was reordered as STAT. It was noted in the lab section of the medical record there were no labs results present. On 1/13/2026 at 1005, Director of Nursing Staff C was queried as to why there were no labs on the chart. She stated they were “having issues with lab results.” She explained she was the only person who had access to look up labs and it was difficult to print them and have them put into the record. Additionally, they were receiving multiple reports stating there was insufficient blood in the tube, the testing couldn’t be done for one reason or another, or they had a delay getting a report from the lab whether it was a message it couldn’t be done or an actual result. She further stated this had been going on “for a while.” Staff C said initially they were using a local lab and there were no issues; however, shortly thereafter, they were switched to a lab approximately 45 minutes away and it “just isn’t working.” She stated they had been trying to get their own machine to run the PT/INR test on site. During the conversation, Staff C got on the computer to look up the lab results for P-21 and said, “Oh, of course. It says, ‘Test not done. Specimen underfilled.’” Staff C stated the note for the test result was put in 1/12/2026. On 1/14/2026 at 1325, Medical Director Staff L stated the issue with obtaining labs was “a corporate issue” that has been going on “for quite some time.” She stated originally a lab was used through a local acute care hospital and there were no issues; however, they now used a new lab and they only pick up at 5 pm and there are certain labs they can’t do ... We don’t have an appropriate lab provider.””

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to document vital signs according to the facility’s policy for 2 (P-9, P-11) of 2 patients reviewed for vital sign documentation and failed to ensure lab results were available for 1 (P-21) of 2 patients reviewed for labs, resulting in the increased likelihood of negative outcomes for the patients. Findings include: On 1/14/2026 at 1030, P-9’ s medical record was reviewed. On 11/20/2025 during the 1900 to 0700 shift, P-9’s Daily Nursing Assessment note in the vital sign section revealed no documentation of vital signs but contained the statement “see V/S chart.” P-9’s patent Daily Care Form for 11/20/2025 for the 1900-0700 shift (same shift) also revealed that there were no vital signs documented. On 11/21/2025 during the 0700 to 1900 shift, P-9’s vital sign documentation in the Daily Nursing Assessment revealed: - Temperature 91.6 - Pulse 44 - Respiration 14 - O2 saturation 90 - Blood pressure 80/58 On 11/21/2025 at 1031, P-9 was transferred to an outside facility for further treatment of low blood pressure and low body temperature. On 1/14/2026 at 1335, Director of Quality Staff G was queried about the P-9’s incident report dated 11/21/2025. The report revealed P-9 was transferred to a higher level of care (outside facility) for treatment of low blood pressure and low body temperature and Staff G revealed that in their investigation of the incident that even though P-9 would “refuse vitals,” Staff G expected “vitals” to be documented. A review of Nurse Staff EE email dated 11/21/2025 at 1900 to Director of Nursing Staff C revealed, “While finishing the filing for night shift paperwork, I noticed (P-9) had no vitals taken on Thursday after 0900. There were no vitals charted in his nurse narrative. I check the rest of night shift and discovered that no one had vitals taken after 0900 on Thursday.” On 1/14/2026 at 1030, P-11’ s medical record was reviewed. P-11 was admitted to the facility on 12/13/2025 and was discharged to a skilled nursing facility on 1/8/2026. According toe P-11’s Patient Daily Care Form vital sign documentation, vital signs were not documented on the following shifts: - 12/20/2025 for the 0700-1900 shift - 12/21/2025 for the 1900 - 0700 shift - 1/1/2026 for the 1900-0700 shift - 1/2/2026 for the 1900-0700 shift According to the facility’s policy “Nursing Documentation,” dated 8/2022, “Document at least once per shift, including but not limited to: Vital signs and other monitored parameters, such as pain.” 36887 On 1/13/2026 at 1056, review of the medical record for P-21 revealed she was a 57-year-old female who was admitted 1/5/2026 to present for major depressive disorder, recurrent, severe, without psychotic symptoms. Review of provider orders revealed on 1/6/2026 a laboratory test for PT/INR (prothrombin time - measures how many seconds it takes for a blood clot to form; international normalized ratio - measures how long it takes blood to form a clot) to be done STAT (needed immediately) as the patient was being started on Warfarin, a blood thinner. On 01/08/2026 the record revealed the PT/INR was reordered as STAT. It was noted in the lab section of the medical record there were no labs results present. On 1/13/2026 at 1005, Director of Nursing Staff C was queried as to why there were no labs on the chart. She stated they were “having issues with lab results.” She explained she was the only person who had access to look up labs and it was difficult to print them and have them put into the record. Additionally, they were receiving multiple reports stating there was insufficient blood in the tube, the testing couldn’t be done for one reason or another, or they had a delay getting a report from the lab whether it was a message it couldn’t be done or an actual result. She further stated this had been going on “for a while.” Staff C said initially they were using a local lab and there were no issues; however, shortly thereafter, they were switched to a lab approximately 45 minutes away and it “just isn’t working.” She stated they had been trying to get their own machine to run the PT/INR test on site. During the conversation, Staff C got on the computer to look up the lab results for P-21 and said, “Oh, of course. It says, ‘Test not done. Specimen underfilled.’” Staff C stated the note for the test result was put in 1/12/2026. On 1/14/2026 at 1325, Medical Director Staff L stated the issue with obtaining labs was “a corporate issue” that has been going on “for quite some time.” She stated originally a lab was used through a local acute care hospital and there were no issues; however, they now used a new lab and they only pick up at 5 pm and there are certain labs they can’t do ... We don’t have an appropriate lab provider.””

“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: 47415 Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment, resulting in the potential for the spread of infectious agents to all 43 patients being served at the time of survey. Findings include: On 1/13/26 at 1000, during observation of the medication storage area in the alcove between units 300 and 400, three open multidose vials of insulin were observed stored in a drawer, 2 were not dated and 1 was dated 11/11/25, which exceeded the facility’s beyond use date. Staff M confirmed the findings at the time of discovery. Review of policy titled “Use of Multiple Dose Vials,” dated effective 12/2021, revealed, “The beyond-use date for an open or entered ...multi-dose vial ...shall be 28 days ...The Pharmacy Department shall verify that Multi-Dose Vials are stored and labeled correctly when inspecting medication storage areas.” 53399 On 1/14/2026 at 0908, during a tour of 300-unit, Behavioral Health Aide (BHA) Staff G and BHA Staff Y were observed wearing disposable gloves while in the hallway. Staff G and Staff Y were observed entering and exiting patient rooms while wearing disposable gloves and failing to exchange gloves or perform hand hygiene between patients. Staff G was observed exiting a patient room, walking to a common area, and taking a patient’s blood pressure with unchanged gloves. After performing vitals, Staff G was observed entering the locked nurse’s station and completing documentation while still donning soiled gloves. Director of Quality Staff G was present during observations and when queried acknowledged the lapse in infection prevention practice. Review of policy titled “Infection Control and Prevention,” dated effective 02/2021 revealed, “Adherence to the practice of Standard Precautions is expected of all nursing staff. Nursing staff serves as a role model for all healthcare workers in the use of personal protective equipment and adherence to established guidelines.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36887 Based on interview and record review, the facility failed to protect and promote the rights of patients resulting in the loss of patient rights and the potential for unrecognized, unmet patient needs and poor patient outcomes for all patients. Findings include: See Specific Tags: A-117 Failure to provide the Important Message From Medicare A-118 Failure to develop and implement policy for grievance A-130 Failure to have the patient/representative participate in care A-131 Failure to have the patient/representative sign consents to care A-142 Failure to provide safety A-144 Failure to provide care in a safe setting A-145 Failure to provide freedom from abuse A-154 Failure to evaluate seclusion A-160 Failure to be free of chemical restraint A-171 Failure to follow and renew physician orders for seclusion A-175 Failure to monitor patients in seclusion per policy A-178 Failure to provide a face-to-face assessment within one hour of initiating restraint or seclusion”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 47415 Based on interview and record review, the facility failed to have an organized nursing service with a consistent plan for administrative authority and delineation of responsibilities for the oversight of nursing services, resulting in poor patient outcomes, and the potential of harm for all patients served at the facility. Findings include: See tags: A0392 - Staffing and the Delivery of Care A0396 - Nursing Care Plan A0398 - Supervision of Contract staff A0405 - Administration of Drugs A0407 - Verbal Orders for Drugs”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 50585 Based on interview and record review, the facility failed to maintain accurate medical records and make physician notes readily accessible for all care providers, authenticate the patient’s consents and orders, and ensure the patient’s history and physical exams were performed in a timely manner resulting in increased likelihood of negative consequences and poor outcomes for all patients. Findings include: See Tag; 0438 Failure to make medical records readily accessible and maintain accurate records 0454 Failure to authenticate consents and orders 0458 Content of Record: History and Physical”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 38269 Based on observation, interview and record review, the facility failed to maintain an active hospital-wide program with oversight of the surveillance, prevention, and control of Health Care Associated Infections and other infectious diseases resulting in the potential for transmission of infectious agents to all 57 patients served by the facility at the time of survey. See specific tags: See Tags: A-0748 Failure to have an Infection Control Professional on staff to lead the infection prevention and control program. A-0749 Failure to monitor and conduct infection surveillance activities. A-0750 Failure to maintain a sanitary environment. A-0774 Failure to integrate infection control into the QAPI program. A-0775 Failure to provide evidence of infection control competency. A-0776 Failure to adhere to policies and procedures.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to provide information regarding discharge rights to Medicare patients for 4 (P-1, 4, 27, 45) of 13 patients reviewed resulting in the loss of patient rights. Findings include: Review of the medical record for P-1 revealed a document titled “Important Message From Medicare” (IMM) with a patient sticker in the upper right corner of the first page present. There was no signature, date, or time present on the document indicating a patient/representative was provided the information. Review of the medical record for P-4 revealed the IMM form with the patient’s sticker in the upper right corner of the first page. The patient signature was present; however, it was not dated or timed. Review of the medical record for P-27 revealed an IMM form with the patient’s sticker in the upper right corner of the first page. There was no signature, date or time present on the document indicating a patient/representative was provided the information. Staff N stated on 10/9/2025 at 0948 the IMM was signed by the patient on admission. Policy regarding the provision of information for discharge rights (IMM) was requested but not provided. 29955 On 10/8/2025 at 1900, during an interview with P-55 confidential informant revealed P-45 was transferred to the facility with concerns of potential drug interaction and neurological changes from an unwitnessed fall hitting her head. P-55 stated that the patient had stroke-like symptoms and was documented as being in a catatonic state on admission. On 10/12/2025 at 1445, during an interview with staff FF they stated P-45 should not have been transferred to the facility due to her (P-45) neurological changes as reported from caregivers and changes in physical abilities such as inability to swallow, inability to ambulate, and constant gaze to the left. Staff FF further stated P-45 could not participate in the admission assessment. Staff FF was queried if they had reported concerns to anyone in the facility. Staff FF stated they had reported concerns to the interim Chief Nursing Officer (CNO) staff B and Psychiatrist staff D, but nothing had been done. On 10/12/2025 at 1450, during an interview, staff G stated P-45 upon admission could not participate in the admission assessment. Staff G further stated P-45’s cognitive ability was in question when they assessed P-45 on 09/02/2025. Staff G was queried if they had reported concerns of P-45’s cognitive ability and they stated they had but were told P-45 would continue to be monitored. On 10/13/2025 during review of P-45’s medical chart it was revealed that on 09/01/2025, P-45 was admitted to the facility with concerns of two suspected falls with possible hitting of her head, unable to move extremities and unable to transfer from the transfer stretcher to patient bed, right arm droop, constant gaze to the left, and possible drug interaction. However, review of admission consent for P-45 revealed that P-45 gave verbal consent on 09/01/2025 and review of P-45’s IMM (Important Message from Medicare) revealed the admitting nurse staff Q signed the document on behalf of P-45 despite her neurological condition and being unable to participate in the admission process. There was no evidence of attempts to contact family or other designated caregivers to obtain admission consent.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to identify a grievance and what steps to take when a grievance was submitted for 1 (P-5) of 3 patients reviewed for grievances resulting in the potential loss of patient rights and the potential for unidentified, unmet patient needs and poor patient outcomes. Findings include: On 10/7/2025 at 1300, review of the Grievance Log from April 2025-present revealed nine entries dating from 5/1/2025-8/1/2025. Grievances listed included wanting a phone to look up an address, wanting a Bible, wanting a Quran, wanting a lawyer phone number, feeling unsafe when a member of the opposite sex entered the bedroom, feeling unsafe with another patient on the unit, staff threatening and bullying, not liking the food served, and was refused graham crackers. On 10/7/2025 at 1547, Staff L was queried as to the difference between a complaint and grievance to which she stated a grievance was “something simple, like ‘it’s cold.’” She explained that a complaint required a more in-depth investigation. On 10/7/2025 at 1547, review of a complaint submitted by P-5 regarding staff threatening and bullying revealed a written complaint by P-5 that was submitted 7/28/2025. The complaint was treated by Staff L as a Recipient Rights case, #7082. The “Case File Sheet” listed “Name of accused” as “staff and Pt.” The form indicated the case was resolved by intervention and was not substantiated. A small handwritten note toward the bottom of the page stated, “7/29/2025 around 1:20pm went to talk with pt b/c (because) pt was agitated.” A copy of nursing notes from 7/27/2025 and provider orders for a chemical restraint dated 7/27/2025 were present in the case file. Additionally, an “Intervention acknowledge letter” dated 7/29/2025 which stated, “...It has been determined that an intervention can be completed regarding your complaint. A Rights Advisor will intervene on your behalf to resolve your concern and will advise you, in writing, of the results within 30 days.” There were no notes, interviews, or other follow-up documentation present in the file. On 10/7/2025 at 1555, Staff L stated she realized part way through her investigation this should have been considered a grievance. Facility policy #13554552 titled “Section 504 Grievance Procedure” effective 4/2023 states, “Grievances must be submitted to the Section 504 Coordinator/designee within 30 days of the date the person filing the grievance becomes aware of the alleged discriminatory action. A complaint must be in writing, containing the name and address of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought. The Section 504 Coordinator/designee shall investigate the complaint. This investigation may be informal, but it must be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Section 504 Coordinator/designee will maintain the files and records of the Hospital relating to such grievances. The Section 504 Coordinator/designee will issue a written decision on the grievance no later than 30 days after its filing. The person filing the grievance may appeal the decision of the Section 504 Coordinator/designee by writing to the CEO within 15 days of receiving the Section 504 Coordinator’s/designee’s decision. The CEO shall issue a written decision in response to the appeal no later than 30 days after its filing.” Facility policy #13517670 titled “Patient Rights and Responsibilities” effective 4/2023 states, “File a grievance or complaint verbally, by phone or in writing to any staff member. All grievances will be addressed in a timely manner. This organization will make every attempt to provide a response within seven (7) days of receiving a grievance. All grievances will be investigated with efforts made toward resolution within seven (7) days of receiving a grievance. You may file a grievance or complaint with the hospital or any of the agencies listed below whether or not you use the hospital’s complaint/grievance process. Lighthouse Services Compliance Reporting...Chicago, IL (phone number); Indiana State Department of Health...IN (Indiana) Div. of Mental Health & Addiction Consumer Complaint Line (phone number); The Joint Commission... Indiana Protection and Advocacy Services (phone number).” The policy fails to provide any information for grievances to be made to the State of Michigan or to the facility’s accreditation organization, DNV (Det Norske Vertias).”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to include the patient’s Durable Power of Attorney (DPOA) in a review of the patient’s care plan for 1 (P-3) of 1 patients reviewed with a DPOA resulting in the increased likelihood of negative consequences for the patient. Findings include: On 10/7/2025 at 1000, P-3’s medical record was reviewed. P-3’s Legal/Admit Status in the patient information sheet revealed P-3 had a “POA (Power of Attorney)/Guardian.” P-3’s medical record included a copy of an Advance Directive, dated 6/27/2020 that revealed a family member would serve as P-3’s Patient Advocate. P-3’s Treatment Plan for 6/17/2025 revealed “pt unable to sign due to cognitive deficit” and the section for Legal Rep Signature was left blank. P-3’s Treatment Plan for 6/24/2025 revealed “pt unable to sign due to cognitive deficit” and the section for Legal Rep Signature was left blank. P-3’s Treatment plan for 7/1/2025 revealed “pt refused to sign” and the section for Legal Rep Signature was left blank. On 10/7/2025 at 1210, Staff B acknowledged the findings. According to the facility’s policy “Patients Treatment Plan.” dated 9/2022, revealed that the “Treatment plans will be provided to the patient or the guardian.””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 47415 Based on interview and record review, the facility failed to obtain the general consent for treatment, for 1(P-1) of 1 patients reviewed, and failed to have the patient make informed decisions regarding treatment with psychotropic medications for 5 (P-3, P-4, P-17, P-33, P 34) of 6 patients reviewed for psychotropic medication consents, resulting in the loss of the patient’s right to make an informed decision regarding their care and treatment. Findings include: On 10/9/25 review of the medical record reviews revealed: P-4 was a male 37-year-old male, admitted to the facility on 7/25/25 at 2024. P-4 was admitted with the primary diagnoses of schizophrenia and depression. Two (2) incomplete psychotropic medication consent forms were found in the record. One informed consent listed Risperdal and Uzedy (both Risperidone) used to treat schizophrenia, blank spaces on form included dose, frequency and route, and the form was not signed by the patient, staff or prescriber. The second psychotropic consent form listed Trazodone, Zyprexa, and Ativan medications, but did not contain signatures of the patient, staff, or prescriber. Review of medical record for P-4 revealed that psychotropic medications were delivered to P-4 on numerous occasions during stay including Risperdal 1 milligram (mg) on 7/26/25 at 0900 and 2235, and Zyprexa 10 mg on 7/26/25 at 0900 and 2100 without the informed consent signed. P-17 a 27-old-male admitted to the facility on 8/28/25. On 8/29/25 the psychotropic informed consent form revealed the patient signed, dated, and timed the psychotropic medication form that did not list any psychotropic drugs. Review of the record revealed P-17 was ordered/and given Risperidone. Interview with RN Staff N on 10/6/25 at 1115, revealed that informed consents are initiated and signed on admission for psychotropic medications, after orders and patient education. On 10/6/25 at approximately 1140, an interview with the Director of Nursing (DON), Staff B revealed the informed consent should be signed before psychotropic medications are administered. Review of policy titled, “Use of Psychotropic Medications”, dated 5/2024 (last approved), revealed: “ Informed Consent ...Clients (or their legally authorized representatives) must be informed about the purpose, benefits, risks, and potential side effects of psychotropic medications ...Informed consent must be obtained and documented before initiating or changing any psychotropic medication”. 50585 On 10/6/2025 at 1135, during a tour of the inpatient unit, P-33 and P-34 medical records were reviewed. P-33 medication administration record revealed P-33 received Risperidone (antipsychotic medication) 2 mg oral doses on 9/21/2025, 9/22/2025, and 9/23/2025. P-34 medication administration record revealed P-34 received Risperidone 2 mg oral doses on 9/29/2025 at 0900 and 2000. Medication consents for both patients were blank. Staff Z confirmed the findings at the time of discovery. On 10/7/2025 at 1000, P-3’s medical record was reviewed and P-3’s Informed Consent for the Use of Psychotropic Medications was observed to be incomplete with all sections of the medication consent left blank. According to P-3’s medication administration record, P-3 received Zyprexa (antipsychotic medication) 5 mg orally on 6/29/2025 at 1148 and 2100, on 6/30/2025 at 0844 and 2000, and on 7/1/2025 at 0840 and 2014. 36887 Review of the medical record for P-1, who had a legal guardian, revealed admission consents were not signed by the guardian including: “Conditions of Admission Authorization for Medical Care and Psychiatric Treatment Assignment of Benefits and Financial Agreement”, the “Consent Addendum for Medications”, the “Important Message from Medicare”, the “Notice of Physician On-Site Availability”, the “Notification of Patient’s Admission”, the “Patient Visitation Rights”, the “Informed Consent for Telehealth Services”, the “Release of Patient Access Code”, and the “Influenza Vaccine Consent Form”. Facility policy #12500799 titled “Consent for Admission and Treatment” effective 4/2024 states, “When a patient admits voluntary the following steps are to take place to ensure consents are completed accurately: The reception department will receive documentation from the intake department via email stating the patient is admitting voluntarily. Once the patient arrives, the receptionist will then meet with the patient and go over each consent for signature. Once the consents are signed, the receptionist will place the original copies into the patient’s chart...When a patient is being admitted and has a Power of Attorney or Guardian the following steps are to take place to ensure consents are completed accurately and in a timely manner: The reception department will receive documentation from the intake department stating the patient is admitting and has a Power of Attorney or Guardian. The receptionist will then call the Power of Attorney or Guardian for consent to treat. The receptionist will go over each consent with them and get their verbal permission for each. The receptionist will make a copy of the consents and mail them to the Power of Attorney or Guardian if they are not going to be in to visit within that same week...The reception department will follow up weekly with the Power of Attorney or Guardian regarding the status of receiving the signed consents back... The following steps are taken if a patient admits to our facility voluntarily but is having difficulties signing the consents: The receptionist will speak with the voluntary patient regarding signing consents and have the patient attempt to sign. If the patient is having difficulty signing due to fatigue, tremors, visibility, they may then express their wishes to give verbal consent. The receptionist will call in a witness to hear the verbal consent given by the patient. The receptionist will then go over each consent and get the patient’s verbal consent. The receptionist will write on the consents that the patient gave verbal consent and they, along with the witness will both sign on each form as witnesses to the consent... When a patient is being admitted on a 72 hour hold the following steps are to take place to ensure proper documentation is occurring: The reception department will receive documentation from the intake department stating the patient is coming involuntarily along with a copy of the Emergency Detainment Order. The receptionist will put a copy of the Emergency Detainment Order in the patient’s chart. The receptionist will take a copy of the Emergency Detainment Order consent form to the patient to sign. The patient will decide whether they want family or friends to be given their patient specific passcode to visit or call or they will decide whether they do not want anyone to have their passcode... Once the 72-hour hold is concluding, the receptionist will speak with the patient and have them sign consents for admission and treatment. If the patient refuses to sign, reception will inform social services, nursing and the physician... Should the psychiatrist determine that the patient needs further care, an application for Temporary Commitment for treatment will be filed with the county court. Continued treatment or discharge will be determined by the judge.” The policy failed to address the appropriate time-frame in which the consents should be obtained and failed to provide guidance on the process after hours.”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 47415 Based on interview and record reviews, the facility failed to notify 2 (P-40, P-42) of 4 patients of a Healthcare Information and Portability (HIPAA) breach, resulting in a denial of their rights. P-40 had a voice message regarding personal health information (patient name and medication) left on a voice message at a wrong number. (5/30/25). No documentation found that P-40 was notified of the breach or that a HIPAA Breach letter was sent by certified mail. P-42 had his medication list given to another patient (P-40) at discharge (6/25/25). No documentation found that P-42 was notified of the breach or that a HIPAA Breach letter was sent out by certified mail. On 10/7/25 at 1020 an interview with Staff K revealed that she was also the privacy officer, who handles HIPAA (Health Insurance Portability and Accountability Act) breaches that occur at the facility. Staff K stated that she carries out the investigations and notifications according to HIPAA regulations. A HIPPA policy was requested during survey and not provided.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47415 Based on observation and interview, the nursing staff failed to follow policy and check the crash cart including emergency supplies and equipment daily and failed to provide a safe environment for care for 1 (P-9) of 1 patients reviewed resulting in the injury and subseqent death of P-9 and the potential for unsatisfactory outcomes for all other patients served by the facility. Findings include: On 8/12/25 at 1120, the emergency crash cart was inspected. The Crash Cart log for Unit 200 and Unit 400 had numerous dates in which there was no documentation that the cart was checked per policy. Findings include: Unit 200’s crash cart log was not checked on: July 1-10,13-15, 17, 18, 20 -23, and 30, August 1, August 20, September 4, 10, 16, 26, 28 Unit 400’s crash cart log was not checked on: July log not in book at time of observation August 1, 2, 8, 15-16, 20, 31 September 7-9, 15, 18, 29, 30 October 2 These findings were reviewed and confirmed with Staff B at the time of discovery who commented it is the responsibility of the night shift. On 10/6/25 at 1015 an interview with Staff R revealed staffing is on the low side for the night shift, running units with 1 registered nurse and 1 behavioral health assistant, when matrix calls for 2 on “low side”, night shift with 1 registered nurse (RN) and 1 behavioral health assistant (BHA) per unit, when matrix calls for 2 RN’s and 2 BHA’s. Review of policy titled, “Crash Cart and Emergency Medication Kit” dated approved 8/2022 revealed, “Purpose: To assure that an emergency supply cart containing supplies and monitoring equipment used in the care and initial treatment of cardiopulmonary arrest victims, including suction and defibrillator components are available and ready for use ...Nursing is responsible for checking and documentation of the integrity of the crash cart and all equipment on top of cart ...Nursing is responsible for monitoring crash cart supplies ...Daily check includes AED (automatic external defibrillator).” 36887 Upon entrance to the facility on 10/6/2025 at 0930, a request was made for a list of all patient deaths in the facility. Staff B stated on 10/6/2025 at 1111 there had been no deaths at the facility; however, one patient was assaulted at the facility and later died at another hospital. Staff B identified the patient as P-9. At that time, a request was made for medical records, incident reports, and the facility’s investigation. Review of the medical record for P-9 revealed he was a 70-year-old male with a court-appointed guardian who was admitted to the facility on 1/21/2025 with the diagnoses of Dementia in Other Diseases Classified Elsewhere, Unspecified Severity with Psychotic Disturbances; Anxiety Disorder, Unspecified; Schizoid Personality Disorder; Major Depressive Disorder. The treatment plan included “Immediate Safety Measures: Given the patient’s aggressive behaviors and threats of harm, the patient should remain in a secure setting with constant supervision.” Provider notes dated 1/26/2025 at 1105 indicated P-9 was in the day area, was calm and cooperative although confused. It further noted he was medication compliant. Mood was calm. He was alert and oriented to person only. Insight and judgment were described as “Poor.” No provider notes were present for 1/27/2025. Review of the medical record for P-28 revealed he was a 38-year-old male who was involuntarily admitted to the facility 1/20/2025 for Bipolar I Disorder (a mental illness characterized by extreme mood swings), current episode manic with suicidal and homicidal ideation; Major Depressive Disorder (serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), recurrent, severe, without psychotic features; Generalized Anxiety Disorder (excessive, ongoing anxiety and worry that are difficult to control and interfere with day-to-day activities); Attention-Deficit/Hyperactivity Disorder (unable to keep focus with excessive movement that is not fitting to the setting with impulsivity); History of substance misuse. The treatment plan in the “Initial Psychiatric Assessment” dated 1/20/2025 included medication review and adjustment, addressing medication non-compliance, initiating psychotherapy with a focus on coping strategies and anger management, and discussion of triggers for harming himself or others. Insight and judgment were described as “Poor.” In conclusion, the provider wrote, “The patient presents with severe psychiatric symptoms, including suicidal and homicidal ideation, impulsivity, and a history of substance misuse. His psychiatric conditions, including bipolar disorder and major depressive disorder, appear to be inadequately managed, with significant risks to his safety and the safety of others. Immediate psychiatric hospitalization and close monitoring are essential for his stabilization.” P-28 was in a wheelchair due to a right BKA (below the knee amputation). The discharge summary dated 2/6/2025 indicated precautions included “suicide, assault, and fall. He was 1:1 due to current assaultive behavior.” On 10/8/2025 at 1615, review of the provided incident reports (IR) revealed one for P-9 and one for P-28. The IR for P-9 indicated a severity of “Temporary Harm” and stated he “suffered injuries post assault from another Patient.” Injuries included a “laceration above the right eye brow that was actively bleeding” and P-9 had complained of “right rib and right shoulder pain and pain in the mid lower back.” P-9’s neck “was stabilized” and he was sent to a near by emergency department via EMS (emergency medical services). Included with the incident reports were multiple radiology reports including a CT (computerized tomography - “cat scan”) of the chest, abdomen and pelvis dated 1/26/2025 at 1603. Findings included: “...Subcutaneous emphysema (air accumulation under the skin) is noted in the right neck... small right predominantly basilar pneumothorax (collection of air at the bottom of the lung space near the diaphragm) without signs to suggest tension. Small right hemothorax (blood accumulation in the lung cavity)... Mildly displaced right scapular (shoulder blade) fracture inferiorly (fracture of the inferior angle of the scapula that typically occurs due to high-energy trauma). Right fourth, fifth, sixth, seventh, eighth, ninth rib fractures. The sixth rib fracture is comminuted (reduced to minute particles or fragments) with small butterfly fragment. The seventh and eighth rib fractures are subcutaneous emphysema is present (sic) along the right posterior chest wall (the back portion of the rib cage, composed of the 12 thoracic vertebrae, 12 ribs, and the muscles, nerves, and vessels between them). Displaced.” Further review of the medical record for P-9 revealed a death certificate which indicated he passed away 2/14/2025. Manner of death was listed as a homicide. The incident report for P-28 indicated a severity level of “Emotional Distress/Inconvenience” and stated he “assaulted another patient for wandering into his room. Patient’s Rt (right) hand was noted as red and swollen... ROM (range of motion) is WNL (within normal limits).” Staff N stated during interview on 10/9/2025 at 0948 it was time for lunch and she was in the nurse’s station documenting blood sugars when P-28 “hopped to the nursing station and started yelling, ‘I told you that (swearing) kept coming into my room. Now that (swearing) is on the floor laying in his own blood.’” P-9 was found on the floor in P-28’s room “mumbling about finding a tackle box.” Staff N was queried as to what, if anything, happened with P-28 following the assault. Staff N stated, “Nothing happened to (P-28). After the assault, he was calm and went down to the dayroom and was watching TV (television).” Staff N was then queried as to what constituted assault precautions. Staff N stated it did not automatically mean the patient was 1:1, but was meant for staff to be aware of what behaviors could occur. On 10/9/2025 at 1051, Staff O stated he was helping with lunch when a blind patient had asked for help. While turning to help the blind patient, he overheard P-9 say he had to use the restroom and saw him start walking down the hallway. Staff O described P-9 as confused. Staff had hung a sign on P-9’s door to help him recognize his own room. “The next thing I knew, I heard P-28 saying, ‘I kicked his ass’ repeatedly.” Staff O went down the hallway and found P-9 in P-28’s bathroom bent over with blood by his eye and complaining of rib pain. Further review of the medical record for P-28 revealed a provider progress note dated 1/27/2025 which documented, “Pt was heard bragging how he sent another pt to the hospital d/t (due to) using his hands to hurt someone else.” The same progress note indicated P-28 was to continue have rounding observations every 15 minutes with suicide, assault, and fall precautions. He was not placed into 1:1 observation until 1/30/2025. Review of provider progress notes for 1/30/2025 indicated there was a discussion regarding the reason for 1:1; however, the notes do not provide the reason for the 1:1. Review of nursing notes revealed P-28 was placed into 1:1 observation due to verbal and physical aggression and destruction of property. Staff L stated on 10/9/2025 at 1120 that at the time of the incident, she reviewed the video and based her investigation off the video findings. The timeline from the video documentation was placed into an incident report and listed as a grievance under P-28’s name. The timeline is as follows: “12:10:45 pm (P-9) went into (P-28) room 12:11:29 pm (P-28) came out of his room yelling something 12:11:50 pm a BHA (behavioral health aide) walks down the hall to see what happened and Patient (unknown patient name) followed behind. 12:12 pm (unknown patient name) has (P-28) sit down.” No in-person interviews were conducted. Staff L described the video as seeing P-9 walking down the hall and entering P-28’s room. “Within a minute, (P-28) came hopping out and yelling. Staff O walked down to P-28’s room followed by the nurse. P-28 went into the milieu and sat to watch TV.” Staff L stated the video of the incident was not retained. No RCA was completed by the facility and no changes were made regarding facility response following a patient-to-patient assault with serious injury. Facility policy #13517670 titled “Patient Rights and Responsibilities” effective 4/2023 states, “You have the right to:... Receive care in a safe setting, free from verbal or physical abuse or harassment...” Facility policy (no policy number present) titled “Abuse and Neglect” effective 8/2024 states, “Abuse: Non-accidental harm or threatened harm to an individual’s health or welfare caused by another person... Physical Abuse Type: Hitting slapping, pushing, shaking or other forms of physical harm. Severity: Mild: Minor bruises or abrasions not requiring medical treatment. Moderate: Injuries requiring medical evaluation but not hospitalization. Severe: Injuries requiring hospitalization or causing permanent damage... Response and Investigation 1. Immediate Action Ensure the safety and well-being of the individual involved. Provide immediate medical and psychological support if necessary. 2. Internal Investigation The designated safeguarding officer will conduct a thorough investigation of the incident, including interviews with the individual involved, witnesses, and the accused party. The investigation must be documented and concluded within a specified time frame (e.g., 30 days). 3. Corrective Action Based on the investigation findings, appropriate corrective actions will be taken, which may include disciplinary action against the perpetrator, changes in procedures, or additional training for staff. 4. Follow-up Monitor the individual’s well-being and provide ongoing support. Review and update the policy and procedures based on lessons learned from the incident.””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 29955 Based on interview and record review the facility failed to keep 3 patients (P-3, P-7, and P-45) of 5 patients reviewed for abuse and neglect, free from abuse and neglect resulting in neglect of a patient’s basic needs for survival and abuse of a patient. Findings include: On 10/12/2025 at 1535 during an interview with staff Q they stated that the facility failed to have trained staff on site to conduct swallow screening for admissions. Staff Q stated that a patient was received at the facility who displayed neurological concerns and could not swallow. Staff Q further stated that there was not anyone at the facility that could do a swallow study. At the time of admission, staff Q brought those concerns to the Interim Chief Nursing Officer staff B and the Nurse Practitioner staff G that P-45 was unable to swallow and had a constant gaze to the left. On 10/12/2025 at 1545 Staff FF was interviewed if they were able to perform a swallow screen and they stated they were not able to perform a swallow screen, but was aware of P-45’s inability to swallow when they had initially assessed P-45. Staff FF stated they had shared concerns of P-45’s neurological symptoms of a constant gaze to the left and limited ability to move, to psychiatrist staff D. On 10/12/2025 at 1600 Nurse Practitioner Staff G was asked if they had been alerted by nursing staff concerning P-45’s inability to swallow, constant gaze to the left, and limited movement. Staff G stated yes and they had examined P-45 on 09/02/2025 as part of the admission process and did document in the assessment P-45’s inability to swallow and neurological concerns in their assessment. Staff G stated she also recommended to staff D that P-45 be transferred out to an acute care hospital for neurological concerns. Review of P-45’s Interdisciplinary Care Plan dated 9/1/2025 noted the patient was an “aspiration risk”. However, the record revealed a “regular diet” was ordered for P-45. A review of P-45’s medical record revealed P-45 was a 64-year-old female that had been transferred to the facility from a hospital emergency room on 09/01/2025 at 1835. P-45 was transferred out of the psychiatric facility on 09/03/2025 at 0825. P-45’s discharge summary from the psychiatric facility revealed the following, “Patient transferred and admitted to an outside facility for further medical evaluation and management due to concerns of failure to thrive, hypertension, and hypoxia requiring a higher level of medical care. Condition at transfer - Medically unstable with ongoing altered mental status and catatonic features; partially responsive to IM (intramuscular) lorazepam. Requires comprehensive medical evaluation and stabilization before return to psychiatric services.” 47415 The facility failed to prevent patients from being abused by other patients and failed to follow policy and implement corrective actions to prevent P-7 from physically attacking patients, on 2 occasions, causing injury and the potential for injury to other patients on the unit. On 10/29/25 at 1000, incident reports were reviewed, revealing: on 8/1/25 at 0415, 2 patients were having an altercation in the milieu. P-7 (a third patient) physically attacked one of the patients having the altercation, by pulling her hair and hitting her. Injury documented as a bump to left side of head, and that a chunk of hair was pulled out). No follow up actions to mitigate future risks documented. On 8/7/25, in the dayroom, P-7 punched a peer in the face. (P-7 was on 1:1 observation, prior to incident) No follow up actions to mitigate future risks documented. An interview on 10/30/25 at 0930, with Staff B and Staff C confirmed corrective actions were not documented. Review of the facility’s policy titled, “Patient Rights and Responsibilities”, dated 4/2023, revealed: “You have the right to: ...Receive care in a safe setting, free from verbal or physical abuse or harassment ...” Review of the facility’s policy titled, “Abuse and Neglect,” dated 05/2024, “3. Corrective Action ... Based on the investigation findings, appropriate corrective actions will be taken, which may include ...changes in procedures, or additional training for staff.” 50585 On 10/9/2025 at 1250, P-3’s incident report was reviewed with Staff C and the report revealed that P-3 entered the room of another patient and “Pt was then seen coming out of another pt’s room holding (their) left side of (their) face.” The incident report under Injury or Adverse Outcome revealed “red mark on left cheek, no break in skin.” The actions reported on the incident report revealed “MD notified” and “Supervisor notified.” The Follow Up/Resolution section revealed “Incident reviewed. Unable to substantiate report, No further review needed.” A second incident report regarding the same incident involving P-3 was reviewed. The report revealed “This Nurse overheard another Patient yelling and swearing “Get out of my room” when this Nurse went to Investigate, Patient was noted coming out of the room “holding the left side of her face.” The report revealed “redness noted” and Actions Taken Post-Incident included “MD notified, Supervisor notified, Family Notified and Treatment/evaluation conducted.” The Follow-up Resolution by the DON revealed “Incident reviewed, Patient observed entering another patient’s room and exiting. Unable to substantiate any other details. No further review needed.” The Follow -Resolution by the Risk manager revealed “staff responded appropriate with post incident interventions” and by Compliance “Can not review video in room, staff responded to the incident, no need for ORR (Officer of Recipients Rights).” Staff C was queried whether the two patients were interviewed post incident and they could not confirm. Staff C was queried in their role would you expect both patients to be interviewed and to include documentation about the interviews, and they said “yes.” According to the facility’s policy “Abuse and Neglect,” dated 05/2024, “Internal Investigation, The designated safeguarding officer will conduct a thorough investigation of the incident, including interviews with the individual involved, witnesses, and the accused party.””

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to discontinue seclusion at the earliest possible time for 1 (P-2) of 2 patients reviewed for seclusion resulting in the loss of patient rights. Findings include: On 10/13/2025 at 1510 review of seclusion documentation for P-2 revealed she was a 45-year-old female who was placed in seclusion on 7/10/2025 at 0540 for threatening behavior and irrational verbal aggression. She remained in seclusion until 7/10/2025 at 0650 (65 minutes). The “Assessment of Patient’s Immediate Situation” had only respirations documented for vital signs with a note which stated, “refused, sleeping. No signs of distress.” Areas for nutrition/hydration, pain, attitude, aggression, thought process/content, and level of consciousness were not addressed. In the section for mood, the box titled “Other”was checked with “Sleeping” written on the explanation line. There was no date or time of the assessment present. In the “Vital Sign Flow Sheet” section, entries were made at 0600, 0620, and 0645. The first line at 0600 stated “Refused-Sleeping-No signs of distress.” At 0620, a note stated, “Refused” with ellipses marks and a line through the boxes indicating the same note as the previous note at 0600. The note at 0645 stated, “Sleeping No signs of distress.” On 10/14/2025 at 0915, Staff C admitted “work needed to be done” regarding documentation for restraint/seclusion. Facility policy #13483128 titled “Restraint or Seclusion Use” effective 4/2023 states, “Patients at the Hospital have the right to be free from restraints of any form that are not medically necessary...Seclusion may only continue until the precipitating self-or other-injurious behavior ceases or for 2 hours whichever is less.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to ensure chemical restraint was used appropriately for 9 (P-5, 18, 19, 21, 22, 23, 24, 25, 26) of 15 patients on the unit resulting in the loss of patient rights and the potential for poor patient outcomes. Findings include: Staff D stated during interview on 10/7/2025 at 1333 it had been brought to her attention that multiple patients on the 100 unit were given Ativan (benzodiazapine that causes sleepiness) as well as other medications that cause sleepiness on the evening of 7/16/2025 out of staff convenience rather than patient need. On 10/8/2025 at 0727, Staff D provided a screenshot of a text message she had received regarding the chemical restraint with patient initials and room numbers as well as the medications that were given. Staff D noted that all of the meds were given near or during the 2000 hour, approximately 1-2 hours after the start of the evening shift. The patients were identified as follows: Review of the medical record for P-5 revealed she was hospitalized for anxiety and bipolar disorder with mania (periods of high energy and impulsive behavior). The 7/16/2025 “Daily Nursing Assessment” for “Night Shift” indicated she was cooperative and appropriate. The rounding sheet from 7/16/2025 revealed she was alert and cooperative or sleeping for the entire day (0000-2355). Nursing notes dated 7/17/2025 at 0034 stated, “Patient A&Ox4 (alert and oriented to person, place, time, and situation) but can be very grandious (sic) and & is up to the nursing station with many moods, patient is social with peers and medication compliant...” Review of the MAR (medication administration record) for P-5 revealed an order for Ativan 1 mg (milligram) by mouth every 6 hours prn (as needed) for agitation. The MAR revealed she received the Ativan at 2200. Review of the medical record for P-18 revealed he was hospitalized for depression. The 7/16/2025 “Daily Nursing Assessment” for “Night Shift” indicated he was cooperative and appropriate. The assessment further indicated the patient was in no pain; however, the assessment did not provide a time that it was completed. Nursing notes dated 7/16/2025 at 2252 stated, “Patient is A&Ox4, calm & cooperative with assessment...Patient is social in an appropriate manner...” Review of the MAR revealed an order for Oxycodone 5 mg every 6 hours as needed for pain and Ativan 1 mg by mouth every 6 hours as needed for agitation. On 7/16/2025, MAR revealed both the Oxycodone and Ativan was given at 2054. Review of the medical record for P-19 revealed he was hospitalized for depression and anxiety. Review of the “Daily Nursing Assessment” for “Night Shift” which indicated P-19 had no self-harm behaviors, attitude/mood was “guarded”, he was “isolative” and “withdrawn”, his affect was “flat”, and he was not experiencing any pain. Review of nursing documentation from 7/16/2025 at 2306 stated P-19 was “alert and oriented x4 (person, place, time, and situation)” and was “fairly isolative.” The note further stated P-19 would come out of his room to watch television; however, had “little interaction with peers and staff.” Review of the rounding sheet from 7/16/2025 revealed from 1500-2355 P-19 was either “alert and cooperative” or was sleeping. No documentation was present for behaviors of anxiety or agitation. Review of the MAR revealed physician orders for P-19 for Ativan 1 mg every 6 hours PRN (as needed) for anxiety with a start date of 7/12/2025. Review of the (medication dispensing machine name) report revealed Ativan 1 mg tablet was dispensed at 2009. Further review of the MAR (medication administration record) revealed the Ativan was given at 2016. Review of the medical record for P-21 revealed he was hospitalized with schizophrenia (mental health condition that affects how people think, feel, and behave) and suicidal ideation. Review of the 7/16/2025 “Daily Nursing Assessment” for “Night Shift” indicated he was having some auditory hallucinations, was guarded and irritable, had a flat affect, and was in no pain. Review of nursing documentation on 7/16/2025 at 2335 indicated P-21 was asking for “an extra dinner tray” which was unavailable and was “irritable (having or showing a tendency to be easily annoyed or made angry) even though he was given snacks.” Review of the MAR revealed physician orders for P-21 for Ativan 1 mg every 6 hours PRN for agitation (a state of anxiety with a start date of 7/15/2025. Review of the (medication dispensing machine name) report revealed Ativan 1 mg tablet was dispensed at 2026. Further review of the MAR (medication administration record) revealed the Ativan was given at 2029. Review of the medical record for P-22 revealed he was hospitalized for suicidal ideation. The 7/16/2025 “Daily Nursing Assessment” for “Night Shift” indicated he was cooperative and behaving appropriately. Nursing notes dated 7/16/2025 at 2343 indicated P-22 was “calm and cooperative... social in an appropriate manner very pleasant to speak with (sic).” Review of the MAR for P-22 revealed physician orders for Ativan 0.5 mg every 6 hours as needed starting 7/12/2025 for anxiety. Review of the (medication dispensing machine name) report revealed Ativan 1 mg tablet was dispensed at 2044. Further review of the MAR revealed the Ativan was given at 2049. Review of the medical record for P-23 revealed he was hospitalized for depression and anxiety. The 7/16/2025 “Daily Nursing Assessment” for “Night Shift” indicated he was cooperative and behaving appropriately. Nursing notes from 7/16/2025 at 2349 stated P-23 was “very calm (and) cooperating with assessment and is social in an appropriate manner...” Review of physician orders for 7/16/2025 at 0900 revealed an order for P-23 to “D/C (discontinue) Ativan Start Atarax (mild sedative with side effects of drowsiness) 25 mg po (by mouth) TID (three times per day) prn (for) anxiety.” The MAR revealed the Atarax was given at 2008. Review of the medical record for P-24 revealed she was hospitalized for paranoid schizophrenia (a mental disorder in which the patient displays hallucinations, delusions, and unusual ways of thinking and expressing themselves). The 7/16/2025 “Daily Nursing Assessment” for “Night Shift” indicated she was “cooperative”, although “suspicious” and “angry”, was “appropriate” and “loud.” Nursing notes from 7/17/2025 at 0010 stated, “Patient was up on the unit and watching TV with peers, can be argumentative with peers but the most part is pleasant...” Review of the MAR revealed an order for Trazadone (anti-depressant with side effects of drowsiness and fatigue) 25 mg po at bedtime prn with a start date of 6/30/2025. Review of the (medication dispensing machine name) report for P-24 revealed Trazadone 25 mg was dispensed 7/16/2025 at 1949. Further review of the MAR revealed the medication was given at 2000. Review of the medical record for P-25 revealed she was hospitalized for depression, suicidal ideation and anger issues. The 7/16/2025 “Daily Nursing Assessment” for “Night Shift” indicated he was “cooperative”, “appropriate” and had “normal” affect. Review of nursing notes dated 7/17/2025 at 0030 stated, “...was calm and cooperative all shift appropriate on the unit (sic).” Review of the MAR for P-25 revealed an order for Trazadone 200 mg by mouth at bedtime for insomnia. The MAR revealed Trazadone was given at 2000. Review of the medical record for P-26 revealed she was hospitalized for a suicide attempt. The 7/16/2025 “Daily Nursing Assessment” for “Night Shift” indicated she was cooperative and behaving appropriately. Nursing notes dated 7/17/2025 at 0040 stated, “Pt...up on the unit in a good mood, medication compliant.” Review of the MAR for P-26 revealed an order for Vistaril (anti-histamine that has sedative and anti-anxiety effects) 50 mg by mouth three times a day prn for anxiety starting 7/4/2025. Review of the (medication dispensing machine name) report revealed Vistaril 50 mg was dispensed 7/16/2025 at 1948. Further review of the MAR revealed no documentation that the medication was given. Facility policy #13483128 titled “Restraint or Seclusion Use” effective 4/2023 states, “Patients at the Hospital have the right to be free from restraints of any form that are not medically necessary... Restraint and Seclusion are never used as a means of coercion, discipline, convenience, or retaliation by staff... Chemical Restraint (Medication used as a Restraint) - a medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is NOT a standard treatment or dosage for the patient’s condition...””

“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: 36887 Based on interview and record review, the facility failed to follow and renew physician orders for seclusion for 2 (P-2, P-46) of 3 patients reviewed for seclusion resulting in the potential for poor patient outcomes. Findings include: On 10/13/2025 at 1420, review of restraint and seclusion documentation for P-46 revealed on 8/21/2025 he was a 37-year-old male who was “charging at patients and staff”, was yelling, and making threats. As a result, he was placed in a physical hold, given a chemical restraint, and was placed in seclusion. Orders were given on 8/21/2025 at 1525. In parenthesis next to the marked order for seclusion was an italicized note stating “not to exceed 60 minutes.” The order was authenticated by the physician on 8/21/2025 at 1600. Documentation revealed the initiation of the interventions started at 1531 with no entries present in the “stop time” or “total time” areas. Continued review of the restraint documentation for P-46 revealed a note in the “Criteria (Justification) for Release” section which stated, “Remains in seclusion-refused to come out.” This statement was not dated or timed. In the section titled “Patient’s Response to the Intervention (complete for Restraint, Seclusion, or Emergency Med)” a note stated, “Started to calm Then (sic) when asked if he was able to control behavior states ‘no (sic) I am gonna keep going.” The note was not dated or timed. In an area for “Continue Intervention”, the “Yes” box is marked with a note stating, “continues to be verbally aggressive & threateny (sic) to ‘beat their asses’ when comes out.” This note was not dated or timed. In a box designated to outline any injuries that may have occurred during the restraint/seclusion was a note stating, “out (sic) of Seclusion (sic) 8/22/2025@1930 Door opened, then pt agreeable to meds and going to Room (sic). Pt remains a 1:1 until can be re-eval’d (sic) in AM.”. This note was not dated or timed. Further review of the restraint documentation P-46 remained in seclusion 27 hours, 59 minutes with no renewal of the seclusion orders documented. On 10/13/2025 at 1510, review of restraint and seclusion documentation for P-2 revealed she was a 45-year-old female who was placed in seclusion 7/10/2025 at 0540 for threatening behavior and irrational verbal aggression. Orders were given 7/10/2025 at 0540. In parenthesis next to the marked order for seclusion was an italicized note stating “not to exceed 60 minutes.” Review of the restraint packet for P-2 revealed in the “Assessment of Patient’s Immediate Situation” section a note stating, “Refused, sleeping. No signs of distress.” The note was not dated nor timed. In the “Continued Intervention” box was a note, “While sleeping then reassess.” The note was not dated or timed. Further review of the restraint documentation revealed P-2 remained in seclusion until 7/10/2025 at 0650 (1 hours, 5 minutes) with no renewal of the seclusion orders documented. Staff C admitted during interview on 10/14/2025 at 0915 “work needed to be done” regarding documentation for restraint/seclusion. Facility policy #13483128 titled “Restraint or Seclusion Use” effective 4/2023 states, “Patients at the Hospital have the right to be free from restraints of any form that are not medically necessary...The hospital is committed to: limiting the use of restraints and/or seclusion through the assessment of risk potential by determining and addressing underlying causes of behavior, triggers, and by promoting preventive strategies and use of safe, effective and least restrictive alternatives to the use of restraints...Seclusion-the confinement of a person alone in a room or an area where the person is physically prevented from leaving...Restraints/seclusion may only be utilized upon the written or telephone order of the physician permitted by the hospital and state law to write orders or through emergency application...Seclusion may only continue until the precipitating self-or other-injurious behavior ceases or for 60 minutes, whichever is less...EVALUATION DURING RESTRAINT/SECLUSION...All documentation should include date, time and staff signature/initials... Restraints/seclusion must be discontinued as soon as safely possible, regardless if the length of time identified in the order is longer.” The policy did not address renewing orders for restraint/seclusion.”

“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: 36887 Based on interview and record review, the facility failed to monitor patients in seclusion per facility policy for 3 (P-2, P-27, P-46) of 3 patients reviewed for seclusion, resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include: On 10/13/2025 at 1420, review of restraint and seclusion documentation for P-46 revealed he was a 37-year-old male who was placed in seclusion 8/21/2025 at 1531 after “charging at patients & staff...yelling & threatening.” P-46 remained in seclusion until 8/22/2025 at 1930 (27 hours, 59 minutes). Review of the restraint packet revealed in the “Assessment of Patient’s Immediate Situation” a section to document one set of vital signs. In this section it was noted the patient refused vital signs and only respiration was documented. To the left was a portion regarding medical condition allowing a one-time assessment of circulation, respiratory, skin, nutrition/hydration, and pain. Under the nutrition/hydration section, a box was marked indicating hydration was offered every 15 minutes, however, there was no documentation showing the times hydration was offered. There was no documentation regarding meals or provision for elimination needs. To the right was a portion for the behavioral condition allowing a one-time assessment of attitude, aggression, mood, thought process/content, speech, level of consciousness, and patient orientation. Each part of the medical condition and behavioral condition area was addressed in some way for P-46; however, it was incomplete and there was no date or time as to when the items, portions, and/or sections were assessed. Further review of the restraint packet for P-46 revealed another section of that included a 9-line grid titled “Vital Signs Flow Sheet (for emergency meds-every 15 minutes x2 and PRN (as needed); for restraint/seclusion-every 15 minutes until terminated)” with columns for time, blood pressure, pulse, respirations, temperature, pulse oximetry, and staff initials. Written across the top line was a note which stated, “Refused all attempts to complete vitals.” There was no date or time present, nor was the refusal documented every 15 minutes. On 10/13/2025 at 1510, review of restraint and seclusion documentation for P-2 revealed she was a 45-year-old female who was placed in seclusion 7/10/2025 at 0540 for threatening behavior and irrational verbal aggression. She remained in seclusion until 7/10/2025 at 0650 (65 minutes). Review of the restraint packet revealed in the “Assessment of Patient’s Immediate Situation” only respirations were documented for vital signs and a note stating “refused, sleeping. No signs of distress.” Areas for nutrition and hydration, pain, attitude, aggression, thought process and content, and level of consciousness were not addressed. In the section for mood, the box titled “Other” was checked with “Sleeping” written on the explanation line. There was no date or time of the assessment present. On 10/14/2025 at 1300, review of restraint and seclusion documentation for P-27 revealed he was a 66-year-old male who was placed in seclusion 10/9/2025 at 0845 for verbal aggression, swearing at staff, and posturing toward staff. He remained in seclusion until 10/9/2025 at 0902 (17 minutes). Review of the restraint packed revealed in the “Assessment of Patient’s Immediate Situation” no vital signs were documented and no documentation was found under attitude, aggression, mood, thought processes/content, speech, level of consciousness, and orientation. Upon termination of the intervention the vital signs, and physical status was blank. Review of the vital sign flowsheet area was also blank. Further review of the restratin packet for P-27 revealed in the “Vital Sign Flow Sheet” section, entries were made at 0600, 0620, and 0645. The first line at 0600 stated “Refused-Sleeping-No signs of distress.” At 0620, a note stated, “Refused” with ellipses marks and a line through the boxes indicating the same note as the previous note at 0600. The note at 0645 stated, “Sleeping No signs of distress.” On 10/14/2025 at 0915, an interview was conducted with Staff C at which time Staff C admitted “work needed to be done” regarding documentation for restraint/seclusion. Facility policy #134873128 titled “Restraint or Seclusion Use” effective 4/2023 states, “ONGOING ASSESSMENT, MONITORING AND EVALUATION DURING RESTRAINT/SECLUSION: Patients in seclusion will be directly observed by one-to-one staff observation; A nurse shall observe and assess patients in restraint or seclusion approximately every 60 minutes including respiratory and circulatory status, skin integrity and vital signs. In some circumstances, approaching the patient may be dangerous and may increase patient agitation. Visual checks may be performed if the patient is too agitated to approach. but [sic] at a minimum, the patient must be assessed for safety and signs of injury, as well as readiness for discontinuation of restraint or seclusion; The patent’ response to the intervention or interventions used shall be documented every fifteen (15) minutes throughout the duration of the restraint or seclusion. The fifteen (15) minute monitoring must include the monitoring of the patient’s physical and psychological condition including, but not limited to: Respiratory and circulatory status; Skin integrity; Vital signs; An unlicensed trained staff member who is knowledgeable of the seclusion/restrain [sic]) policy may provide this monitoring and documentation. The nurse shall notify the physician of any changes in the patient’s physical condition or mental status and document in the medical record; Nursing assessments shall be documented using the restraint/seclusion packet; All documentation should include date, time and staff signature/initials.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to conduct a face-to-face assessment within one hour following the intiation of restraint and seclusion for 2 (P-27, P-46) of 3 patients reviewed for seclusion resulting in the loss of patient rights and the potential for unidentified, unmet patient needs and poor patient outcomes. Findings include: On 10/13/2025 at 1420, review of restraint and seclusion documentation for P-46 revealed he was a 37-year-old male who was placed in seclusion on 8/21/2025 at 1531 after “charging at patients & staff...yelling & threatening.” Further review revealed there was no documentation of a of the face-to-face assessment having been completed. On 10/14/2025 at 0915, an interview with Staff C was conducted at which time Staff C admitted “work needed to be done” regarding documentation for restraint/seclusion. On 10/14/2025 at 1300, review of restraint and seclusion documentation for P-27 revealed he was a 66-year-old male who was placed in seclusion 10/9/2025 at 0845 for verbal aggresseion, swearing at staff, and posturing towards staff. P-27 was placed into restraint 10/9/2025 at 0845 and was released 10/9/2025 at 0902. Review of the face-to-face assessment had a comment written acoss the date and time which read, “Did not exceed 1 hour.” Facility policy #134873128 titled “Restraint or Seclusion Use” effective 4/2023 states, “ONE-HOUR FACE-TO-FACE ASSESSMENT A Registered Nurse with a working knowledge of the restraint/seclusion policy and is specially trained to do so will provide a Face-to-Face assessment in person within 1 hour of the use of restraint/seclusion using the restraint/seclusion packet. The one-hour face-to-face assessment will include; (sic) An evaluation of the patient’s immediate situation; The patient’s reaction to the intervention; The patient’s medical and behavioral condition; The need to continue or terminate the restraint or seclusion If one hour face-to-face completed by an RN, the attending provider must be consulted as soon as possible (no later than 30 minutes) of completion of the face-to-face. Consult to include-Discussion of the findings of the 1-hour face-to-face evaluation, the need for other interventions or treatments, and the need to continue or discontinue the use of restraint or seclusion.””

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 47415 Based on interview and record review, the facility failed to have staff available to complete posted nursing run therapy groups, that all RN’s were trained to work as a staff RN prior to being scheduled; that personal hygiene was being provided to 2 (P-11, P-12) of 2 patients reviewed for hygiene; and that 1 (P-16) of 1 current patients reviewed was provided with 1:1 observation as ordered by a physician and according to facility policy, resulting in an increased risk of less than optimal outcomes and the potential for patient injuries. Findings include: On 10/6/25 at 1110, during unit tours, an interview with Behavioral Health Assistant (BHA) Staff AA revealed that staffing does not always support all duties of the BHA, today they were unable to run the BHA activities on the schedule because of short staffing. On 10/6/25 at 1110, on unit 400, an interview with P-31 revealed that no group therapy is ever offered, when he asks to see a therapist, he is told every time they are too busy. P-31 was aware of the activity schedule posted. Review of the activity schedule revealed on 10/6/25, between 1030 -1130, BHA Activity engagement was on schedule; however, no group activity was occurring on the unit On 10/9/25 at 1045, an interview was conducted with the Director of Quality (Staff C) and revealed she was required to work as a staff RN on patient care units, due to short staffing. Staff C confirmed that she worked as a direct patient care provider in July/August, (dates not provided at the time of interview). Staff C was asked if she received an orientation to the Unit Staff RN role, and she responded “no”. On 10/09/25 at 1100, in an interview, Staff B shared her personal documentation, revealed that on August 28, 2025, Staff C worked as a staff nurse, passing medications and completing admissions due to short staffing. On 10/09/2025 a review of personnel files revealed no RN unit orientation was documented in Staff C’s personnel file. Open record review on Unit 300 on 10/7/25, at approximately, 1000, revealed, that on 1n 10/5/25 at 1615, P-16 had an order written for 1:1 monitoring for the indication of “hyper-sexual” that was acknowledged by the nurse at 1615. The observational record for P-16 for 10/5/25 was reviewed and it revealed no indication that 1:1 observation was implemented from 1615 - 2355. Documentation from 1615-2355 was at 15-minute intervals, and an observation level was not checked on the form. Review of the observation rounding form for 10/6/25, revealed the form did not have any precautions or observation levels documented, and monitoring was 5-minute intervals. On 10/6/25 at 1015 an interview with Staff R revealed staffing is on the “low side for the night shift”, running units with 1 registered nurse and 1 behavioral health assistant, On 10/7/25 at 1105, Staff B confirmed 1:1 monitoring requires observation and documentation every 5 minutes, and observation forms should be complete with observational level and special precautions. Review of policy titled, “Patient Observation” dated last approved 10/24, revealed, “On admission, each patient will be assessed for the level of observation. The provider will order one of three observation levels. All patients will be admitted to the patient care unit with a minimum of “every 15 minutes” observation level ...Observation levels can be increased or decreased by a provider’s order ... Documentation ...Documentation of all observations will be completed in the patient’s record per their ordered observation status ...Staff will complete the patient observation record using a coding system described on the Patient Observation Monitoring Form ...Staff will initial, date and/or time appropriate documentation in the designated areas for observation of a patient. 29955 On 10/6/2025 at 1125, P-11’s medical record revealed no documentation of personal hygiene care from 8/10/2025 to time of review. Documentation for patient hygiene on the daily sheets were blank. Staff U confirmed the findings. On 10/13/2025 at 1450 staff HH, BHA (Behavioral Health Associate), stated that she was not trained on how to do showers because she was not a CNA (Certified Nursing Assistant). Staff HH stated, “a CNA or the nurse are trained to give patients hygiene care, and I assist with helping a patient get dressed but have rounding to do at the same time.” On 10/13/2025 at 1515 registered nurse staff Q, stated the staffing for the medical unit (400 unit) was supposed to be 1 nurse for every 8 patients and 1 BHA to every 8 patients. Staff Q reported that the unit consistently exceeded 12 patients and there was only one nurse and one BHA. Staff Q was asked how many patients were currently on the medical unit which she replied 13. Staff Q was also asked if another nurse was on the unit with the census at 13. Staff Q replied, “No...this is the usual back here. (Staff A, CEO) constantly tells me that they’re working on it (staffing) but it is highly unlikely.” On 10/13/2025 at 1600, review of a document titled, “KBHH Nurse & BHA Assignment - Patient Worksheet” dated 10/13/2025 revealed under “AM Shift Nurses” two open blocks for nursing coverage from 7A - 7P, and three open blocks for BHA coverage from 7A-3P. Staff II confirmed the findings. On 10/13/2025 at 1430, P-12’s medical record revealed no documentation of personal hygiene care from the time of admission on 8/15/2025 to 8/17/2025 the date of discharge. Staff II confirmed the findings. On 10/13/2025 at 1100 a review of the job description “Behavioral Health Associate,” dated 3/3/2025 revealed the following, “Assists the nursing staff in performing selected nursing procedures and functional tasks to specific patients...Provided direct physical care, and/or one to one observation to selected patients under supervision,...other duties as assigned.””

“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: 50585 Based on interview and record review, the facility failed to immediately implement a care plan for fall risk for 1 (P-3) of 4 patients reviewed for fall risk resulting in increased likelihood of negative consequences for the patient. Findings include: On 10/7/2025 at 1000, P-3’s medical record was reviewed. P-3’s initial nursing admission assessment revealed that P-3 had a fall risk score of 53 (High Risk). P-3’s initial care plan did not contain any documentation including interventions to prevent falls for P-3. According to P-3’s incident report, P-3 had an unwitnessed fall on 6/27/2025. P-3’s care plan for fall risk was initiated on 6/28/2025. On 10/7/2025 at 1210, Staff B confirmed the care plan should have been initiated at the time of admission for a high-risk patient. According to the facility’s policy “Fall Prevention Program,” dated 4/2023, “Patients who score a moderate risk for falls (scoring 25-44 on the Morse Fall Scale) and high risk for falls (scoring 45 and higher on the Morse Fall Scale) will receive red colored non-skid socks, as well as other potential interventions.” The policy also revealed “Individualized fall prevention interventions will be developed in the Interdisciplinary Treatment Plan for all fall risk patients. Fall prevention interventions specific to the patient’s needs will be implemented as needed.””

“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: 50585 Based on interview and record review, the facility failed to document a skin assessment according to facility policy for 2 (P-3, P-31) of 2 patients reviewed resulting in the increased likelihood of negative outcomes for the patient. Findings include: On 10/6/2025 at 1053, Staff N was queried how skin assessments were performed, and Staff N revealed “head to toe” and “mark tattoos.” Staff N also revealed each patient had a “weekly assessment” and that was documented in the medical record. On 10/7/2025 at 1525, Staff U was queried how a patient in a wheelchair would develop a pressure injury on their heel, Staff U revealed that the pressure injury would be from lying in “bed” and not from sitting in wheelchair. When queried how pressure injuries were prevented, Staff U revealed skin assessments were performed every “Wednesday” and that an initial skin assessment would be performed and documented in the record. On 10/7/2025 at 1000, P-3’s medical record was reviewed. P-3’s history and physical on 6/14/2025 at 1015 revealed P-3’s skin was “WNL (within normal limits).” P-3’s weekly skin assessment for 6/15-6/21 was blank (i.e., no initials that the skin check was performed). On 6/22/2025, P-3’s Daily Nursing Assessment revealed P-3 “refused” assessment on the night shift and the skin assessment was not performed. On 6/27/2025, P-3’s Daily Nursing Assessment revealed there was no skin assessment performed on the night shift. The day shift skin assessment by Staff BB revealed “Skin Issue” next to the “Document on Narrative” and the narrative on 6/27/2025 did not contain any documentation about skin issues. Staff BB no longer worked at the facility according to Staff C when Staff C was queried on 10/9/2025 at 0935. On 7/1/2025, P-3’s skin assessment revealed that no skin assessments were performed on the day shift and the night shifts. On 7/2/2025, P-3 weekly skin assessment revealed “Stage 1” pressure ulcer on bilateral heels. P-31 was admitted on 9/27/2025 and was discharged on 10/8/2025. P-3’s nursing admission assessment revealed P-3’s skin was “intact-No Issues.” According to P-31’s daily skin assessments, P-31 did not have a skin assessment on 9/30/2025 on the day shift. The daily nursing assessments for 10/3/2025 to 10/8/2025 could not be reviewed since the assessments were not provided. P-31’s weekly skin check for 9/28-10/4 was blank (i.e., no initials that the check was performed). On 10/9/2025 at 1330, the facility’s policy “Assessment/Reassessment,” dated 09/2022, was reviewed and revealed “Nursing will re-assess each patient every shift and as warranted by the patient’s medical condition and document findings.””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 47415 Based on interview, and document review, the facility staff failed to administer medications to patients according to policy in 2 (P-6, P-32) of 3 instances reviewed; and failed to follow policy for the use of single dose vials, resulting in the potential for less-than-optimal outcomes. Findings include: Two (2) medication errors reviewed, both involved the nursing staff overriding the system to dispense medication. On 6/30/25 at 0701 the nurse performed on override and gave P-32 divalproex sodium (DR) release 750 milligrams (mg), instead of divalproex sodium, extended release (ER) 750 mg. On 8/6/25 at 1329, P-6 had an order to discontinue haloperidol 5 mg twice daily (BID). At 2038, the nurse performed an override, documenting “med not on profile” and administered medication after it was discontinued. The nurse performed an override to obtain the medication from dispensing system. On 10/06/25 at 1015, during unit tours, 4 single use vials of sterile water were found open and dated in a medication drawer between units 100 and 200. Vials were clearly labeled as single use only by the manufacturer. All 4 vials had plastic cap removed and obvious puncture marks in rubber stopper. These open and previously used single use vials were readily available for reuse.’ On 10/6/25 at 1017, RN Staff R was asked about the open/dated single use vials, and she stated when you open a vial it is labeled with open date, and it is good for 28 days. When asked about manufacturer label on vial stating, “single use only”, Staff R stated she did not know anything about that. 50585 On 10/7/2025 at 1555, during observation of the medication storage area in the alcove between units 300 and 400, four vials of single dose, sterile water for injection were observed stored in a drawer and each vial had a puncture through the rubber stopper. Staff U confirmed the findings at the time of discovery. On 10/7/2025 at 1556, during an inspection of the medication cupboard, an unopened box of insulin was observed stored in a bin in the cupboard. Observation of the storage instructions on the outside of the insulin box revealed “Refrigerate at 2º C to 8º degrees Celsius (36º F to 46º F) until first use.” Staff T confirmed the findings at the time of discovery. According to the facility’s policy “Injectible (sic) Medication Preparation, Administration, and Safety,” dated 01/2020, “Multiple use of an unpreserved injectable medicine should be eliminated. Most injectable medicines are licensed for ‘once-only’ use. Unless the manufacturer’s label specifically indicates that the injection contains a preservative, the container should only be used to prepare a single dose for a single patient on one occasion.” According to the facility’s policy “Use of Multiple Dose Vials,” dated 01/2020, “The Pharmacy Department shall verify that Multi-Dose Vials are stored and labeled correctly when inspecting medication storage areas.” According to the facility’s policy “Standardize Medication Administration,” dated 05/2021, “Prior to administering the medication(s), the five rights of medication administration should be considered: 1. Right Patient, 2. Right Drug, 3. Right Route, 4. Right Dose, 5. Right Time.””

“VERBAL ORDERS FOR DRUGS CFR(s): 482.23(c)(3)(i) If verbal orders are used, they are to be used infrequently. This Standard is not met as evidenced by: 47415 Based on interview and record review, the facility failed to ensure the proper verbal/telephone order process was followed to prevent miscommunication and inaccurate transcription for 3 (P-3,8,34) of 3 patient admission orders reviewed, resulting in the potential for miscommunication, medication errors and poor patient outcomes for all patients. On 10/09/25 at 0915, P-8’s medical record was reviewed. P-8’s admission orders revealed the nurse selected the medications on a pre-printed order form on 7/19/25 and signed order form at 0821. A nurse practitioner signed the form on 8/19/25 at 1446. The line for TORB (Telephone Order Read Back) was blank. On 10/09/25 at 0935, P-34’s medical record was reviewed. P-34’s admission orders revealed the nurse selected the medications on a pre-printed order form on 7/9/25 and signed order form at 1900. A nurse practitioner signed the form on 7/10/25 at 0700. The line for TORB (Telephone Order Read Back) was blank. On 10/7/25 at 1100, an interview was conducted with the DON Staff B who confirmed that telephone orders were utilized for new admission orders. The facility policy entitled, “Written Telephone Orders”, dated last approved on 8/2022 revealed, “Telephone order must be verified thru the Nationally accepted practice of “read-back verification” (RBVO) ... Notation documenting that the verbal order was read back to the prescriber after it was first rendered to writing. E.g. T.O. Dr___/Nurse___/RB&V.” 50585 On 10/7/2025 at 1000, P-3’s medical record was reviewed. P-3’s admission medication orders revealed that Staff BB selected the medications on the pre-printed medication order form and signed the medication orders on 6/13/2025 at 1905 and Staff G co-signed the medication orders on 6/14/2025 at 1145. The line for TORB (Telephone Order Read Back) was blank. On 10/9/2025 at 0935, Staff C was queried to interview Staff BB and Staff C confirmed Staff BB no longer worked at the facility. On 10/9/2025 at 1330, Staff S was queried if they expected nurses to use the telephone order read back process when ordering medications on the pre-printed medication order form, and they said “yes.””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to maintain complete and accurate medical records for 4 (P-2, P-3, P-27, P-31) of 7 patients reviewed and make medical record information accessible for other care providers in a timely manner resulting in the increased likelihood of negative consequences and poor outcomes for the patients. Findings include: On 10/7/2025 at 1000, P-3’s medical record was reviewed. P-3’s initial nursing assessment on 6/13/2025 revealed that P-3 was at high risk for falls. P-3’s Treatment Plan for 6/17/2025 revealed documentation “No” for Fall Risk, and the section “Falls During/Since Stay” was blank. P-3’s Treatment Plan for 6/30/2025 revealed documentation “No” for Fall Risk, and the “Falls During/Since Stay and the section for “Family/Legal Rep Support/Involvement” was not completed. P-3’s nutrition intake sheet on 6/30/2025 revealed no intake percentage documented for lunch. P-3’s Treatment plan for 7/1/2025 revealed no documentation (i.e., check boxes were left blank) for the sections on Fall Risk, Fall During/Since Stay, and Injury from Fall and the section for “Nutrition” was not completed. On 10/13/2025 at 0800, P-27 and P-31’s Patient Personal Effects Inventory forms in the medical record were reviewed and the lines for the patient’s signature were blank. According to the facility’s policy “Patient Treatment Plan, dated 09/2022, “Overall development, implementation, and supervision of the treatment plan is the responsibility of the patient’s providers. Responsibility for ensuring that the treatment plan is accurate, up-to-date, and reviewed regularly is the responsibility of the interdisciplinary care team.” According to the facility’s policy “Management of Patient Belongings,” dated 07/2023, “Upon admission, staff will inventory all patient belongings, and sign the Personal Belongings Inventory Form. Patient will then sign the form.” On 10/7/2025 at 1023, Staff K was queried about physician documentation. When queried if anyone else assists with this process and Staff K said “no.” Staff K revealed the physicians have a separate electronic medical record (EMR) for documentation of their notes. Medical physicians document in EMR while psych records are printed. Staff K revealed they were responsible for uploading the physician notes into each patient’s medical record and that process may take up to “two days.” 36887 On 10/7/2025 at 1333, Staff D stated she had access to document in the EMR (electronic medical record) for providers only; however, she could only see her documentation and not any documentation from the other providers unless it was printed by someone and placed in the medical record on the patient unit. She stated often there were several days of provider documentation missing from the medical record making it difficult to know what was going on with the patient in real time. “It’s like the right hand doesn’t know what the left hand is doing.” Staff D further stated concerns regarding documentation brought to hospital administration were often ignored or were not followed up. On 10/8/2025 at 0900, a request was made for P-2’s medical record to be provided in it’s entirety. Upon review, on 10/9/2025 at 0845, it was discovered the record was missing restraint documentation. On 10/9/2025 at 1010, Staff C was queried as to if there was any restraint documentation for P-2 to which she stated all restraint packets were kept in a separate binder for review.”

“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: 36887 Based on interview and record review, the facility failed to promptly authenticate consents and provider orders for 10 (P-15, P-27, P-54, P-55, P-56, P-57, P-58, P-59, P-60, P-61) of 17 patients reviewed for orders and consents for psychotropic medications resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include: On 10/13/2025 at 1723, an email was received from Staff GG outlining multiple concerns which included communication with providers and authentication of orders. Staff GG stated, “We have no effective way of communicating with our providers... Per our on call calendar, this directs us to be “texting” the provider first. Then call, then follow up can be done by text as well. (With what communication device? We have nothing) This is a cumbersome process when there is only one nurse, you have to run in the nurses station to call the provider on our land lines, sbar [communication tool for situation, background, assessment, and recommendation], retrieve the order, retrieve from the [medication dispensing machine], then scan the order to the pharmacy, type write a mar [medication administration record] sheet and leave the order on the clipboard to hopefully be signed in a timely fashion. On my hall...there were 21 outstanding orders dating back to the 9-20-25 (as of...10-12) that still needed to be signed. There were 2 orders on pts that had already been dc’d (discharged).” Staff N was queried on 10/14/2025 at 1018 as to how orders were authenticated by the providers to which she stated there were clipboards on each hall containing the orders and the providers were expected to check the clipboard and sign the orders during their daily rounding. Staff N stated it was very inconvenient looking in multiple places for orders for the patients. Staff N was then asked for copies of outstanding orders from each hall which she provided. Review of the consents and orders still awaiting authentication was conducted on 10/14/2025 at 1300 and included the following: 100 Hall: -P-54 Informed Consent for Use of Psychotropic Medications for Memantine 28 mg (milligrams) po (by mouth) daily. Next to the patient signature was a date/time of 10/13/2025 at 1805 written in the same handwriting and pen as the person filling out the consent. The consent indicated the medication was discussed with P-54 in person. There was no indication as to who filled out the consent or had the conversation with P-54. There was no provider signature present. -P-54 Informed consent for Trazadone 150 mg po qhs (every night). Next to the patient signature was a date/time of 10/13/2025 at 1805 written in the same handwriting and pen as the person filling out the consent. The consent indicated the medication was discussed with P-54 in person. There was no indication as to who filled out the consent or had the conversation with P-54. There was no provider signature present. -P-54 Informed consent for Clozapine 300 mg po qhs. Next to the patient signature was a date/time of 10/13/2025 at 1805 written in the same handwriting and pen as the person filling out the consent. The consent indicated the medication was discussed with P-54 in person. There was no indication as to who filled out the consent or had the conversation with P-54. There was no provider signature present. 200 Hall: -P-55 Informed consent for Tryhexaphenidyl (anti-cholinergic medication used to treat symptoms of Parkinson’s Disease) 2 mg po BID (twice daily) for EPS (extrapyramidal symptoms). The consent indicated the patient refused to sign and the medication was discussed in person. A date and time of 10/4/25 at 1315 was written next to the prescribe signature line in the same handwriting as the unknown person filling out the medication portion of the consent. No provider signature was present. -P-55 Informed consent for Uzedy (anti-psychotic medication) 250 mg SubQ (subcutaneous) every 60 days for psychosis. The patient signed the consent; however, no date or time was present as to when that occurred. It also showed the medication was discussed with the patient in person; however, there was no indication as to who filled out the consent or had the conversation with P-55. Additionally, a date and time of 10/10/25 at 1030 was written next to the prescriber signature line in the same handwriting as the unknown person filling out the medication portion of the consent. No provider signature was present. -P-55 Informed consent for Ativan 1 mg po q (every) 6 hours prn (as needed) for agitation. The patient signed the consent; however, no date or time was present as to when that occurred. It also showed the medication was discussed with the patient in person; however, there was no indication as to who filled out the consent or had the conversation with P-55. Additionally, a date and time of 10/4/25 at 1125 was written next to the prescriber signature line in the same handwriting as the unknown person filling out the medication portion of the consent. No provider signature was present. -P-55 Informed consent for Zyprexa Zydis 5 mg po q6 hours prn for psychosis. It was noted the patient refused to sign the consent. The consent also showed the medication was discussed with the patient in person; however, there was no indication as to who filled out the consent or had the conversation with P-55. Additionally, a date and time of 10/4/25 at 1125 was written next to the prescriber signature line in the same handwriting as the unknown person filling out the medication portion of the consent. No provider signature was present. -P-55 Informed consent for Trazadone 50 mg po qhs (every night) for insomnia. The patient signed the consent; however, no date or time was present as to when that occurred. It also showed the medication was discussed with the patient in person; however, there was no indication as to who filled out the consent or had the conversation with P-55. Additionally, a date and time of 10/4/25 at 1125 was written next to the prescriber signature line in the same handwriting as the unknown person filling out the medication portion of the consent. No provider signature was present. -P-55 Order written 10/12/2025, not timed and no signature as to who wrote the order, stating, “Patient may go outside on patio area with staff supervision. No authentication of the order was present. -P-56 Informed consent for Rexulti 1 mg po hs. The consent is missing the reason for the medication to be given. There is no patient signature, date, or time; however, it is marked that the medication was discussed in person with the patient. Additionally, a date and time of 10/4/25 at 1125 was written next to the prescriber signature line in the same handwriting as the unknown person filling out the medication portion of the consent. No provider signature was present. -P-27 A telephone order for seclusion was received 10/9/2025 at 0845 for seclusion. There was no provider signature authenticating the order and no face-to-face-assessment was completed. 300 Hall: -P-57 Admission orders from 10/8/2025 at 2000 including admitting to 300 Hall, code status, frequency of vital signs, height and weight, activity level, bed type, precautions, observation level, allergies, diet, CIWA (Clinical Institute Withdrawal Assessment) frequency for alcohol withdrawal, and medications. No provider authentication of the orders was present. 400 Hall: P-58 On 10/12/2025 at 1932, telephone orders were taken which stated, “Patient may enter seclusion room with staff supervision to calm down. Patient must be able to exit. Door to remain open.” There was no provider authentication signature present. P-58 Order for Ativan 1 mg po one time prn for severe anxiety and an order for 1:1 observation was obtained via telephone on 10/12/2025 at 1440. There was no provider authentication signature present. P-15 Order for Ativan 1 mg po one time prn for anxiety or harm to self was taken via telephone on 10/12/2025 at 1605. No provider authentication was present. P-59 Telephone order for 1:1 observation for suicidal and homicidal ideation was obtained 10/9/2025 at 0007. No provider authentication was present. P-59 Telephone order for discontinuation of 1:1 observation was obtained 10/9/2025 at 1000. No provider authentication was present. P-60 Telephone order for Haldol 10 mg IM (intra-muscular) x1 and Ativan 2 mg IM x1 for agitation/behaviors was obtained 9/6/2025 at 1740. No provider authentication was present. P-60 Telephone order for Klonopin ODT (orally disintigrating tablet) 0.25 mg give 4 tabs inc chocolate shake x1 dose for agitation obtained 9/6/2025 at 1800. No provider authentication was present. P-61 Telephone order for Atarax 25 mg po BID prn for agitation was obtained 9/10/2025 at 0842. No provider authentication was present. Unnumbered facility policy titled “Use of Psychotropic Medications” effective 5/2024 states, “Guidelines for Use of Psychotropic Medications... Informed Consent Clients (or their legally authorized representatives) must be informed about the purpose, benefits, risks, and potential side effects of psychotropic medications. Informed consent must be obtained and documented before initiating or changing any psychotropic medication.” The policy did not address who may present the informed consent or authentication of the consent. Facility policy #13483128 titled “Restraint or Seclusion Use” effective 4/2023 states, “Restraints/seclusion may only be utilized upon the written or telephone order of the physician permitted by the hospital and state law to write orders or through emergency application...Providers may acknowledge and authenticate an order given by another provider... Telephone Restraint/Seclusion orders must be signed within 24 hours.” Facility policy #8834495 titled “Authentication” effective 1/2020 states, “The health care provider who treats a patient shall have the responsibility for documenting and authenticating the care provided. Such documentation shall be in accordance with: Accepted professional standards of documentation; Specifically mandated regulatory, legal, an/or accrediting standards; Documentation guidelines developed with this policy statement and approved by the medical staff; Medical record content policy of this health care institution... Proper Authentication: All entries shall be authenticated and shall consist of the writer’s name and initials indicating the professional credential or writer’s initials where a signature is present on the document. Authentication shall also include the date and time of signature.” The policy failed to determine a time-frame in which authentication should take place. Facility policy #12079630 titled “Written Telephone Orders” effective 8/2022 states, “Verbal/Telephone Orders... Telephone orders shall be used only when necessary to provide patient care when the Provider is not readily available on-site... The prescribing practitioner must sign the written record of the verbal/telephone order in accordance with the Rules and regulations of the Medical Staff.” Facility “Rules and Regulations of the Medical Staff” last amended 8/2023 states, “Orders...All diagnostic and therapeutic orders, including telephone orders, standing orders, order sets, and protocols must be appropriately authenticated by the responsible practitioner...Authentication of the telephone order must occur within 24 hours unless a read back and verify process described under items 1 and 2 is utilized. If a patient is discharged within 24 hours of the time that the telephone order was given, authentication shall occur within 30 days after the patient’s discharge. 1. As an alternative, hospital policy may provide for a read back and verify process for telephone orders. Any read back and verify process must require that the individual receiving the order shall immediately read back the order to the ordering physician or other responsible individual who shall immediately verify that the read back order is correct. 2. The individual receiving the telephone order shall document in the patient’s medical record that the order was read back and verified... Authentication All entries in the medical record must be legible, complete, dated, timed, and authenticated by the responsible practitioner. History and Physical Exams, Psychiatric Evaluations and Discharge Summaries will be countersigned by supervisory or attending medical staff members when performed by mid-level practitioners.” The rules failed to determine how long the provider had to authenticate the order following a read back and sign telephone order.”

“CONTENT OF RECORD: HISTORY & PHYSICAL CFR(s): 482.24(c)(4)(i)(A) All records must document the following, as appropriate: (i) Evidence of-- (A) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(4)(i)(C) of this section. The medical history and physical examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 47415 Based on document review and interview, the facility failed to have the history and physical (H&P) performed within 24 hours of admission for 2 (P-1, P-34) of 3 patients reviewed for H&P completion, resulting in the potential for less-than-optimal outcomes. Findings include: On 10/7/25 at 1020 an interview was held with HIMT (health information management technology) Staff K who stated she tracks provider documentation for completeness and accuracy. Indicators include history and physical being conducted within 24 hours of admission. On 10/9/25 medical record reviews revealed: P-1 was admitted on 7/8/25 at 1818 and H&P was completed on 7/11/25. P-34 was admitted on 7/9/24 at 1715, the H&P was completed on 7/14/25 On 10/09/25 record review of document titled, “RULES AND REGULATIONS OF THE MEDICAL STAFF”, approved by the Governing Board on 8/31/23, revealed, under heading “CONTENTS OF THE MEDICAL RECORDS ... a. History and Physical ...A medical history and physical examination shall in all cases be completed within 24 hours following admission of the patient.”

“INFECTION CONTROL PROFESSIONAL CFR(s): 482.42(a) Infection prevention and control program organization and policies. The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 38269 Based on interview and record review, the facility failed to ensure an Infection Control Program was chaired by a credentialed physician or Certified Infection Control Preventionist, resulting in no oversight of the facility’s Infection Control Program, and an increased risk for infection for all 57 patients being served by the facility at the time of the survey. Findings include: On 10/08/2025 at 1100 during the review of requested credentialing files it was revealed that there was no credential file for a “Physician Infection Control (IC) Chair” or a Certified Infection Control Preventionist. On 10/08/2025 between the hours of 1400 and 1530 an interview was conducted with Staff A, the Chief Executive Officer (CEO). The CEO was queried regarding oversight of the infection control program. The CEO confirmed that there was no physician oversight, and he was unsure of who the infection preventionist was but thought it may be “the Director of Quality, or the Director of Nursing”. When asked if the CEO was part of the infection prevention program, he stated no.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 38269 Based on interview and record review, the facility failed to maintain evidence of a comprehensive infection control program resulting in the potential for the spread of infectious agents to all patients served by the facility. Findings include: On 10/06/2025 at 1135, the facility was asked to provide Infection Control Program documentation including current surveillance, data collection, analysis and infection risk mitigation measures. On 10/08/2025 at 1100 during an interview with the Facility Administrator, Staff A, it was confirmed that there was “no infection control observations or documentation” to support an infection control program. There was no evidence of infection prevention data collection, tracking and trending received prior to exit of the survey. Policy review: POLICY Stat ID: 9286500 effective 01/2020 last revised 01/2020 (note the facility did not open until 2025) Policy titled “Infection Control and Prevention”PROCEDURE: Nursing staff will assess patients under their care for indications of possible infectious diseases or conditions. The nursing staff will notify the Infection Preventionist when: Healthcare associated infections (HAIs) are identified by test results. An infectious communicable disease is diagnosed or suspected. An inpatient has an infectious communicable disease or condition that is reportable to the Public Health Department. When symptoms are observed or infection is suspected by patient history (definitive diagnosis is not necessary first), the nurse will: Notify the patient’s physician and department. Document in the care plan, the date, time, the problems and interventions (i.e., Specific isolation precautions, patient/significant other teaching, diversionary activities) and notification of the Infection. Preventionist: Implement isolation precautions and make necessary room changes including terminal clean of the patient’s room. Arrange for discharge and transfer to a higher level of care when an infectious Patient requires airborne precautions, and cannot be safely managed within the Behavioral Health Unit. Adherence to the practice of Standard Precautions is expected of all nursing staff. Nursing staff serves as a role model for all healthcare workers in the use of personal protective equipment and adherence to established guidelines. Infection prevention and control policies and procedures relative to the Nursing Services Department functions and to the specific units and departments have been developed. Nursing staff is encouraged to also refer to the Infection Prevention and Control Manual for current recommended and approved nursing practices. PROCEDURE: Nursing staff will assess patients under their care for indications of possible infectious diseases or conditions. The nursing staff will notify the Infection Preventionist when: Healthcare associated infections (HAIs) are identified by test results. An infectious communicable disease is diagnosed or suspected. An inpatient has an infectious communicable disease or condition that is reportable to the Public Health Department. When symptoms are observed or infection is suspected by patient history (definitive diagnosis is not necessary first), the nurse will: Notify the patient’s physician and department. Document in the care plan, the date, time, the problems and interventions (i.e., Specific isolation precautions, patient/significant other teaching, diversionary activities) and notification of the Infection Preventionist. Implement isolation precautions and make necessary room changes including terminal clean of the patient’s room. Arrange for discharge and transfer to a higher level of care when an infectious Patient requires airborne precautions, and cannot be safely managed within the Behavioral Health Unit.”

“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: 38269 Based on observation and interview, the facility failed to maintai a clean and sanitary environment, resulting in the potential for the spread of infectious agents to all 57 patients being served at the time of survey. Findings include: On 10/7/2025 at 1555, during observation of the medication storage area in the alcove between units 300 and 400, four vials of single dose, sterile water for injection were observed stored in a drawer and each vial had a puncture through the rubber stopper. Staff U confirmed the findings at the time of discovery. On 10/7/2025 at 1556, during an inspection of the medication cupboard, an unopened box of insulin was observed stored in a bin in the cupboard. Observation of the storage instructions on the outside of the insulin box revealed “Refrigerate at 2º C to 8º degrees Celsius (36º F to 46º F) until first use.” Staff T confirmed the findings at the time of discovery. According to the facility’s policy “Injectible (sic) Medication Preparation, Administration, and Safety,” dated 01/2020, “Multiple use of an unpreserved injectable medicine should be eliminated. Most injectable medicines are licensed for ‘once-only’ use. Unless the manufacturer’s label specifically indicates that the injection contains a preservative, the container should only be used to prepare a single dose for a single patient on one occasion.” According to the facility’s policy “Use of Multiple Dose Vials,” dated 01/2020, “The Pharmacy Department shall verify that Multi-Dose Vials are stored and labeled correctly when inspecting medication storage areas.” According to the facility’s policy “Standardize Medication Administration,” dated 05/2021, “Prior to administering the medication(s), the five rights of medication administration should be considered: 1. Right Patient, 2. Right Drug, 3. Right Route, 4. Right Dose, 5. Right Time.” On 10/06/2025 at 1140 while conducting a tour in the nutrition room on unit 100, observation of the patient food refrigerator was found to have different colors and sizes of debris scattered in the freezer, on the refrigerator storage shelves, and in the corners of the drawers. The refrigerator shelving had yellow liquid on two out of three shelves used for food storage. Staff B confirmed the findings. On 10/07/2025 at 1550 while conducting a tour in the nutrition room on unit 300, observation of the patient food refrigerator revealed splashes of yellow fluid spattered through-out on the shelving and crumb like debris in the drawers. At the time of observation Staff E confirmed the findings. Staff E stated he was not aware of who should keep the refrigerator clean and free of debris. On 10/07/2025 at 1530 an open pudding cup was observed in the medication refrigerator between units 300 and 400. Staff T was queried regarding the purpose of an open container of pudding in the medication refrigerator. Staff T stated, “pudding is used for medication pass. People who have a hard time taking medication can sometimes take it with pudding.” When asked if the pudding was just opened, labeled, used for more than one person, Staff T stated, “I don’t know when it was opened, and it is used for multiple patients.” A policy regarding labeling multidose vials and refrigeration sanitation was not provided prior to exit.”

“IC PROFESSIONAL COMMUNICATION QAPI CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (iii) Communication and collaboration with the hospital’s QAPI program on infection prevention and control issues. This Standard is not met as evidenced by: 38269 Based on interview and record review, the facility failed to ensure the hospital wide Quality Assessment and Performance Improvement Program (QAPI) incorporated infection control information, resulting in the increased potential for transmission of infection to all 57 patients in the facility at the time of survey. Findings include: On 10/06/2025 at 1045 during an interview with the Interim Director of Nursing (DON), Staff B it was confirmed that she was not the infection preventionist. Staff B stated, “I am not aware of who the infection preventionist is”. Staff B confirmed that she was unaware of who had oversight of the infection prevention program. Staff B did not add insight regarding an infection control committee, or how information from such committee would be shared with the quality improvement team. On 10/07/2025 at 1515 during an interview with Director of Quality (DOQ), Staff C, it was confirmed that to her knowledge, a risk evaluation for infection prevention has not been conducted. Staff C further stated that she is not an infection preventionist, and is new to her role. On 10/08/2025 between 1400 and 1530 the Chief Executive Officer (CEO) Staff A confirmed that he was aware that an infectious risk analysis should be shared at quality improvement meetings, but that he cannot recall that happening. Staff A further stated he was unaware of who was designated as the infection preventionist. QAPI meeting minute review between the dates of 04/2025 - 10/2025 failed to have evidence of any infection prevention/control communication or collaboration, performance improvement projects, analysis of infection control data, or recommend improvement projects. Policy Review “Policy Stat ID; 12508722, titled: Infection Prevention Annual Evaluation & Risk Analysis effective 01/2020 last revised 01/2020 (note the facility did not open until 2024) The effectiveness of the Infection Control Program will be evaluated by the Infection Control Committee annually, and interventions will be implemented, as necessary. 1. Changes in the scope of the IC Program (such as new services or sites of care) 2. The success or failure of interventions for controlling or preventing infections 3. Response to concerns raised by leadership and others within the medical center 4. Evolution of relevant evidence-based guidelines. 5. Evaluations of program risk analysis The infection control and Prevention Program Risk Analysis will be performed annually and whenever significant changes occur in the above factors. The risk analysis will be based on the Infection Control Risk Assessment Tool (see Attachment 1), which is designed to target prioritize risks. Evaluation and modification of the information in the tool is a continual and ongoing process. Additional components may be added at the discretion of the facilities CEO.””

“IC PROFESSIONAL TRAINING CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (iv) Competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of infection prevention and control guidelines, policies, and procedures. This Standard is not met as evidenced by: 38269 Based on interview and record review, the facility failed to ensure that clinical staff had infection control education by a trained infection preventionist, resulting in the potential for adverse patient outcomes for all 57 patients at the facility at the time of survey. Findings include: On 10/06/2025 at 1035, an interview conducted with the interim DON (as of 08/2025) Staff B revealed she was unaware that the infection preventionist responsibilities fell within the role of DON. Staff B was unable to provide any evidence of competency-based education or training to fulfill the role of infection preventionist. Staff B was unable to identify which nationally recognized guidelines the facility followed to develop infection control policies and training. Staff B was further unable to provide infection control (IC) practice audits, or evidence of competency-based infection control staff training that occurred within the last six months (04/2025-10/2025). On 10/07/2025 at 1530 an open pudding cup was observed in the medication refrigerator between units 300 and 400. At the time of observation Registered Nurse Staff T was queried regarding the purpose of an open container of pudding. Staff T stated, “People who have a hard time taking medication can sometimes take it with pudding.” When asked if the pudding was just opened, labeled for one persons use, Staff T stated, “I don’t know when it was opened, and it is used for multiple patients.” Staff T was unable to identify the IC liaison who could help find a policy for IC guidance related to opened undated food sources being used for patient consumption (medication pass). On 10/07/2025 at 1550 while conducting a tour in the nutrition room on unit 300, an observation of the patient food storage refrigerator revealed splashes of yellow fluid spattered on the shelving, crumb like debris in the drawers and on the shelving. At the time of observation, Behavioral Health Assistant Staff E confirmed the findings. Staff E stated he was not aware of who should keep the refrigerator clean and free of debris. Staff E was not able to identify an infection control liaison available to assist employees. Staff E did not recall receiving infection prevention training. On 10/07/2025 at 1555, during observation of the medication storage area in the alcove between units 300 and 400, four vials of single dose, sterile water for injection were observed stored in a drawer, each vial contained a handwritten date and the rubber stoppers were punctured. Registered Nurse Staff U confirmed the findings at the time of discovery and shared, “single use vials should have been thrown away” after use.”

“IC PROFESSIONAL ADHERENCE TO POLICIES CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by hospital personnel. This Standard is not met as evidenced by: 38269 Based on interview and record review, the facility failed to provide a system of surveillance, detection, safety, and oversight, for all patients as outlined in the facility policies. Findings include: Interview on 10/06/2025 at 1035 with interim DON (as of August 2025) revealed she was unaware that the infection preventionist responsibilities were under her role. Staff B was unable to provide any evidence of audits related to adherence to infection prevention practices, policies, and procedures. On 10/08/2025 at 1100 during the review of requested credentialing files it was revealed that there was no file available for an “Infection Control (IC) Chair”. Infection Prevention documents including audits, surveillance records, documentation of completion (or scheduled courses) professional/certifications/education were requested for review and not received prior to survey exit. On 10/08/2025 between the hours of 1400 and 1530 an interview was conducted with Staff A, the Chief Executive Officer (CEO). The CEO was queried regarding oversight of the infection control program. The CEO confirmed that there was no physician oversight, and he was unsure of who the infection preventionist was but thought it may be “the Director of Quality, or the Director of Nursing”. When asked if the CEO was part of the infection prevention program, he stated “no”. Policy review: Policy Title: Infection Control Function, Policy Stat ID:12508721, Origination: 01/2020, Last Revised: 01/2020, (note the facility did not open until 2024). Next Review: 08/2026. PURPOSE: The Infection Control Function will enact policies to prevent the spread of hospital acquired infection within the facility. OBJECTIVES: To establish and maintain a functional surveillance system for the detection of hospital-acquired infections; To propose, design, and implement effective, evidence-based interventions to prevent the spread of infection; To act as an effective infection control liaison to employees, medical staff, families, volunteers, regulatory and healthcare agencies, and the community; To act as an educational resource to those entities listed above. FUNCTIONS 1.To maintain an accurate and timely infection surveillance system, and to present surveillance data in a meaningful format to the appropriate entities;2.To implement successful evidence-based interventions based upon that data, and to continuously assess the need and effectiveness of those interventions;3.To maintain facility compliance with regulatory and accrediting bodies involved in employee health and infection control matters;4.To advocate for prudent antimicrobial usage;5.To educate and to disperse accurate infection prevention information within and without the facility, and to promote the practice of infection control;6.To interface with governmental agencies in epidemiological matters;7.To perform all said functions in an ethical, cost-efficient manner. The Infection Control Function will enact policies to prevent the spread of hospital acquired infection within the facility.”