Anoka Metro Regional Treatment Center

“PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION CFR(s): 482.13(b)(4) The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital. This Standard is not met as evidenced by: 33925 Based on interview and document review, the hospital failed to offer or contact a family member and/or choice of representative upon admission to the psychiatric hospital for 8 of 10 patients (P3, P4, P5, P6, P7, P8, P9, P10) reviewed. Findings include: P3’s hospital record identified P3 admitted to the hospital on 6/2/26. The record lacked evidence they were asked or offered by the hospital regarding having a family member or representative notified of their admission. P4’s hospital record identified P4 admitted to the hospital on 5/1/26. The record lacked evidence they were asked or offered by the hospital regarding having a family member or representative notified of their admission. P5’s hospital record identified P5 admitted to the hospital on 6/16/26. The record lacked evidence they were asked or offered by the hospital regarding having a family member or representative notified of their admission. P6’s hospital record identified P6 admitted to the hospital on 5/27/26. The record lacked evidence they were asked or offered by the hospital regarding having a family member or representative notified of their admission. P7’s hospital record identified P7 admitted to the hospital on 9/22/25. The record lacked evidence they were asked or offered by the hospital regarding having a family member or representative notified of their admission. P8’s hospital record identified P8 admitted to the hospital on 11/21/25. The record lacked evidence they were asked or offered by the hospital regarding having a family member or representative notified of their admission. P9’s hospital record identified P9 admitted to the hospital on 5/27/26. The record lacked evidence they were asked or offered by the hospital regarding having a family member or representative notified of their admission. P10’s hospital record identified P10 admitted to the hospital on 6/1/26. The record lacked evidence they were asked or offered by the hospital regarding having a family member or representative notified of their admission. When interviewed on 6/22/26 at 10:58 a.m., registered nurse (RN)-B stated the nurses provided each patient with a copy of their bill of rights upon admission and asked them if they had a healthcare directive (HCD). RN-B stated the patients were then asked to sign an “e-document” to show they had been given this information. RN-B stated the nurses offered to call someone for a patient about their admission only if a release of information (ROI) was needed. On 6/22/26 at 1:09 p.m., the medical records for P3, P4, P5, P6, P7, P8, P9, and P10 were reviewed with registered nurse supervisor (RN)-D. The records were verified as lacking evidence of the patient being asked about if they’d like a representative or family member notified of their admission to the hospital. RN-D stated the hospital did not have a process to do that adding the requirement to do it had been recently brought to their attention so a work group was being developed to address it. RN-D stated asking patients about notifying a family member upon admission was not included in their admission process and added aloud, “It isn’t something that we’ve been focused on.” A hospital policy on family notification to the hospital was requested, however, none was received. An e-mail correspondence from RN-D, dated 6/22/26, identified the following, “After looking into some policies, I can confirm [the hospital] does not have a procedure, or process in place for patient’s request for notification of admission.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 33925 Based on interview and document review, the hospital failed to ensure a physician’s order for a restraint application was immediately obtained (i.e., within a few minutes) after emergent application for 2 of 2 patients (P9, P10) reviewed who had violent restraints (i.e., seclusion, manual holds) applied. The hospital policy for restraint application provided for a one-hour time frame from application to obtaining the provider order. Findings include: The hospital provided Restraint and Seclusion Detail By Program listing, dated 6/1/26 to 6/22/26, identified a total of two restraint applications had happened at the hospital campus since 6/1/26. These included a holding restraint for P9 on 6/4/26, and a seclusion restraint used for P10 on 6/20/26. P9’s Seclusion/Restraint Record, dated 6/4/26, identified a manual hold was applied to P9 at 9:47 a.m. and released at 9:49 a.m. (two minutes). P9 had been acting intrusive and confrontational with peers, refusing to take medications, and holding up hands towards the staff members. The record included a section which identified the provider was notified of the restraint at 9:47 a.m., but the order for it was not received until 9:56 a.m., (nine minutes after application). P10’s Seclusion/Restraint Record, dated 6/20/26, identified P10 was placed into seclusion at 12:42 p.m. and released from it at 2:15 p.m. (93 minutes). P10 had been screaming in his room and posturing towards staff while making threats of harm to them such as, “I will kill you.” P10 then struck himself repeatedly with a closed fist. The record included a section which identified the provider was notified of the restraint at 12:45 p.m., but an order was not received for the seclusion until 1:00 p.m. (15 minutes after application). When interviewed on 6/22/26 at 10:58 a.m., registered nurse (RN)-B stated the hospital provided education to the staff on restraint use often which included a return demonstration of various holds along with how to use the restraint devices. RN-B stated the provider was responsible for writing the order for a restraint adding they were often present for the application of the restraints anyway. RN-B stated the order needed to be obtained “within the first hour, if not sooner.” On 6/22/26 at 1:09 p.m., P9 and P10’s medical records were reviewed with registered nurse supervisor (RN)-D. The times for each restraint application and subsequent order were verified, and RN-D explained the hospital policy allowed for one hour to obtain an order for a restraint as prior there had been “really no definition of ‘as soon as possible.”’ RN-D stated that may now be different and interpreted more as “like immediate as you can.” RN-D stated the hospital policy to allow for one hour to obtain a provider order had been in use for “a long time.” RN-D stated there were no current plans to adjust the policy to their knowledge adding, “It has been accepted all along, so as far as I am aware, there aren’t any work groups [for it] and we’re not addressing that.” The hospital Seclusion or Restraint policy, dated 6/2024, identified a section of definitions which outlined a restraint was any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of the patient to move their own limbs or head. The section with definitions lacked any hospital-defined language for their interpretation of ‘as soon as possible’ or ‘immediately’. A series of procedures for the provider and RN were listed which included the provider giving a time-limited order for the application of a restraint. The RN was responsible for, “ ... consults with the [provider] and obtains order to authorize the application of seclusion or restraint as soon as possible, not to exceed one hour after initiation of the seclusion or restraint.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49618 Based on observation, interview, and record review, the facility failed to provide care in a safe setting for two of ten residents (P2, and P3) when P2 was on a distant 2:1 observation, staff gave her a toothbrush for hygiene care and P2 swallowed the toothbrush. P3 was on a distant 2:1 in the intensive care area (ICA), when she was given her personal belongings and P3 swallowed a quarter. As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13. See A-0144 for additional information.”

“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: 49618 Based on observation, interview, and record review, the facility failed to provide care in a safe setting for two of ten residents (P2, and P3) when P2 was on a distant 2:1 observation, staff gave her a toothbrush for hygiene care and P2 swallowed the toothbrush. P3 was on a distant 2:1 in the intensive care area (ICA), when she was given her personal belongings and P3 swallowed a quarter. Findings include: Writer observed video footage on 6/8/26 at 2:32 p.m. of P2’s incident on 5/22/26 and P3’s incident on 4/20/26. There are no cameras in either P2’s bedroom or bathroom. There are no cameras in P3’s bedroom in the ICA. - P2’s incident on 5/22/26: “ 6:18:19 a.m.- P2 is seen at the nurse’s station while a staff member behind the nurse’s desk is gathering P2’s hygiene items in paper cups. “ 6:20:30 a.m.- P2 walks away from the nurse’s station with her hygiene products in a hygiene basin. “ 6:20:56 a.m.- P2 walks back to the nurse’s station. “ 6:21:42 a.m.- P2 walks away from the nurse’s station with additional hygiene items, including a dark blue toothbrush. P2 is feeling the toothbrush with her hands as if she were examining it. “ 6:22:33 a.m.- P2 goes back to her room. One of the 2:1 staff member goes into P2’s room with P2 while the other 2:1 staff member stands in the bedroom doorway. The staff looks like they are either talking to each other or the 2:1 staff member that is standing at the doorway talking to P2 because she is smiling and laughing. “ 6:48:08 a.m.- Another staff member goes into P2’s room and it looks like she is asking P2 for the hygiene items back because she is waving the “give it here” motion with her fingers. “ 6:48:16 a.m.- The other staff member comes out of P2 and is looking through the hygiene basin while walking a couple steps outside P2’s door. “ 6:48:48 a.m.- P2, the other staff member, and the two 2:1 staff members are seen walking out of P2’s room. P2 is carrying her bath towels. “ 6:49:13 a.m.- P2 is seen talking with all three staff members near the laundry room door. It looks as though P2 is coughing. “ 6:49:45 a.m.- P2 is seen shaking out her bath towels. - P3’s incident on 4/20/26: “ 4:20:01 p.m.- A staff member is seen standing in the ICA at the doorway of P3’s door. “ 4:21:57 p.m.- P3 is seen leaving her room followed by another staff member. P3 is seen holding her chest. “ 4:26:14 p.m.- P3 is seen on the phone. “ 4:27:00 p.m.- P3 is seen putting the phone down and leaving the day room. “ 4:27:31 p.m.- P3 is seen going back to the day room and sitting down in the chair. Two staff members are following her. “ 4:29:55 p.m.- Another two staff members are seen entering the ICA day room with a vital sign machine. A staff member takes her vitals. P2’s medical records indicated P2 was admitted to the facility on 4/12/26 with a primary diagnosis of unspecified trauma and stressor related disorder. P2’s additional diagnoses included personality disorder with borderline and antisocial personality traits, stimulant abuse, and opioid abuse. P2 was admitted to the facility on a mentally ill (MI)/ chemically dependent (CD), Jarvis, and Price Sheppard commitment. P2 was still at the facility at the time of the survey. P2’s initial nursing care plan dated 4/13/26 indicated P2 had a significant history of foreign body ingestion (FBI). P2 had a history of ingesting foreign body objects (FBO) prior to her admission to the facility. P2’s incident reports indicated P2 swallowed a spork on 4/27/26 and then swallowed a crayon on 5/12/26. P2’s increased observation order dated 5/21/26 indicated P2 was on a distant 2:1 that required her door to always be open. P2 was on an intensive observation. This order was discontinued on 5/22/26 at 6:55 a.m. P2’s progress note dated 5/21/26 indicated on 5/20/26 P2 had spent time in the general milieu for about eight hours with her distant 2:1 staff. P2 did well as she was able to utilize her coping skills and do not engage in unsafe behaviors. On 5/21/26, the ICA was discontinued but her distant 2:1 remained observations at all times. P2 would be encouraged to use coping skills for obsessive compulsive disorder (OCD) symptoms and notify staff if she had urges to engage in unsafe behavior. P2’s care plan dated 5/21/26 indicated P2 had a risk of FBI. Interventions included nursing to assess P2 for suicidality every shift and as needed to determine safety level, nursing would encourage P2 to identify two to three coping skills she found effective at reducing target behaviors, nursing would encourage P2 to attend groups and activities as offered on the unit, nursing would encourage P2 to report to staff increased feedings of suicidal ideation, and nursing would encourage P2 to report to staff with increased anxiety, depression, or agitation. P2’s incident report dated 5/22/26 indicated at 6:15 a.m., P2 went to the nurse’s station and requested hygiene products. P2 was offered a toothbrush as well as other hygiene items. P2 was instructed to return all items given to her. At 6:50 a.m., staff on the distant 2:1 were observed talking to P2 in the hallway asking where P2’s toothbrush was. P2 responded that she swallowed the toothbrush. Vitals were obtained, and P2 denied any pain or discomfort. The on-site provider was updated and P2 was placed on a close 2:1 with observation with eyes on P2 at all times. P2’s progress note dated 5/22/26 indicated P2 was on a distant 2:1 for patient safety. P2 exited her room at 6:15 a.m. and requested hygiene products. P2 was offered a toothbrush and other hygiene items. P2 was instructed to return all items given to her after she was done with her hygiene. At approximately 6:50 a.m., P2 was asked P2 to give them the toothbrush and P2 indicated she swallowed the toothbrush. P2 was placed on a close 2:1 observation with eyes on at all times. P2’s progress note dated 5/22/26 indicated P2 had swallowed a toothbrush on the overnight shift. The provider was notified, and orders had been received to bring P2 to the hospital for further evaluation. P2 underwent an esophagogastroduodenoscopy with foreign body removal under anesthesia. The procedure was completed with successful removal of the toothbrush. P2 was transferred back to the facility and was placed on a close 2:1 observation at all times for patient safety due to self-harm and FBI. P2’s hospital medical records dated 5/22/26 indicated P2 went to the hospital after swallowing a rubber toothbrush. P2 had a medical history of swallowing items. P2 underwent an endoscopy to remove the toothbrush. The facility’s investigation started on 5/22/26 indicated staff reviewed video footage of the incident with P2’s FBI on 5/22/26. It was determined policies were adequate in managing the incident and there was no indication of staff training needed based upon policy review. After P2 came back from the hospital, P2 was placed on a close 2:1 observation. P2’s treatment plan had been updated but no new interventions were added due to P2 having a history of FBI and it was an active problem in P2’s care plan already. P3’s medical records indicated P3 was admitted to the facility on 11/13/25 with a primary diagnosis of borderline personality disorder. P2’s additional diagnosis included post-traumatic stress disorder (PTSD). P3 was admitted to the facility on an MI and Jarvis commitment. P3’s incident reports indicated P3 swallowed a water bottle cap on 12/8/25. On 12/21/25, P3 swallowed screws, a plastic spoon, rubber nose piece from P3’s glasses, and the glasses screws that hold the nose piece to the frames of the glasses. On 12/27/25, P3 swallowed two golf ball sized chunks from her foam wedge pillow. On 1/18/26, P3 swallowed a piece of an earphone. On 3/2/26, P3 swallowed a piece of plastic that was on her shoes. On 4/14/26, P3 swallowed a screw that she got when she dismantled equipment from inside the phone cabinet. P3’s care plan dated 4/15/26 indicated P3 had a history of swallowing FBO. The behavioral assistants (BA) have reported P3 had exhibited aggression when staff set limitations or not being able to get what P3 wanted. One of P3’s care plan goals was she would be able to spend transition periods out of the ICA to reintegrate into the general milieu after demonstrating 48 hours with no physical aggression or FBI. Full discontinuation of the ICA would be considered after at least four weeks of successful transition efforts. It was noted that staff needed to be consistent and firm by setting healthy boundaries with P3. One of P3’s care plan objectives was P3 would maintain safe behavior (not ingesting non-food items) 75 percent of the time to assist with attaining increased independence/privileges such as transition time out of ICA. One intervention was that nursing would monitor P3 daily to assess safe behavior (not ingesting non-food items) and document in progress note the percentage of each shift she was safe, to assist with attaining increased independence/privileges such as transitioning time out of ICA. Another intervention was BA’s would meet with her weekly to practice and identify strategies for demonstrating safe and healthy boundaries. These strategies would include effective communication without the use of aggression and refrain from ingesting non-food items. These interventions were identified on 4/15/26. P3’s progress note dated 4/20/26 indicated at approximately 3:11 p.m., P3 was in the ICA with two staff members. P3 was yelling at staff and attempting to grab staff’s badges and buttons on a staff’s coat. Staff provided verbal redirection, but P3 went into her room, grabbed her wallet, and appeared to swallow an item. P3 was put in a manual restraint. Staff notified the supervisor and the provider, who ordered an x-ray. P3’s progress note dated 4/21/26 indicated P3 had an x-ray completed after P3 swallowed a quarter. P3’s incident report dated 4/20/26 indicated at approximately 3:11 p.m., P3 was in the ICA with two staff members. P3 was yelling about not being able to leave the ICA. P3 was attempting to grab buttons off one staff’s coat. Staff attempted redirection, P3 ran into her room, grabbed her wallet, and swallowed an item. Staff intervened by placing P3 in a manual restraint. The provider was present, assessed P3, and ordered an x-ray. On 4/22/26 during a critical incident review, it was noted the x-ray showed a three millimeter (mm) foreign body that appeared to be working its way through P3’s digestive tract without issue. All coins were removed from P3’s room. The report indicated (registered nurse (RN)-F, mental health program assistant (MHPA)-C, and human service technician (HST)-D were there at the time of the incident. The facility’s investigation started on 4/20/26 indicated staff reviewed video footage of the incident with P3’s FBI on 4/20/26. It was determined P3 was on 1:1 observation with 2:1 staffing in the ICA for history of aggression towards staff and other patients, FBI, and disrobing. It was determined the policies were adequate in managing the incident and no staff training was warranted based upon policy review. After the incident, P3’s items with risk of being ingested were immediately removed from her room and from the ICA. Leadership interviewed MHPA- C who stated P3 had been agitated and was calling the policy. P3 grabbed MHPA-C’s badge and tried to get buttons off MHPA-C’s coat. P3 ran into her room, reached for her purse, and put an object in her mouth. MHPA-S and HST-D put P3 in a manual restraint until additional staff arrived. P3’s care plan was updated after this incident. During an interview on 6/2/26 at 11:37 a.m., RN-A stated when a patient is on a distant 2:1 it means that there are two staff watching one patient. The staff is close enough to intervene, but not close enough to be “hovering “over the patient. When a patient is on a 2:1, staff are to watch the patient and the environment to make sure the patient cannot grab something and swallow it. During an interview on 6/2/26 at 12:12 p.m., HST-A stated when a patient is on a distant 2:1, there are two staff that are within six feet of one patient. The staff is watching for aggression and swallowing behaviors of the patient. HST-A stated P3 has a history of swallowing FBO. During an interview on 6/2/26 at 12:44 p.m., MHPA-A stated when a patient is on a distant 2:1, it means that there are two staff watching one patient. When a patient is in the bathroom, the staff do not have to be in the bathroom with the patient, but they do have to always have eyes on the patient. MHPA-A stated P2 had a history of swallowing FBO. Most of the time, P2 would swallow the item and then she would not tell staff until a later time. During an interview on 6/2/26 at 1:09 p.m., RN-B stated when a patient is on a distant 2:1, staff do not have to be close to the patient, but you must always have eyes on the patient. There cannot be any barriers between the staff and the patient. Staff are to watch for the safety of the patient. RN-B stated when she came in the morning of 5/22/26, she was getting report from the overnight shift. The overnight shift staff asked P2 where the toothbrush was that they had given her. P2 told staff that she swallowed the toothbrush. RN-B stated she had a history of swallowing FBO prior to coming into the facility as well as history of her swallowing FBO while at the facility. During an email correspondence on 6/8/26 at 8:29 a.m., RNS-C stated the facility did not have a policy on deliberate FBI. During an interview on 6/8/26 at 11:46 a.m., registered nurse supervisor (RNS)-B stated P2 had a history of FBI prior to coming to the facility as well as at the facility. RNS-B stated he was not there when P2 ingested the toothbrush but came in that morning when he was told about the incident. RNS-B stated P2 was on a distant 2:1 at the time of the incident. When a patient is on a distant 2:1, staff must always have eyes on the patient with no barriers between the staff and the patient. RNS-B stated HST-E and HST-F were the two staff who were part of the observation. During an interview on 6/8/26 at 12:39 p.m., provider (P)-B stated P2 had a history of swallowing FBO prior to coming to the facility and during her admission at the facility. At the time of the incident, P2 was on a distant 2:1 and had the ability to check out a toothbrush. P-B stated that in hindsight, P2 should have been on a close 2:1 but stated P2 would have likely still swallowed the toothbrush if she was on a close 2:1. During an interview on 6/8/26 at 1:27 p.m., RN-E stated when a patient is on a distant 2:1, staff don’t have to be right next to the patient, but the staff are in close proximity to the patient with no barriers between the staff and the patient. RN-E stated he came into the facility approximately 15 minutes after the incident happened. RN-E stated he went with P2 to the hospital where she had an endoscopy to remove the toothbrush. During an interview on 6/9/26 at 8:11 a.m., HST-F stated when a patient is on a distant 2:1, two staff members must always watch the one patient with their eyes on the patient. If a patient had a history of swallowing FBO, staff would watch to make sure the patient did not swallow anything. HST-F stated P2 had a history of swallowing FBO. HST-F stated she was one of the 2:1 staff with P2 at the time of the incident on 5/22/26. P2 had been on a distant 2:1 when P2 asked another staff member for hygiene items, including a toothbrush. HST-F stated that P2 would have to return all hygiene items after P2 was done using them. P2 returned to her bathroom and HST-F was standing at the doorway of her bathroom watching P2. HST-E was the other staff member on the 2:1 and she was standing at the doorway of P2’s bedroom in the hallway. After P2 brushed her teeth, HST-F asked for the toothbrush back and P2 stated that she was not done using the toothbrush. After that, P2 took a shower. HST-F stated P2 did not have a shower curtain on her shower. After P2 was done with her hygiene items, she was asked where her toothbrush was, and P2 stated she swallowed the toothbrush. HST-F was unsure how P2 swallowed the toothbrush because she “had eyes on the patient at all times”. P2 could not recall if the patient turned away from her in the shower. During an interview on 6/9/26 at 8:32 a.m., RN-D stated when a patient is on a distant 2:1, it means that there are two staff watching one patient. RN-D stated there cannot be any barriers between staff and the patient and you must always have eyes on the patient. Staff would watch for self-injurious behavior as well as environmental safety. RN-D stated P2 had a history of swallowing FBO. RN-D stated she worked the overnight shift going into the morning of 5/22/26. Licensed practical nurse (LPN)-A gave P2 hygiene items, including the toothbrush, after P2 asked for them. P2 along with two staff went back to P2’s room. Once completed with her hygiene items, P2 gave staff back the hygiene items. One of the staff asked P2 where the toothbrush was, and P2 said that she swallowed the toothbrush. RN-D was when called to talk to P2. RN-D took P2’s vitals, checked her mouth for visible bleeding, and checked if P2 had trouble breathing. RN-D informed the supervisor and the provider. P2 was on a distant 2:1 at the time of the incident. The 2:1 staff included HST-F and MHPA-B. During an interview on 6/9/26 at 8:39 a.m., HST-E stated when a patient is on a distant 2:1, one staff has to have eyes on the patient at all times and then the other staff member has to be somewhat close to the other staff member and the patient but has to have their eyes on the other staff member for support. P2 had a history of swallowing FBO. HST-E stated she was one of the staff members on the distant 2:1 when P2 swallowed the toothbrush on 5/22/26. HST-F was standing inside P2’s bathroom doorway watching P2 use her hygiene items. HST-E stated she was standing at the doorway of the bedroom and hallway watching HST-F. HST-E stated she could not see P2 at all while she was in the bathroom but could hear P2 turning on and off the water while she was brushing her teeth. HST-F asked P2 for the toothbrush after she was done brushing her teeth and P2 kept saying that she was not done with the toothbrush. When P2 was done showering, P2 went out of her room in the milieu. Staff asked for the toothbrush back and P2 kept saying that she swallowed the toothbrush while she was in the shower. HST-E stated when she has been on a 2:1 with P2 before, P2 has turned her back in the shower so she would face away from staff. HST-E stated she could not tell P2 to turn around in the shower so staff can see her due to privacy. A call to LPN-A on 6/9/26 at 8:53 a.m. resulted in leaving a voicemail. LPN-A did not return writer’s phone call. During an interview on 6/9/26 at 9:00 a.m., RN-F stated she was not there when P3 swallowed the quarter on 4/20/26. A call to MHPA-C on 6/9/26 at 9:03 a.m. and 10:42 a.m. resulted in leaving a voicemail. MHPA-C did not return writer’s phone call. A call to HST-D on 6/9/26 at 9:04 a.m. and 10:45 a.m. resulted in leaving a voicemail. HST-D did not return writer’s phone call. During an interview on 6/9/26 at 9:05 a.m., RN-G stated he was not at the facility when P3 swallowed the quarter on 4/20/26. During an interview on 6/9/26 at 9:14 a.m., RNS-B stated when a patient is on a distant 2:1, staff need to have a clear line of sight to the patient, meaning there cannot be any barriers between the staff and the patient. RNS-B stated that when a patient has a history of swallowing FBO, staff’s responsibility is to minimize the risk of the patient swallowing. One staff member must always have eyes on the patient. The second staff’s location would be in the order. If the order does not state where the second staff member needs to be, then it would be assumed that the second staff member also had to always have eyes on the patient. RNS-B stated there are times, such as when a patient makes false allegations, where one staff member can always have eyes on the patient and then the second staff member is watching the first staff member for support. During an email correspondence on 6/9/26 at 1:44 p.m., RNS-C forwarded an email she had sent to additional leadership on 5/22/26 at 1:35 p.m. after she reviewed video footage of P2’s incident on 5/22/26. The email indicated a full review of the video footage of the incident. The email indicated between 6:22 a.m. and 6:48 a.m., the 2:1 staff member who was in the doorway was observed to be talking to someone in the bedroom, appeared to be laughing at times, making hand gestures, and moving around in the doorway. The email determined P2 was on a distant 2:1 at the time of the incident and there were no documentation or orders that P2 may or may not have the toothbrush. The facility’s human resource (HR) review completed on 6/9/26 at 11:49 a.m. indicated HST-E completed her deliberate FBI training on 6/26/25, MHPA-C completed her deliberate FBI training on 9/9/19, and HST-G completed her deliberate FBI training on 9/9/19. The facility’s Therapeutic Observations policy dated 1/7/25 indicated a distant 1:1 or 2:1 is when the staff assigned always keep the patient within range of view that maintains continuous observation with no physical barriers, such as glass window or door, separating the patient and the staff.”

“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: 49618 Based on interview and record review, the facility failed to provide care in a safe setting for one of ten patients (P1) when registered nurse (RN)-B crossed professional boundaries by giving P1 her personal phone number while P1 was still a patient at the facility. Findings include: Video footage reviewed on 4/22/26 at 2:41 p.m. -On 12/25/26 at 9:48:22 a.m., RN-B was seen walking into the day room and P1 followed right beside her. RN-B sats down and P1 sats right beside her. They conversed until 10:25:35 a.m. when another patient was seen coming to sit by RN-B and P1, then P1 got up and walked out of the room. During this conversation, RN-B is sitting cross legged on the chair, sitting sideways while facing P1. P1 is in the same position. Throughout the conversation, RN-B is seen laughing and smiling. Throughout the conversation, RN-B and P1 are only focused on each other while other patients were in the day room. At 10:25:35 a.m. when another patient comes and sits by RN-B, RN-B repositioned herself to sit on the chair properly, facing the front of the room. RN-B does not engage in conversation with other patients. -On 12/26/25 at 10:10:32 a.m. RN-B is seen entering the day room while there are no patients in the day room. At 10:29:58 a.m., P1 is seen entering the day room and at the time, RN-B is seen helping another patient. RN-B sits at the table and P1 sits at the same table across from her. RN-B and P1 became a conversation, and both were seen laughing and smiling. Throughout this conversation different staff members and patients come and go briefly. Throughout this conversation, P1 is seen getting up from the table and going to the kitchenette door, which is in the day room, but returning less than two minutes later to sit at the same spot next to RN-B. This conversation goes on until 11:59:10 a.m. when RN-B is seen leaving the day room. - On 1/4/26 at 9:31:40 a.m., RN-B is seen in the day room sitting down at a table when P1 sits down at the same table across from her. P1 is seen coloring a picture and RN-B coloring on the same picture. During this conversation, P1 and RN-B are seen leaving the table briefly. P1 went to the kitchenette door that is in the day room and RN-B to assist other patient’s in the day room, but these brief pauses are no more than a couple minutes long, and then RN-B and P1 return to the same table. This conversation lasts until 11:36:52 a.m. when P1 leaves the room and RN-B remains in the room. -On 1/5/26 at 9:10:00 a.m., RN-B and P1 are seen standing at the nurse’s station having a conversation. Other staff and patients come and go throughout the conversation. At 9:22:30 a.m., RN-B is seen coming out of the activity room with P1’s belongings and goes outside of the unit with P1 and two additional staff to the transportation area. All staff and P1 are seen engaging in a conversation. At 9:29:13 a.m., RN-B is seen loading P1’s belongings in the back of a transportation vehicle as P1 is seen entering the transportation vehicle. P1’s medical record review indicated P1 was admitted to the facility on 11/18/25 due to unspecified schizophrenia spectrum, other psychotic disorders, and post-traumatic stress disorder (PTSD). P1’s additional diagnoses included schizoaffective disorder and other stimulant use. P1 was on a civil commitment while he was at the facility. P1 was discharged from the facility on 1/5/26. P1’s Vulnerability Risk Reduction Plan dated 11/18/25 indicated P1 did not have a risk of predatory behavior towards staff, visitors, general public, or others. The assessment indicated P1 was capable of and likely to self-report an incident of abuse or neglect. P1’s Vulnerability Risk Reduction Plan dated 11/25/25 indicated P1 did not have a risk of predatory behavior towards staff, visitors, general public, or others. The assessment indicated P1 was capable of and likely to self-report an incident of abuse or neglect. P1’s progress note dated 11/27/25 written by RN-B indicated P1 maintained safe behavior on the unit. P1’s progress note dated 12/8/25 indicated P1 heard voices, and the voices were talking to P1 about his love life and P1 indicated he was lonely. P1’s progress note dated 12/12/25 written by RN-B indicated RN-B sat with P1 and another patient and watched them play cards and engaged in casual conversation. RN-B indicated P1 exhibited safe pro-social behavior throughout the day. P1’s Vulnerability Risk Reduction Plan dated 12/17/25 indicated P1 did not have a risk of predatory behavior towards staff, visitors, general public, or others. The assessment indicated P1 was capable of and likely to self-report an incident of abuse or neglect. P1’s Vulnerability Risk Reduction Plan dated 12/18/25 indicated P1 did not have a risk of predatory behavior towards staff, visitors, general public, or others. The assessment indicated P1 was capable of and likely to self-report an incident of abuse or neglect. P1’s progress note dated 12/21/25 indicated P1 began asking the staff about her hobbies and the staff encouraged P1 to concentrate on his treatment plan and how he was doing. P1’s Vulnerability Risk Reduction Plan dated 12/30/25 indicated P1 did not have a risk of predatory behavior towards staff, visitors, general public, or others. The assessment indicated P1 was capable of and likely to self-report an incident of abuse or neglect. P1’s progress note dated 1/4/26 written by RN-B indicated P1 had been visible and engaged on the unit throughout with day with safe, social behavior. P1 interacted with other patients and staff. RN-B indicated she listened to P1 and provided positive feedback. P1’s progress note dated 1/5/26 written by RN-B indicated P1 was discharged from the facility. P1 had a bright affect and verbalized positive feelings regarding upcoming life changes he hoped to embark on. RN-B indicated all personal property was sent with P1, including hygiene items and medications. During an interview on 4/21/26 at 11:22 a.m., RN-A stated she worked with RN-B a lot. P1 would seek RN-B out throughout the day. P1 would enjoy talking to RN-B. RN-A stated these interactions started happening shortly after P1 was admitted to the facility. RN-A stated she is friends with RN-B on Snapchat. RN-A stated RN-B posted a picture of P1 on her Snapchat “5-6 weeks ago”. The next time RN-A worked with RN-B, RN-A asked her about the photo she posted on Snapchat and RN-B did not answer the questions about it. RN-A stated she did not report the photo when she saw it but admitted she should have reported it. RN-A stated she was talking to RN-E “a couple weeks ago” and RN-E asked if RN-A saw the Snapchat picture, and RN-A stated yes, she saw it. During an interview on 4/21/26 at 11:43 a.m., nursing assistant (NA)-A stated she saw RN-B and P1 spending a lot of time together. NA-A stated he would see RN-B seeking P1 out more than the rest of her patients. NA-A stated RN-B would get a lot and talk to P1. NA-A observed RN-B “flirt” with P1 during her conversations with him. NA-A noticed these interactions start “a couple weeks” prior to P1 discharging. During an interview on 4/21/26 at 3:22 p.m., P1 stated his relationship with RN-B was “very” professional during his admission at the facility. P1 stated he and RN-B talked about each other’s life experiences and checked in on recent life updates daily. The relationship became romantic after P1 was discharged from the facility. P1 has seen RN-B after he was discharged from the facility. P1 reached out to RN-B immediately after he was discharged. P1 stated he reached out to RN-B because RN-B gave him her personal phone number. P1 stated they talked about the situation, and both felt very passionate about each other and continued to talk. P1 stated they were going to talk after P1 was discharged even if they both got in trouble for it. P1 stated the surveyor’s interview with P1 felt awkward because P1 and RN-B knew the surveyor’s phone call was coming. During an interview on 4/21/26 at 3:30 p.m., RN-B stated her relationship with P1 was “completely” professional during P1’s admission. RN-B stated she talked to P1 about his treatment plan objectives, P1’s past experiences, music, and spirituality. RN-B stated she had seen P1 outside of the facility. Her relationship with P1 turned romantic because she enjoyed talking to P1, she was attracted to P1, had the same interests, and felt like they had “met each other in another life”. P1 reached out to RN-B after he was discharged because she gave P1 her personal phone number the day prior to P1’s discharge. RN-B stated, “this is unprofessional, but it is what it is”. During an unsolicited phone call from RN-B to the surveyor on 4/21/26 at 3:38 p.m. RN-B stated “P1, the state just called me”. Surveyor concluded that RN-B was with P1 when the surveyor called RN-B for the interview. During an interview on 4/22/26 at 8:30 a.m., RN-D stated he would consider all the patients at the facility vulnerable adults. RN-D’s expectations when it comes to boundaries are that there needs to be professional boundaries between staff and patients. Staff are there to provide therapy and communication to patients. RN-D stated that after a patient is discharged, his expectations are that staff follow the policies and procedures. RN-D’s expectation is that staff do not engage in relationships with patients who have been discharged. RN-D staff should never give patients their personal phone numbers. RN-D stated staff go through boundary training upon orientation and staff would sign off on knowing on to keep professional boundaries with patients. RN-D stated he found out about the allegations between RN-B and P1 the day after a staff member reported the picture on Snapchat to RN-E. RN-E and RN-D initiated an investigation. RN-D reviewed RN-B’s badge access and there were a couple of times when RN-B came in on her days off. The first time RN-B came in on her day off she was wearing a hooded sweatshirt and sunglasses. RN-B went on the unit, found P1 and sat down by P1 and another patient. RN-B was seen holding up a finger to her lips making the “shush” motion. The second time RN-B came in on her day off she walked around the unit looking like she was looking for someone. RN-B looked in a room where patient’s do their court hearings and then P1 came out of that room. RN-B and P1 walked over to the front of the nurse’s station and were having a private conversation. A staff member walked up by RN-B and P1 and then RN-B and P1 ended the conversation. RN-D stated these videos do not include audio. RN-D stated these instances were concerning and seemed as though there were boundary violations. RN-D stated on the day of P1’s discharge, RN-B was one of the staff members in the room that day and RN-B was “highly” focused on P1. While RN-B was preparing P1’s discharge belongings, RN-B wrote something on a small piece of paper. RN-D did not see her put the note in P1’s bag. RN-D thought maybe RN-B was going to staple the note to the outside of P1’s bag but when the camera focused, the note was not stapled on P1’s bag, so RN-D assumed RN-B put the note inside P1’s belongings. RN-D did not have any other involvement in the investigation besides the video review. RN-D stated RN-B is out of the facility on workers comp due to an unrelated instance and has been out of the facility since the day before the incidents were reported to RN-E. RN-D stated RN-B can’t enter the facility right now because her badge has been deactivated. There has been some staff training about not coming in on their days off and boundaries with patients. RN-D stated he is unsure what is going to happen when RN-B comes back to the facility after her workers comp ends. During an interview on 4/22/26 at 9:19 a.m., RN-E stated her expectations when it comes to staff boundaries with patients is not to engage in a relationship or communicate with patient’s after the patient has been discharged. RN-E stated staff should not be giving patients their personal phone numbers under any circumstances as all the patients at the facility are vulnerable adults. RN-E stated nurse practitioner (NP)-A reported to her that staff were heard talking about RN-B’s involvement with P1. RN-E immediately reported this allegation to director (D)-A. RN-E stated she is not RN-B’s direct supervisor, but RN-D is. RN-E stated she interviewed a couple of staff, including RN-C who stated he saw an inappropriate interaction but did not want to disclosure too much information. RN-E stated she called RN-A about an unrelated topic and RN-A told RN-E that she saw a photo of P1 on RN-B’s Snapchat. RN-B is currently out on workers comp due to an unrelated incident. During an interview on 4/22/26 at 10:38 a.m., NP-A stated she overheard a couple staff on Unit talking about RN-B having an inappropriate relationship with P1. NP-A could not recall the staff members’ names or what they looked like. After NP-A overheard this conversation, NP-A reported these allegations to RN-E. During an interview on 4/27/26 at 10:21 a.m., security (S)-A stated the video of RN-B loading P1’s belongings in the activity room has been recorded over and there is no longer the video. S-A stated there is no longer the video of RN-B coming in on her days off to see P1. During an interview on 4/27/26 at 10:56 a.m., RN-K stated her expectation when it comes to staff and patient boundaries is that staff are professional, kind, and respectful towards the patients. Staff are expected not to share their personal lives. RN-K’s expectations when it comes to boundaries and patients who have been discharged are that the patient is still considered a patient for up to three years after discharge. RN-K’s expectation is that staff never give patients their personal phone numbers. RN-K stated she teaches the boundaries class during new employee orientation. The boundary class goes over the dress code, the boundaries policy, talk about manipulative patients, and tips and tricks on redirecting conversations with patients. The class goes over not answering questions about the staff’s personal lives. The class talks about not being in a romantic relationship with patients during and after the patient’s admission. This class is about one to two hours when a new staff is hired and then staff take a web-based training annually thereafter that covers everything the initial boundaries class covers. RN-K stated she was alerted to the allegations regarding RN-B and P1 that they were in a romantic relationship. At the time, RN-K did not know whether it started before, during, or after P1’s admission. After the incident had been reported, RN-K was notified that RN-B deleted her social media accounts. After RN-K was informed of the incident, RN-K started the vulnerable adult report. RN-K stated RN-B was already on workers comp due to an unrelated incident. RN-B is out on workers comp until 5/1/26. RN-K does not know what administration will be doing with RN-B after she returns to the facility, but states RN-K does not trust RN-B with patient cares. During an interview on 4/27/26 at 11:11 a.m., RN-L stated she would expect staff to maintain boundaries with patients. She would expect staff to protect the patients and provide safe care for patients. RN-L stated all patients at the facility are considered vulnerable adults. RN-L stated that after a patient has been discharged, her expectations are that staff do not engage with patients on a personal level. RN-L states under no circumstance should staff give a patient their personal phone number. RN-L stated she did not have any involvement in the investigation of RN-B and P1. During an interview on 4/27/26 at 11:18 a.m., D-A stated she would expect staff to follow boundary policies and procedures when it comes to patients and not engage in inappropriate interactions with the patients. D-A stated the nursing statue indicated staff cannot engage in romantic relationships with patients for two years after the patient has been discharged. D-A stated she would expect staff would not give patients their personal phone numbers. D-A stated she was alerted to the allegations involving RN-B and P1 immediately. D-A worked with human resources (HR) to deactivate RN-B’s badge, so she did not have access to patient care. D-A reviewed camera footage. D-A stated RN-B is out on workers comp until 5/1/26 due to an unrelated incident but is working with HR to determine the plan of action when RN-B returns to the facility. D-A stated the facility is still investigating this incident because the facility cannot contact RN-B while she is out on workers comp. During an interview on 4/27/26 at 11:27 a.m., administrator (A)-A stated her expectations would be that staff create boundaries to remain therapeutic for the patients. A-A stated there are nursing licensures that nurses are expected to follow. A-A stated she would expect the same thing when it comes to patients who have been discharged. A-A stated she would expect that staff would not give patients their personal phone numbers. A-A stated that she was alerted to the allegations on 4/9/26 when staff overheard other staff talking about RN-B and P1’s relationship. Staff investigating could not find the photos RN-B had posted of P1 because it was posted on Snapchat and the photos disappear after 24 hours. A-A stated RN-B was out on workers comp since 4/8/26 due to an unrelated incident. Administration deactivated RN-B’s badge to patient care areas so that she cannot come to the facility while she is on workers comp. Administration initiated the investigation by doing a video review and interviewing staff. A-A stated D-A wrote a report regarding RN-B and P1’s relationship to the Minnesota Board of Nursing. Once RN-B returns from workers comp, there is no plan for RN-B to return to patient care areas. During an interview on 4/27/26 at 11:49 a.m., RN-A stated after surveyors’ initial interview with RN-A on 4/21/26 at 11:22 a.m., RN-B had called RN-A and asked RN-A what she told the surveyor about her and P1. RN-A stated RN-B admitted that she was in a relationship with P1 but stated the relationship did not turn romantic “until recently”. During an interview on 4/27/26 at 12:09 p.m., HR-A stated his expectations is that staff follow the boundaries policy and procedure. The policy indicated the expectation is that staff keep interactions therapeutic and medically necessary. Once a patient is discharged, the boundaries policy and procedure would still apply. HR-A stated staff should not be giving patients their personal phone numbers. HR-A stated there is an active investigation going on regarding RN-B and P1’s relationship. Administration deactivated her badge from all patient care areas. HR-A stated RN-B is out on workers comp until 4/30/26 and the administration team is still exploring options on what to do with RN-B’s employment after she returns but knows that RN-B will no longer be able to access patient care areas. RN-B’s personnel records included a facility safety guideline that was signed by RN-B on 11/24/25 that indicated staff should avoid being at the facility for non-work-related reasons. Entry into the facility is permitted only when performing assigned duties, attending to urgent work-related matters, or when scheduled for a specific task. RN-B’s personnel records did not indicate she had a history of boundary issues with other patients. RN-B’s badge events and worked times printed on 4/10/26 indicated RN-B had badged in the facility on 12/27/26 and 1/1/26 when she was not scheduled to work. On 12/27/26, RN-B entered the building at 1:53:32 p.m. and entered a unit at 1:55:18 p.m. RN-B had left that unit at 1:58:30 p.m. and exited the facility at 2:00:05 p.m. On 1/1/26, RN-B entered the facility at 4:33:57 p.m. and entered a unit nurses station at 4:58:39 p.m. RN-B exited that unit, was at the nurses station at 4:58:39 p.m. and exited the facility at 5:05:39 p.m. RN-B’s education transcript printed on 4/22/26 indicated RN-B completed the Boundary and Ethical Issues training module on 12/3/21, 1/11/22, 2/4/23, 6/22/23, 7/16/24, 9/15/24, and 10/16/25. This course’s objectives indicated the definition for professional boundaries, discussion on the importance of maintaining professional boundaries at work, identifying situations which could cause boundary problems in your workplace, and identifying ways to maintain appropriate professional boundaries at work. The facility’s investigation was initiated on 4/9/26 that included video reviews of eight days where RN-B was in the facility, pulled RN-B’s badge events from the time P1 was admitted to the facility, and deactivated RN-B’s badge to patient care areas. RN-B was reported to the Board of Nursing on 4/17/26. Administration sent out an email to all facility staff on 4/10/26 at 3:31 p.m. stating staff should not be in the facility outside their scheduled workdays and shifts unless it was approved by their supervisor. Administration sent out an email to all facility staff on 4/15/26 at 8:17 a.m. stating what constitutes as professional boundaries and informing a supervisor if the staff had concerns with boundaries. Attached to this email was the boundaries policy and procedure. Administration sent out an email to all supervisors on 4/21/26 at 12:55 p.m. indicating supervisors would be required to complete the boundary education with their staff within one month. The supervisors would be responsible for tracking who they have educated. Once educated, the staff would sign a document and that document would be placed in their personnel files. This education consisted of reporting boundary violations, examples of boundary violations, boundaries once a patient has been discharged, licensure requirements about boundaries, and two scenarios and talking points. This education has been tracked and at the survey exit, the facility had 45% of their staff educated. The facility’s Boundaries policy dated 7/1/25 indicated staff would maintain professional interactions with patients. Staff must not share private information about themselves, their family, or co-workers with patients. Staff would not engage in dual relationships with patients. Including involvement in non-work related or social relationships with patients including all social media. Staff would not engage in emotional and/or physical relationships with patients. Staff would maintain therapeutic boundaries and a professional relationship with patients. The facility’s Conflicts of Interest policy dated 2/3/26 indicated a conflict of interest was any conduct or circumstance that would, or might appear to, affect an employee’s independence of judgement in exercising their official duties. Staff are responsible for recognizing and avoiding situations that result in or appear to be a conflict of interest. Staff would consult with their supervisor if they had any questions or believe they may have a conflict of interest. Staff may consult the ethics officials instead of their supervisors.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 40550 Based on observation, interview, and document review, the hospital failed to ensure 1 of 1 oxygen tank was stored in a secure manner on the E Unit. Findings include: Observation and interview during a tour of the facility completed on 1/22/24 at 12:45 p.m., on the E unit with the safety administrator (SA) identified an oxygen tank was observed free-standing and unsecured on a two inch high wooden platform in the oxygen storage room. The SA stated oxygen tanks could be stored in that manner as long as they were stored off the floor on a platform. During a follow-up observation and interview on 1/23/24 at 11:30 a.m., with the SA, the oxygen tank remained stored free-standing and unsecured on the wooden platform in the oxygen storage room. The SA was unaware the oxygen tank was not secured while stored in that manner. He verified the oxygen tank could have tipped over and fallen off of the wooden platform, which could potentially cause the cylinder to fracture and allow the compressed gas to become a projectile. Observation and interview on 1/24/24 at 11:10 a.m., with registered nurse (RN)-B (the RN supervisor), the program administrative supervisor principal (S) and RN-A identified the oxygen tank was no longer in the oxygen storage room. RN-B stated SA had removed it from the storage room the day before and was not certain where it had been brought to. RN-A stated oxygen tanks were brought to the unit from the facility warehouse and were stored in the oxygen storage room. RN-A indicated nursing staff completed visual checks of the storage rooms and verified oxygen tanks needed to be secured in a stand to prevent them from tipping over and potentially causing the cylinder to fracture. RN-A was unaware an oxygen tank had been stored in an unsecured manner in the storage room. During an interview on 1/24/24 at 11:50 a.m., the executive director stated it it was an expectation staff stored oxygen in a secure manner for safety purposes. Review of facility policy titled Compressed Gases dated 3/1/22, identified oxygen tank cylinders were to be stored in a secured manner to prevent the cylinder from falling or rolling.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b)(1)(2)(3) (b) Standard: Life safety from fire. (1) Except as otherwise provided in this section— (i) The hospital must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) Outpatient surgical departments must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. (ii) Notwithstanding paragraph (b)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. (2) In consideration of a recommendation by the State survey agency or Accrediting Organization or at the discretion of the Secretary, may waive, for periods deemed appropriate, specific provisions of the Life Safety Code, which would result in unreasonable hardship upon a hospital, but only if the waiver will not adversely affect the health and safety of the patients. (3) The provisions of the Life Safety Code do not apply in a State where CMS finds that a fire and safety code imposed by State law adequately protects patients in hospitals. This Standard is not met as evidenced by: 40550 Based on observation, interview, and document review, the hospital was found to be out of compliance with the provisions of Life Safety Code requirements. These findings have the potential to affect all patients currently admitted to the hospital. Findings include: Please refer to Life Safety Code inspection tags: K-0293, K-0353, K-0363 and K-0920 for additional information.”

“Arrangement with Other Facilities CFR(s): §403.748(b)(7), §418.113(b)(5), §441.184(b)(7), §460.84(b)(8), §482.15(b)(7), §483.73(b)(7), §483.475(b)(7), §485.625(b)(7), §485.920(b)(6), §494.62(b)(6). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] *[For Hospices at §418.113(b), PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients. This Standard is not met as evidenced by: 40550 Based on interview and document review, the hospital failed to develop written arrangements with other hospitals. This has the potential to affect all patients in the event of limitations or cessation of operations to maintain the continuity of services to hospital patients. Findings include: Interview and document review on on 1/22/24 at 11:05 a.m., with the safety administrator (SA) identified during review of the 8/22/23, Emergency and Continuity of Operations Plan the SA stated in the event the patients had to be emergently evacuated to another hospital, the hospital would transfer them to another hospital within their sister healthcare hospital system. The SA was not aware of any written transfer agreements. There was no documentation to support a contractual transfer agreement was in effect as required. During an interview on 1/24/24 at 10:10 a.m., state program administrative supervisor principal (S) confirmed the facility did not have a written transfer agreement with another hospital. During an interview on 1/24/24 at 11:50 a.m., executive director (ED) stated the facility would transfer their patients to another hospital within their healthcare system when an emergency arose. The ED confirmed the hospital did not have a written transfer agreement with another hospital to transfer patients to during an emergency.”

“FIRE SAFETY A Life Safety Code survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on January 22, 2024. At the time of this survey, Anoka Metro Regional Treatment Center was found not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR, 482.41(b), Life Safety from Fire, and the 2012 edition of National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care and the 2012 edition of NFPA 99, Health Care Facilities Code. THE FACILITY’S POC WILL SERVE AS YOUR ALLEGATION OF COMPLIANCE UPON THE DEPARTMENT’S ACCEPTANCE. YOUR SIGNATURE AT THE BOTTOM OF THE FIRST PAGE OF THE CMS-2567 FORM WILL BE USED AS VERIFICATION OF COMPLIANCE. UPON RECEIPT OF AN ACCEPTABLE POC, AN ONSITE REVISIT OF YOUR FACILITY MAY BE CONDUCTED TO VALIDATE THAT SUBSTANTIAL COMPLIANCE WITH THE REGULATIONS HAS BEEN ATTAINED IN ACCORDANCE WITH YOUR VERIFICATION. PLEASE RETURN THE PLAN OF CORRECTION FOR THE FIRE SAFETY DEFICIENCIES (K-TAGS) TO: IF PARTICIPATING IN THE E-POC PROCESS, A PAPER COPY OF THE PLAN OF CORRECTION IS NOT REQUIRED. Healthcare Fire Inspections State Fire Marshal Division 445 Minnesota St., Suite 145 St. Paul, MN 55101-5145, OR By email to: FM.HC.Inspections@state.mn.us THE PLAN OF CORRECTION FOR EACH DEFICIENCY MUST INCLUDE ALL OF THE FOLLOWING INFORMATION: 1. A detailed description of the corrective action taken or planned to correct the deficiency. 2. Address the measures that will be put in place to ensure the deficiency does not reoccur. 3. Indicate how the facility plans to monitor future performance to ensure solutions are sustained. 4. Identify who is responsible for the corrective actions and monitoring of compliance. 5. The actual or proposed date for completion of the remedy. Anoka Metro Regional Treatment Center Building 1 is a 2-story building with a no basement linked to 6 other buildings and was constructed in 1999 and was determined to be of Type II(222) construction. The facility is fully protected throughout by an automatic fire sprinkler system and has a fire alarm system with smoke detection in corridors and spaces open to the corridor that is monitored for automatic fire department notification. The building is fully sprinkler protected throughout. The facility has a fire alarm system with smoke detection in the corridors and spaces open to the corridors that is monitored for automatic fire department notification. The facility has a capacity of 96 beds and had a census of 91 at the time of the survey. The requirement at 42 CFR, Subpart 482.41(b) is NOT MET as evidenced by:”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility failed to maintain and/or install proper exit signage under NFPA 101 (2012 edition), Life Safety Code sections 19.2.10.1, 7.10.1.2.2, 7.10.8.3, 7.10.8.31 and 7.10.8.3.2. This deficient finding could have a patterned impact on the patients within the facility. Findings include: On 01/22/2024 between 10:00 AM and 12:00 PM, it was revealed by observation that the two sets of double doors leading to the center courtyard area, located outside the serving kitchen (room number 1123) were missing a “NO EXIT” sign. An interview with the Physical Plant Director verified this deficient finding at the time of discovery.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 45749 Based on observation and staff interview, the facility failed to maintain the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, section 5.2.2.2. This deficient finding could have an isolated impact on the patients within the facility. Findings include: On 01/22/2024 at 10:49 AM, it was revealed by observation that there were wires wrapped around and laying on the sprinkler pipes located above the ceiling near room E021 Staff Lounge. An interview with the Physical Plant Supervisor verified this deficient finding at the time of discovery.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility failed to maintain corridor doors per NFPA 101 (2012 edition), Life Safety Code, section 19.3.6.3.10. These deficient findings could have an isolated impact on the patients within the facility. Findings include: 1. On 01/22/2024 between 10:00am and 12:00pm, it was revealed by observation that the corridor door leading to the breakroom in the first level maintenance corridor was being propped open with a metal wedge device. 2. On 01/22/2024 between 10:00am and 12:00pm it was revealed by observation that the doors leading to the following first level maintenance corridor offices were being propped open with metal wedge devices: Office 1017, Office 1046, and Office 1016A. 3. On 01/22/2024 between 10:00am and 12:00pm, it was revealed by observation that the corridor door leading to the Boiler Room in the first level maintenance corridor was being propped open with a metal wedge device. An interview with the Physical Plaint Director verified these deficient findings at the time of discovery.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility failed to maintain the usage of electrical adaptive devices per NFPA 99 (2012 edition), Health Care Facilities Code, sections 10.5.2.3.1 and 10.2.4.2.1, NFPA 70, (2011 edition), National Electrical Code, sections 400-8, and UL 1363. These deficient findings could have a patterned impact on the patients within the facility. Findings include: On 01/22/2024 between 10:00 AM and 12:00 PM, it was revealed by observation that there were several electrical appliances plugged into power strips in the following areas: 1) Quality Office near the front desk area 2) Workroom 2066 on the counter surface on back wall 3) Physical Plant Directors office (Office 1016A) An interview with the Physical Plant Director verified these deficient findings at the time of discovery.”