Lakeland Behavioral Health System

“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: 48359 Based on observation, interview, record review, video review and policy review, the Governing Body failed to: - Ensure the medical staff were accountable for the quality of care provided to three current patients (#29, #30 and #31) and four discharged patients (#14, #26, @28 and #37) of nine medical records reviewed with medical complaints; (A-0049) - Ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital; (A-0057) - Follow their policy for grievances (a formal written or verbal complaint related to care or service that cannot be resolved immediately at the bedside) for five current patients (#34, #51, #57, #60 and #62) of five patients interviewed; (A-0118) - Notify the guardian (the person appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves) for 20 current patients (#11, #29, #33, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 & #62) of 20 patient’s medical records reviewed with restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) episodes and one discharged patient (#14) of one medical record reviewed with a self-harm (behavior that is harmful or potentially harmful to oneself) injury; (A-0131) - Ensure care was provided in a safe setting when 20 current patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) were placed on hard reset and secluded (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) to their rooms from 03/28/26 through 03/30/26 and failed to provide continuous observations; (A-0144) - Ensure observations were competed every five minutes for one current patient (#50) of one patient’s medical record reviewed with a provider order for every five-minute observation; (A-0144) - Follow policy for safety precautions for one current patient (#50) and one discharged patient (#14) of two medical records reviewed; (A-0144) - Follow the hospital policy for patient identification bands for 13 current patients (#29, #34, #35, #36, #44, #49, #50, #51, #53, #55, #56, #57 and #61) of 22 patients observed; (A-0144) - Ensure a safe milieu (a person’s social environment) when patients threw chairs, and six patient rooms were not locked while unoccupied for five of six units observed; (A-0144) - Ensure staff did not consume food/drink in work areas where blood or other potentially infectious materials may contaminate work surfaces in two units of two units observed during staff meals; (A-0144) - Ensure the patient’s dietary trays were provided to the patients in a timely manner for one of two units observed; (A-0144) - Follow policy for incident reporting for 19 current patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) and one discharged patient (#14) of 21 patient’s medical records reviewed; (A-0144) - Ensure a medical diagnosis was documented in the multidisciplinary treatment plan for one discharge patient (#14) of one patient’s medical record reviewed with a hospital acquired injury; (A-0144) - Ensure a restraint debrief was completed for 20 current patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) of 20 patient’s medical records reviewed; (A-0144) - Follow their policy when staff failed to immediately report allegations of physical, sexual and verbal abuse to the Risk Manager and Administrator on Call and failed to investigate allegations of abuse for six current patients (#34, #51, #56, #57, #60 and #62) of six patients interviewed; (A-0145) - Follow their policy and ensure all patients who were placed in restraints and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) had a physician order and orders signed within 24 hours for 20 current patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) and four discharged patients (#63, #67, #68 and #71) of 30 patient’s medical records reviewed; (A-0168) - Follow their policy and ensure patients placed in restraints or seclusion had documented initiation and discontinuation times for 20 current patients of (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) of 20 patients observed and medical records reviewed; (A-0174) - Follow policy for safety observations for 20 current patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) of 20 patients observed and medical records reviewed; (A-0175) - Follow their policy to ensure a qualified staff member completed a face-to-face (a qualified staff members evaluation of a patient in restraints) for ten (#3, #65, #66, #67, #70, #71 and #72) discharged patients out of ten discharged patients reviewed within one hour of the initiation of a restraints or seclusion; (A-0178) - Ensure that staff were trained on a periodic basis in first aid related to restraints, for all staff; (A-0206) - Ensure that seven nurses (Staff F, J, M, EE, FF, WW and XX) were orientated and had verified competency in the patient care they provided of nine nurses personnel files reviewed; (A-0208) - Ensure staff had the required certification and licensure for two staff members (P and NN) of 14 personnel files reviewed; (A-0394) - Ensure that the Chief Nursing Officer (CNO) provided adequate oversight and supervision of nursing personnel when the staff failed to assess and communicate patient medical concerns for three current patients (#29, #30 and #31) and four discharged patients (#14, #26, #28 and #37) of nine medical records reviewed with medical complaints. (A-0395) - Ensure that seven nursing staff (Staff F, J, M, EE, FF, XX, and WW) of nine nurses personnel files reviewed, were orientated and verified competency in the patient care they provided; and (A-0398) - Follow their policies for medication administration for 10 current patients (#3, #10, #11, #29, #38, #49, # 51, #55, #56 and #61 ) of 19 patients observed and 12 current patients (#11, #29, #34, #35, #50, #52, #56, #57, # 60, #61, #62 and #74) of 17 medical records reviewed. (A-0405) These failures had the potential to affect the quality of care and safety of all patients. This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.12 Condition of Participation (CoP): Governing Body. Please refer to the 2567 for further details.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48359 Based on observation, interview, record review, and policy review, the hospital failed to: - Follow their policy for grievances (a formal written or verbal complaint related to care or service that cannot be resolved immediately at the bedside) for five current patients (#34, #51, #57, #60 and #62) of five patients interviewed; (A-0118) - Notify the guardian (the person appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves) for 20 current patients (#11, #29, #33, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 & #62) with restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) episodes and one discharged patient (#14) with a self-harm (behavior that is harmful or potentially harmful to oneself) injury of 21 patient’s medical records reviewed; (A-0131) - Ensure care was provided in a safe setting when 20 current patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) were placed on hard reset and secluded (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) to their rooms from 03/28/26 through 03/30/26 without providing continuous observations; (A-0144) - Ensure observations were competed every five minutes for one current patient (#50) of one patient’s medical record reviewed with a provider order for every five-minute observation; (A-0144) - Follow the policy for safety precautions for one current patient (#50) and one discharged patient (#14) of two medical records reviewed; (A-0144) - Follow the hospital policy for patient identification bands for 13 current patients (#29, #34, #35, #36, #44, #49, #50, #51, #53, #55, #56, #57 and #61) of 22 patients observed; (A-0144) - Ensure a safe milieu (a person’s social environment) when patients threw chairs, and six patient rooms were not locked while unoccupied for five of six units observed; (A-0144) - Ensure staff did not consume food/drink in work areas where blood or other potentially infectious materials may contaminate work surfaces in two units of two units observed during staff meals; (A-0144) - Ensure the patient’s dietary trays were provided to the patients in a timely manner for one of two units observed; (A-0144) - Follow the policy for incident reporting for 19 current patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) and one discharged patient (#14) of 21 patient’s medical records reviewed; (A-0144) - Ensure a medical diagnosis was documented in the multidisciplinary treatment plan for one discharge patient (#14) of one patient’s medical record reviewed with a hospital acquired injury; (A-0144) - Ensure a restraint debrief was completed for 20 current patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) of 20 patient’s medical records reviewed; (A-0144) - Follow their policy when staff failed to immediately report allegations of physical, sexual and verbal abuse to the Risk Manager and Administrator on Call (AOC) and investigate allegations of abuse for six current patients (#34, #51, #56, #57, #60 and #62) of six patients interviewed; (A-0145) - Follow their policy and ensure all patients who were placed in restraints and seclusion had a physician order and orders signed within 24 hours for 20 current patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) and four discharged patients (#63, #67, #68 and #71) of 30 patient’s medical records reviewed; (A-0168) - Follow their policy and ensure patients placed in restraints or seclusion had documented initiation and discontinuation times for 20 current patients of (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) of 20 patients observed and medical records reviewed; (A-0174) - Follow the policy for safety observations for 20 current patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) of 20 patients observed and medical records reviewed; (A-0175) - Follow their policy to ensure a qualified staff member completed a face-to-face (a qualified staff members evaluation of a patient in restraints) for ten discharged patients (#3, #65, #66, #67, #70, #71 and #72) within one hour of the initiation of a restraints or seclusion out of ten discharged patients reviewed; (A-0178) - Ensure that staff were trained on a periodic basis in first aid related to restraints for all staff; and (A-0206) - Ensure that seven nurses (Staff J, WW, XX, F, FF, EE and M) were orientated and had verified competency in the patient care they provided of nine nurse personnel files reviewed. (A-0208) Additionally, after the discovery of three unsafe patient care practices and limited recognition of the potential for negative patient outcomes the situation constituted Immediate Jeopardy (IJ) and placed all patients of the hospital at risk. On 04/01/26, the hospital submitted a document to abate the IJ and to provide an acceptable plan of correction to prevent further risk to patients. These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights. Please refer to A-118, A-0131, A-0144, A-0145, A0168, A-0174, A-0175, A-0178, A-0206 and A-0208.”

“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: 48359 Based on observation, interview, record review and policy review, the hospital failed to: - Ensure staff had the required certification and licensure for two staff members (NN and P) of 14 personnel files reviewed; (A-0394) - Ensure that the Chief Nursing Officer (CNO) provided adequate oversight and supervision of nursing personnel when staff failed to assess and communicate patient medical concerns for three current patients (#29, #30 and #31) and four discharged patients (#14, #26, #28 and #37) of nine medical records reviewed with medical complaints; (A-0395) - Ensure that seven nursing staff (Staff J, WW, XX, F, FF, EE and M) of nine nurses’ personnel files reviewed were orientated with verified competency in the patient care they provided; and (A-0398) - Follow their policies for medication administration for 10 current patients (#3, #10, #11, #29, #38, #49, # 51, #55, #56 and #61) of 19 patients observed and 12 current patients (#11, #29, #34, #35, #50, #52, #56, #57, # 60, #61, #62 and #74) of 17 medical records reviewed. (A-0405) This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services. Please refer to A-0394, A-0395, A-0398 and A-0405.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to ensure that the Governing Body held the medical staff accountable for the quality of care provided to three current patients (#29, #30 and #31) and four discharged patients (#14, #26, #28 and #37) of nine medical records reviewed with medical complaints. Findings included: Review of the hospital’s document titled, “Medical Staff Rules and Regulations,” dated 05/12/22, showed a progress note shall be written each time the patient is seen by the Physician or Allied Health Professional (a diverse group of healthcare workers, excluding doctors and nurses, who diagnose, treat, and rehabilitate [the action of restoring someone to health or normal life through training and therapy] patients). Review of the hospital’s policy titled, “Employee Injuries,” effective 06/2024, directed staff to: - Determine if the injury is a bloodborne pathogen (infectious microorganisms [organisms, such as bacteria, too small for the naked eye], such as viruses or bacteria, carried in human blood and bodily fluids that can cause serious or fatal diseases in humans) exposure (needle stick, an injury creating an opportunity for exposure to blood or body fluids). - Facilitate post-exposure testing on the patient for any suspected exposure. - Primary care provider orders include human immunodeficiency virus (HIV, virus that attacks the cells that help the body fight infection) and hepatitis B and C (inflammation of the liver. The various forms of viral hepatitis are named after different letters of the alphabet) testing. Although requested, the hospital failed to present a medical book entry related to Patient #14. Review of Patient #14’s medical record, dated 11/01/25, showed: - He was 14 years old. - On 11/13/25 at 12:54 PM, he complained of a pain to his right hand with a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) score of seven. A narrative note showed, “the patient hit the wall in his room when he was mad. The patient would be seen by the medical provider.” - On 11/14/25 at 3:24 PM, an x-ray (test that creates pictures of the structures inside the body-particularly bones) of his right wrist was ordered. - On 11/16/25 at 2:14 PM, a nursing note showed the provider reviewed the x-ray report and examined his hand. The provider recommended to continue as needed medications and the application of ice as needed. The provider did not order a splint. The plan was to order another x-ray if the patient re-injured his hand. - There was no provider progress note. - On 11/19/25 at 2:45 PM, Staff YY, Physician, reviewed the x-ray and a progress note showed he had an injury to the right hand a week ago and an x-ray was ordered. The result was available on 11/14/25. The patient had tenderness to his right fourth and fifth fingers, six days after the injurious event. Review of the hospital’s document titled, “Medical Practitioner Consult Log,” dated 03/23/26, showed Patient #29, Patient #30 and Patient #31 pierced their nose with an earring. Review of Patient #29’s medical record, dated 03/19/26, showed: - She was 12 years old. - There was no provider progress note related to the nose piercing. - No blood borne pathogen laboratory work was ordered. Review of Patient #30’s medical record, dated 03/13/26, showed: - She was 15 years old. - There was no provider progress note related to the nose piercing. - No blood borne pathogen laboratory work was ordered. Review of Patient #31’s medical record, dated 03/14/26, showed: - She was 13 years old. - There was no provider progress note related to the nose piercing. - No blood borne pathogen laboratory work was ordered. During an interview on 03/27/26 at 10:00 AM, Staff T, Manager, stated that Staff YY, Physician, saw the girls with the nose piercing and stated it was “okay and did not look infected.” No orders were written for bloodborne pathogen testing. No progress notes were written. Review of the hospital’s policy titled, “Medication Administration,” effective 06/2024, directed staff to not administer medications that exceed the parameters specified in appropriate medication literature without first consulting the provider and documenting such consultations in the progress notes. Nurses will notify the provider when medication parameters were not provided by the provider in the order. Review of Patient #28’s medical record, dated 02/26/26, showed: - He was 75 years old. - On 02/28/26 at 8:19 AM, his blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) was 88/55 and his heart rate (HR, the number of times the heart beats within a certain time period, normal pulse/heartbeats for adults range from 60 to 100 per minute) was 58. He was given Losartan (a medication used to treat high blood pressure) and Lopressor (a medication used to treat high blood pressure and chest pain). - At 5:07 PM, his HR was 58. He was given Lopressor. - No order parameters were written for the medications. - There was no provider progress note written in relation to the low BP and HR. During an interview on 04/01/26 at 9:00 AM, Staff TT, Pharmacist, stated that the hospital was working to develop parameters for some medications, but he was not aware there were not parameters for Lopressor and Losartan. After review of Patient 28’s vital signs (VS, measurements of the body’s most basic functions) he stated that the medications should not have been administered. He expected the medical providers to review all non-psychiatric (relating to mental illness) medications and to include parameters for administration. He stated that the hospital had opportunities to mitigate patient harm. Review of the hospital’s document titled, “Medical Practitioner Log,” dated 03/02/26, showed Patient #26 complained of chest pain with a pain scale assessment score of seven and her left arm felt heavy. Review of Patient #26’s medical record, dated 03/02/26, showed she was 35 years old. There were no provider progress notes or orders related to her complaint of chest pain. During an interview on 03/26/26 at 10:00 AM, Staff T, Manager, stated that a patient’s complaint of chest pain should not be entered into the medical book. The provider should have been directly notified. Review of the hospital’s document titled, “Medical Practitioner Log,” dated 03/21/26, showed patient #37 complained of a fall on her left knee with a pain scale assessment score of 10. Review of Patient #37’s medical record dated 02/27/26, showed she was 12 years old. There were no provider progress notes or orders related to her complaint of knee pain. During a telephone interview on 04/15/26 at 10:00 AM, Staff ZZ, Physician, stated that he expected all staff members to follow all of the hospital’s policies and procedures. He expected the medical providers to address medical concerns such as pain, wounds, injuries, etc., and a progress note to be written every time a provider performed an assessment of a patient. He stated that it was important for him to be aware of missing documentation so he could begin to audit. He expected bloodborne pathogen testing would have been completed for the nose piercings and was disappointed that it wasn’t. He expected medical providers to provide medication administration parameters for any ordered medications, and he planned to take those concerns to the medical providers. During an interview on 03/27/26 at 10:00 AM, Staff T, Manager, stated that when a Nurse Practitioner (NP, a nurse with advanced clinical education and training) was notified of a medical complaint their typical response was to “write it in the medical book, unless it was an urgent concern.” Urgent concerns were sent out to the local Emergency Department (ED). The medical provider typically rounded on each unit daily between 2:30 PM and 4:00 PM. Staff T stated that there were issues with the medical providers failing to document in the medical records. When a complaint was written in the medical book the medical provider would “just scratch through it and not see the patient.” The hospital had no clear guidelines for why, when or how to enter a complaint into the medical book. During a telephone interview on 03/25/26 at 9:30 AM, Staff Q stated that medical providers did not document and the hospital could not get them to document in the medical records.”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 48359 Based on observation, interview and policy review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights and 42 CFR 482.23 CoP Nursing Services. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s document titled, “Lakeland Behavioral Health System Organization Chart,” updated 02/16/26, showed all administration leaders reported to Staff U, CEO. During a telephone interview on 04/15/26 at 8:35 AM, Staff U, CEO, stated that she had full oversight of the hospital.”

“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: 47504 Based on observation, interview and record review, the hospital failed to follow their policy for grievances (a formal written or verbal complaint related to care or service that cannot be resolved immediately at the bedside) for five current patients (#34, #51, #57, #60 and #62) of five patients interviewed. This failure placed all patients at risk for their health and safety. Findings include: Review of hospital policy titled, “Grievance, Patient-Hospital,” dated 08/2025 showed: - An important part of providing quality care and service to our patients is providing an effective mechanism for handling patient/family grievances. - All patients and their families should have access to a clear process by which they may be heard if they believe their rights or other privileges have not been respected or responded to appropriately by the facility or medical staff. - It is the policy of Lakeland Behavioral Health System to encourage responsive and open communication. - The Governing Board is responsible for the effective operation of the grievance process, which includes the hospital’s compliance with all the Centers for Medicare and Medicaid Services (CMS) and state grievance process requirements. - The Governing Board has appointed the Patient Advocate the responsibility to execute the grievance program, in conjunction with the Grievance Committee. - If the Patient Advocate, Chief Executive Officer (CEO) or Medical Director determines resolution of the grievance requires additional review and input into the resolution process, or if the patient is not satisfied with the actions taken to resolve the grievance, the Grievance Committee will be convened. - All patient grievances will be investigated and the results of the investigation reported back to the complainant. - A grievance is considered resolved when the patient is satisfied with the actions taken on his/her behalf or if hospital has taken appropriate and reasonable action and followed the CMS/State required processes. - Patients and/or legal representatives will be provided with written information upon admission regarding how to file a grievance. The information will also be posted, along with a picture and contact number of Patient Advocate. - A patient grievance is a when a formal or informal, written or verbal complaint is made to the hospital/staff by a patient, or the patient’s representative, regarding the patient’s care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CRF 489. - Any reported grievance by patients, families, staff and/or visitors that directly relates to patient neglect or abuse will be forwarded to the Administrator On-Call (AOC) immediately for review. - A written complaint is always considered a grievance. This includes written complaints from an inpatient, a discharged patient, or a patient’s representative regarding the patient care provided, abuse or neglect. An email or fax is considered “written.” - All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances for the purposes of these requirements. - Whenever the patient or the patient’s representative requests that his or her complaint be handled as a formal complaint or grievance, or when the patient requests a response from the hospital, the complaint is considered a grievance and all the requirements apply. - Staff present who receive a grievance/concern from a patient or patient’s legal representative will acknowledge receipt of the grievance by documenting the time and date the Patient Concern Notification form, attempt to resolve the issue at the time received, document any actions taken, and forward the form to the Patient Advocate. - Staff will assist patients who state a concern and are unable to complete a Patient Concern Notification form, or the staff will complete the form if a patient states a concern but is unwilling to complete the form. - The Patient Advocate will record the concern/grievance on the designated tracking tool, summarize the unresolved concern on the Grievance Process Tool, and immediately review and assess any reported abuse/neglect. - The Patient Advocate or CEO/designee will review the grievance, assign follow-up to an appropriate Director/Manager (one who is not connected to the grievance, supervises the staff involved, or is responsible for the process involved), and establish a date by which a response is expected. - If grievances are not resolved within seven days, the patient will be notified the Patient Advocate is still processing the grievance and provided the expected date of resolution. - The Director/Manager to whom follow-up was assigned will investigate the grievance within two days, record findings of the investigation on the Grievance Process Tool and return it to the Patient Advocate. Although requested, the hospital failed to present grievances written by five patients (#34, #51, #57, #60 and #62) prior to the state surveyor’s investigation. Review of Patient #34’s medical record, dated 03/13/26, showed she was a 14-year-old who was admitted to the Four South Unit for suicidal ideation (SI, thoughts of causing one’s own death) and was diagnosed with Major Depressive Disorder (MDD, a mental health condition that causes persistently low mood and loss of interest in activities that once brought joy). During an interview on 03/31/26 at 9:00 AM, Patient #34 stated she had filed multiple grievances with allegations of verbal abuse from staff members. No one from the hospital had discussed any of the grievances or allegations she had made. She requested to speak with the patient advocate several times, but the patient advocate did not have any knowledge of her grievances. She filed a grievance when she was having thoughts of self-harm and had talked to Staff CC. Staff CC laughed at her and told her to go back to her room. Another grievance was filed when Staff CC yelled and cussed at the patients on the unit. She also filed a grievance when Staff M did not respond to her request for help. Staff M responded to her room when she asked for a nurse. She explained to Staff M that she was not doing good and was thinking about her trauma. She had been locked in her room for four days and that was causing her to want to self-harm. Staff M, told her “You don’t know what trauma is, you don’t know what abuse is, you’re just having a panic attack.” Patient #34 stated she was having a panic attack due to being on a hard reset and not being allowed to leave her room for the last four days. Staff M Ignored her issue and when she confronted her at the nurse’s station, Staff M told her that she would speak with the NP and have him extend her stay. She filed another grievance when Staff MM called her “Rapunzel” and told her she looked like a “fidget spinner.” She requested to call her mother on 03/30/26 because she felt unsafe and was denied a phone call. When she discussed this with Staff JJ that evening, she was given a grievance form to fill out. She completed the form and turned it in to staff. Review of Patient #51’s medical record, dated 03/27/26, showed she was a 12-year-old who was admitted for SI with a plan. She was diagnosed with MDD and had a history of self-harm (behavior that is harmful or potentially harmful to oneself). During an interview on 03/31/26 at 9:30 AM, Patient #51 stated she had completed several patient grievance forms and had turned them into the nurse. One of the filed grievances alleged Staff CC yelled and cussed at the patients. She alleged there were several employees that verbally abused the patients. She did not know where the grievances went but when she inquired about them, she was told the Patient Advocate did not have them. Review of Patient #56’s medical record dated 03/28/26 showed she was a 15-year-old who was admitted for homicidal ideation (HI, thoughts or attempts to cause another’s death), defiance, elopement (when a patient makes an intentional, unauthorized departure from a medical facility) and self-harm. She was diagnosed with disruptive mood dysregulation disorder (DMDD, condition of extreme irritability, anger, and frequent, intense temper outbursts.) During an interview on 03/31/26 at 9:45 AM, Patient #56 stated she filed a grievance. She stated that she was drug off the bed, down to the floor, into the hallway and was given a shot. Staff II verbally, physically and sexually assaulted her. He grabbed her breast on purpose and squeezed as hard as he could when he took her down on the bed. Review of Patient #57’s medical record, dated 03/25/26, showed she was a 15-year-old who was admitted for homicidal ideation (HI, thoughts or attempts to cause another’s death) and was diagnosed with DMDD). She had a history of Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring because of injury or severe psychological shock) and a traumatic history of being locked in a room, sex trafficked and injected with various drugs. During an interview on 03/31/26 at 9:30 PM, Patient #57 stated that she was given a grievance form by the social worker. She filled it out and gave it to a staff member. She stated, “We file grievances, but no one listens.” Review of Patient #60’s medical record, dated 03/25/26, showed she was a 13-year-old who was admitted being placed into state custody due to parental neglect. She was admitted for self-harm, SI without a plan and was diagnosed with MDD and Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock). During an interview on 03/31/26 at 9:45 AM, Patient #60 stated that she had filed grievances against staff members, but no one knew where they were, and the Patient Advocate did not have them. When patients completed a grievance, they were instructed to give the forms to the nurse. She gave several complaints to different nurses. She witnessed abuse last night, on 03/30/26, by staff members towards other girls on the unit. She was given a grievance form and told to fill it out. She filled it out and turned it in to staff that morning but did not remember the name of the person she gave it to. that morning. She stated, “It doesn’t matter, they just allow it to happen, they won’t do anything about it.” Review of Patient #62’s medical record, dated 03/26/26, showed she was a 15-year-old who was admitted for SI and self-harm (behavior that is harmful or potentially harmful to oneself). She was diagnosed with disruptive mood dysregulation disorder (DMDD, condition of extreme irritability, anger, and frequent, intense temper outbursts). During an interview on 03/31/26 at 10:00 AM, Staff #62 stated that she filed a grievance for the abuse of patients and submitted several grievances regarding how staff talk to the patients. Other grievances she submitted had to do with the unit being on a hard reset, Staff CC being verbally abusive to patients and for all the abuse that she witnessed last night. During an interview on 03/31/26 at 10:30 AM, Staff JJ stated they were unable to locate the grievance forms from the Four South Unit. No one was investigating them until the State Agency began to ask questions. He was going to give the girls another grievance form to fill out. Staff JJ stated, “I know that these girls are filling these grievances out and unfortunately the nurses are discarding them.” None of the staff members who were involved in the alleged grievances were removed from patient care. During an interview on 03/31/26 at 10:50 AM, Staff T stated that patients were given a grievance form to complete, and the grievances were forwarded to the Patient Advocate for an investigation. He did receive grievances completed the previous night, but he did not know where they were or what had been done with them. He expected staff members to sign the forms to indicate they were received and to forward them to the Patient Advocate. Abuse allegations were to be immediately reported to the supervisor forwarded to the Chief Nursing Officer and the staff member should be removed from patient care. He expected grievances to be investigated but did not know the expected timeframe for the investigation completion. During an interview on 03/31/26 at 4:10 PM, Staff KK stated that at the end of her shift on 03/30/26, the girls were still writing their grievances. She believed the girls gave the grievance forms to Staff OO and that was why they could not be located. She stated that she has witnessed staff discard the grievances when patients turn them in. During an interview on 03/31/26 at 1:15 PM, Staff HH stated “I know the nursing staff and managers are not turning in grievances.” Staff HH believed the hospital had a pattern of abuse and she escalated her concern to the unit Managers and the CNO. During an interview on 04/15/26 at 10:00 AM, Staff YY stated “yelling and cussing at patients was not the best practice and that it should be considered verbal abuse. Staff members who had allegations against them should all be investigated. If substantiated, they should be removed from patient care.” He has discussed abuse allegations by staff, towards patients and instructed them to file a grievance. He stated, “I have been told by patients that their grievances are not being investigated, and I am sure that they are not all being investigated.””

“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: 48359 Based on observation, interview and record review, the hospital failed to notify the guardian (the person appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves) for 20 current patients (#11, #29, #33, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 & #62) with seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) episodes and one discharged patient (#14) with a self-harm (behavior that is harmful or potentially harmful to oneself) injury of 21 medical records reviewed. Findings included: Although requested, the hospital failed to present a policy related to guardian notification. Review of the hospital’s policy titled, “Incident Reporting,” effective 04/2025, showed: - Any staff member who witnesses, discovers or has direct knowledge of an incident must complete an incident report before the end of the shift/workday. - Under-reporting or failure to report a known incident is not acceptable. - An “incident” is an unanticipated event resulting in, or nearly causes, a negative impact on patient care. Any harm caused can be temporary, long-term, or permanent and range in severity from no obvious or significant injury, up to death. Review of Patient #14’s medical record, dated 11/01/25, showed: - He was a 15-year-old admitted to the hospital with recurrent and severe Major Depressive Disorder (MDD, a mental health condition that causes persistently low mood and loss of interest in activities that once brought joy) without psychotic features (characterized by defective or lost contact with reality). - On 11/13/25 at 12:54 PM, he complained of a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) score of seven to his right hand. A narrative note showed he hit the wall in his room when he was mad. - On 11/14/25, the interdisciplinary treatment plan update showed on 11/13/25, he punched a refrigerator, and his hand appeared to be very swollen and bruised. - At 3:24 PM, an x-ray (test that creates pictures of the structures inside the body-particularly bones) of his right wrist was ordered. - On 11/15/25, the x-ray results showed right fourth and fifth finger fractures (break in a bone). - There was no documentation of guardian notification. Review of the hospital’s document titled, “Incident Report Form 5076,” dated 11/15/25, showed the incident report was completed two days after the event. On 11/18/25, the patient’s guardian was notified, five days after the event. During an interview on 03/25/26 at 2:07 PM and 03/26/26 at 9:15 AM, Staff K, Quality Director, stated that the guardian was expected to be notified every time an event report was indicated. On 11/19/25, six days after the injury, Patient #14’s guardian was notified when the x-ray results were reviewed. The hospital did not have a policy related to guardian notification. Review of the hospital’s policy titled, “Seclusion/Restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head): Acute (sudden onset) and Sub-Acute Services,” effective 11/2025, showed: - The nurse will notify the guardian of the seclusion/restraint as soon as possible and in no case later than 24 hours after the occurrence. - Document attempts to contact the guardian, including instances of no answer. - When there is no answer, a minimum of two attempts to contact the guardian should be completed and documented. During concurrent observation on 03/30/26 at 2:30 PM and review of 20 patient’s (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) medical records showed these patients were placed in a hard reset and could not leave their rooms on 03/28/26, 03/29/26 and 03/30/26. There was no documentation to show that the guardians were notified of these events. Although requested, no incident reports were provided for these days. During a telephone interview on 04/15/26 at 10:00 AM, Staff ZZ, Physician, stated that he expected all staff members to follow all of the hospital’s policies and procedures. He expected guardians to be notified with each seclusion/restraint episode, at the time of an injury and with any test results.”

“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: 47504 Based on observation, interview, record review and policy review, the hospital failed to: - Ensure care was provided in a safe setting when 20 current patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) of 20 patient records reviewed were placed on a hard reset and secluded (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) to their rooms without documentation of an indication or the completion of a debrief. - Ensure observations were competed every five minutes for one current patient (#50) of one patient’s medical record reviewed with a provider order for every five-minute observation; - Follow the policy for safety precautions for one current patient (#50) and one discharged patient (#14) of two medical records reviewed; - Follow the hospital policy for patient identification bands for 13 current patients (#29, #34, #35, #36, #44, #49, #50, #51, #53, #55, #56, #57 and #61) of 22 patients observed; - Ensure a safe milieu when patients threw chairs, and six patient rooms were not locked while unoccupied for five of six units observed; - Follow the hospital’s policy for incident reporting (a staff report of an unexpected occurrence) for 20 current patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) and one discharged patient (#14) of 21 patients reviewed. - Ensure staff did not consume food/drink in work areas where blood or other potentially infectious materials may contaminate work surfaces in two units of two units observed during staff meals; - Ensure the patient’s dietary trays were provided to the patients in a timely manner for one of two units observed; and - Ensure a medical diagnosis was documented in the multidisciplinary treatment plan for one discharged patient (#14) of one patient’s medical record reviewed with a hospital acquired injury. These failures had the potential to result in serious injury to patients and/or staff. Findings included: Review of the hospital’s policy titled, “Seclusion/Restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head): Acute (sudden onset) and Sub-Acute Services,” effective 11/2025, showed: - Non-physical techniques are the preferred interventions in the management of behavior. - Seclusion, physical restraints and chemical restraints (a form of medical restraint in which a drug is used to restrict the freedom of movement of a patient) are used only to prevent the patient from harming self or others. - Restraint techniques are never to be used as punishment, for the convenience of staff or as a substitute for supervision. - The nurse will determine if a seclusion or physical restraint is warranted. - The nurse will document the specific behaviors/circumstances leading to the need for the restriction on the provider order sheet of the seclusion/restraint packet. Document only the behaviors which indicate harm to self and others and support the need for emergency use of seclusion/restraint. - The nurse will make staff assignments for all episodes of seclusion. - A staff member should be assigned to monitor the patient continuously and document at least every 15 minutes. - Document the supervision being provided (i.e. report of groups or activity the patient was involved in at the time of occurrence) and ensure the seclusion/restraint packet is completed prior to leaving at the end of the shift. - The nurse will ensure the patient is removed from seclusion or restraint as soon as they are no longer a danger to self or others. - The nurse will complete an incident report regarding the occurrence and submit it to the Director of Risk Management. - A Handle with Care (HWC, a trauma-informed behavior management program focusing on verbal de-escalation and safe physical intervention for healthcare) trained staff member involved in the intervention will conduct a patient debriefing within 24 hours of the event. The concurrent observation and review of 20 patients (#11, #29, #33, #34, #35, #36’s, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) medical records showed: - On 3/28/26, 3/29/26 and 3/30/26, the patients were placed on a hard reset and secluded to their rooms. - There was no documentation to indicate the reason the patients were placed on a hard reset/seclusion. - There was no documentation to show debriefs were completed. During a telephone interview on 04/15/26 at 10:00 AM, Staff ZZ, Physician, stated that he expected all staff members to follow all of the hospital’s policies and procedures. Patients placed in seclusion/restraints must be observed one to one (1:1, continuous visual contact with close physical proximity) at all times. The placement of a patient in seclusion for 48 to 60 hours was an egregious violation of their rights, and he could not endorse the action. He had issues with the Behavioral Health Aides (BHAs) controlling the units. He had brought this concern to leadership and had not seen any follow-up interventions. He believed there was not enough guidance and education for the BHAs. A hard reset could be perceived as punishment, and he never liked making a flat across the board intervention for patients. The hard reset was an egregious intervention. He expected incident reports to be completed for all seclusion/restraint and self-harm events. During an interview on 04/01/26 at 9:00 AM, Staff SS, Nurse Practitioner (NP), stated that the hard reset was false imprisonment and the same as seclusion. The nursing staff tried to initiate another hard reset the evening of 03/31/26, but he told them not to. The patients were hospitalized for treatment. During an interview on 03/31/26 at 10:50 AM, Staff T stated that he preferred for patients to reset daily when indicated, but not to punish patients. He believed a long hard reset was punishment. He stated that the BHAs made the decision for patients to be “on their beds.” Most of the contract staff “go with the flow” and the BHA staff controlling the units could be a problem. The charge nurse should have made the unit decisions with the BHA’s collaboration. He had reminded the nursing staff that they were the unit’s authority. A full unit hard reset was easier for staffing issues, which was not okay. He was made aware of the full unit room restrictions on the morning of 03/30/26. The restrictions were removed that evening, and the patients began to riot. He believed the 2.5 days of restrictions could have something instigated the riot. The full unit hard reset over the weekend should not have happened. A full unit hard reset was not therapeutic, especially when the patients were not offered therapy. On 03/30/26, the patients did not receive recreational therapy (RT). He believed most of the patients could have gone but when he called for RT to return to the unit he was refused. During an interview on 03/30/26 at 2:30 PM, Staff CC stated that all of the patients on the Four South Unit had been placed on a hard reset since Saturday 03/28/26. She explained that “due to behaviors they had decided to do the hard reset.” Hard resets lasted for 24 hours. Patients were limited to staying in their assigned bedroom and were only allowed to come out if a therapist, nurse or provider requested to see them individually. They were served meals in their rooms, were not allowed to speak with their roommates, and were given a workbook to work on positive thinking skills while on the hard reset. During an interview on 03/26/26 at 11:30 AM, Staff A stated that any patient who had a restraint or was placed in seclusion would have a debrief within 24 hours of the initiation of the restraint or seclusion. The team would process with the patient and discuss behaviors that led up to the restraint or seclusion. Review of the hospital’s policy titled, “Observations, Patient,” revised on 11/2024, showed: - A one to one was when a team member was assigned to one patient. That team member must remain close enough to intervene if the patient attempts inappropriate behavior, but at such a distance to avoid being injured, and at all times maintains a continuous visual observation of the patient. - Staff document all levels of observation on each patient’s profile on the hospital issued device using proximity based electronic technology. - Each entry should detail the patient’s location, behavior and activity. - The time is recorded when the entry is made. - In the event of an emergency situation where without immediate intervention harm could result, the team members will safely intervene and summon help but not delay observations. The team member will verbally hand off the observations to another team member. Review of Patient #50’s medical record, dated 03/28/26, showed: - At 4:40 AM, documentation showed she was at a high suicide risk and was placed on elopement (when a patient makes an intentional, unauthorized departure from a medical facility) precautions. Staff SS, NP, ordered every five-minute observation. - At 4:45 AM, documentation indicated she was admitted for four attempts to commit suicide (to cause one’s own death) that week and was diagnosed with Major Depressive Disorder (MDD, a mental health condition that causes persistently low mood and loss of interest in activities that once brought joy). - At 8:18 PM, every five-minute observations were discontinued. There were 14 observations from 4:40 AM through 8:18 PM, that were greater than five minutes apart. - On 03/29/26 at 5:07 AM, an order was written for every five-minute observation with an end date of 03/30/26 at 8:23 AM. During that time frame, there were 27 observations that were greater than five minutes apart. During a telephone interview on 04/15/26 at 10:00 AM, Staff ZZ, Physician, stated that he expected patient observations to be completed as ordered. Chest rise and fall were to be observed when patients were sleeping in dark rooms. Review of the hospital policy titled, “Suicide Precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm),” revised 03/2026, showed: - Staff were to identify patients at risk for suicide. - Suicide risk assessments occur at prescribed frequencies and as needed on an ongoing basis as indicated by the patient’s clinical presentation. - The psychiatric (relating to mental illness) practitioner should order observation and precautions consistent with the assessed level of risk. - The registered nurse (RN) should implement SP as indicated based on the result of assessment and/or observations such as self-harm (behavior that is harmful or potentially harmful to oneself) behavior, suicidal ideation (SI, thoughts of causing one’s own death), talk of self-harm, acknowledged plan for suicide, preadmission history of suicide attempts or ideation. The RN should notify the physician if any of this occurs. Review of the hospital’s policy titled, “Self-Injurious Behavior/Prevention: Early Identification, Observation, Response and Notification,” effective 06/2025, showed non-suicidal self-injury (NSSI) is when a patient deliberately causes injury to him/herself without intent to die. Nursing staff are to contact the attending provider to discuss/communicate risks and obtain orders for NSSI behavior precautions. Review of Patient #50’s medical record, dated 03/28/26, showed at 4:40 AM she had a high suicide risk assessment and was placed on elopement precautions, but no SP were initiated. On 03/30/26 at 8:24 AM, the physician wrote an order for SP. Review of Patient #14’s medical record, dated 11/01/25, showed: - He was a 15-year-old admitted to the hospital with recurrent and severe MDD without psychotic features (characterized by defective or lost contact with reality). - On 11/13/25 at 12:54 PM, he complained of a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) score of seven to his right hand. A narrative note showed he hit the wall in his room when he was mad. - The provider was not notified of the self-harm event and NSSI precautions were not initiated. During a telephone interview on 04/15/26 at 10:00 AM, Staff ZZ, Physician, stated that he expected suicidal and self-harm behaviors to be reported to the provider to obtain an order for appropriate precautions, including SP and NSSI. Review of the hospital’s policy titled, “Identification Bands (ID), Patient,” effective 06/2024, showed all patients on acute units will wear a patient ID bands at all times. If at any time, the patient is found to not have an ID band, the initial identification process must be performed and a replacement ID band applied. Observation on 03/30/26 at 2:30 PM, on the Four South Unit, showed seven patients (#34, #35, #36, #50, #53, #56, and #57) did not have ID bands on. Observation on 03/31/26 at 7:31 AM, Staff EE administered medications by mouth to Patient #49 who did not have an ID band on. Observation on 03/31/26 at 7:37 AM, Staff EE administered medications by mouth to Patient #55 who did not have an ID band on. Observation on 03/31/26 at 8:00 AM, on the Three South Unit, showed three patients (#42, #43 and #44) did not have ID bands on. Observation on 03/31/26 at 8:29 AM, showed Staff EE administered medications by mouth to Patient #56 who did not have an ID band on. Observation on 03/31/26 at 8:45 AM, showed Staff EE administered medications by mouth to Patient #51 who did not have an ID band on. Observation on 03/31/26 at 8:52 AM, showed Staff EE administered medications by mouth to Patient #61 who did not have an ID band on. Observation on 03/31/26 at 8:55 AM, showed Staff EE, RN, administered medications by mouth to Patient #29 who did not have an ID band on. During a telephone interview on 04/15/26 at 10:00 AM, Staff ZZ, Physician, stated that he expected all patients to wear ID bands. He sometimes rounded on the units for the specific purpose of identifying patients without ID bands. It was an on and off issue at the hospital. Review of the hospital’s policy titled, “Workplace Violence Prevention (WVP),” effective 04/2025, showed: - The purpose of the WVP Policy is to help increase safety in the work environment for all. - Acts of unmanageable behavior including throwing objects qualifies as a WPV event. - A critical element in prevention is identifying the risks associated with the physical environment. - Changes to the physical environment often can make the workplace safer. - Arrangement of furniture and other objects to minimize their use as a weapon is an example of a prevention method. - The hospital is committed to ensuring all safety and health policies and procedures involving workplace safety and security are clearly communicated and understood by all staff members. Observation on 03/23/26 at 2:45 PM, on the Two Northeast Unit, showed lightweight chairs and folding tables in the milieu. Observation on 03/23/26 at 3:55 PM, on the Three South Unit, showed lightweight chairs and folding tables in the milieu. Observation on 03/23/26 at 3:45 PM, on the Four South Unit, showed lightweight chairs and folding tables in the milieu. Review of Patient #14’s medical record, dated 11/01/25, showed on 11/18/25 at 6:22 PM, he hit himself in the ear with a chair on the Three North Unit. Review of Patient #50’s medical record, dated 03/28/26, showed on 03/28/26 at 11:36 PM and 03/30/26 at 10:10 PM, she threw chairs on the Four South Unit. Review of Patient #63’s medical record, dated 03/11/26, showed on 03/13/26 at 6:56 PM, he threw chairs on the Three North Unit. Review of Patient #64’s medical record, dated 03/03/26, showed on 03/09/26 at 10:10 AM, he threw a chair on the Three South Unit. Review of Patient #65’s medical record, dated 09/06/25, showed on 09/08/25 at 8:37 PM, he pushed a chair on the Two Central Unit. During an interview on 03/23/26 at 3:40 PM, Staff A stated that she would like to have different furniture and agreed there was a safety risk. During an interview on 03/23/26 at 4:00 PM, Staff F stated that he had experienced thrown chairs three times in the last two months and was surprised the furniture was “lightweight.” During an interview on 03/25/26 at 9:30 AM and 2:07 PM, Staff K, Quality Director, stated that he agreed the lightweight chairs could be thrown by patients. He stated that the hospital did not perform appropriate WVP assessments and had recently begun to identify patient on patient events. During an interview on 03/25/26 at 9:45 AM, Staff L, Quality Director, stated that the concern for patients throwing chairs had been explored, and the issue was unit space and comfort. She was unaware of any previous surveyor conversations with the prior CEO regarding the safety of the furniture. Review of the hospital’s undated document titled, “Tracer Observation Form,” directed leaders to observe if unoccupied bedrooms doors were locked when patients were not in the room. If the answer was no, documentation of corrective action was indicated. Observation with concurrent interview on 03/23/26 at 3:26 PM, on the Three South Unit, showed room 328’s door was open without a patient in the room. Staff D stated that room was in use, the door was broken, and a work order had been completed. Although requested, the hospital failed to provide a work order for room 328’s broken door. Observation with concurrent interview on 03/30/26 2:20 PM, on the Three South Unit, showed room 314 was unoccupied and the door was open. Staff D stated that the room was in use, and the door had been broken for at least a month. Observation with concurrent interview on 03/31/26 at 7:30 AM, on the Three North Unit, showed rooms 303, 305 and 306 were unoccupied and the doors were open. Staff T stated that the rooms were open because the kids were getting up and cleaning their rooms. No patients were present in the rooms. Observation on 03/31/26 at 4:00 PM, in the Two Central Unit, showed room 233 was unoccupied and the door was open. Review of the hospital’s document titled, “Proposal Number 24-6318-26,” dated 03/23/26, showed emergency door replacements for room 314, 326 and 328 were placed after a broken door was observed by the hospital surveyor. During an interview on 03/26/26 at 3:40 PM, Staff U, CEO, stated that she focused on milieu management by increasing awareness of the milieu which started in 04/2026. Leadership rounded and performed a risk assessment on each unit with coaching as indicated. During an interview on 03/30/26 at 2:25 PM, Staff T stated that he expected staff to figure out a way to close a room if it was in use and the door was broken. The room should not have been in use if the door could not be closed. During an interview on 03/31/26 at 2:40 PM, Staff K stated that daily leadership rounds assessed for closed doors. Review of the hospital’s policy titled, “Incident Reporting,” effective 04/2025, showed: - Any staff member who witnesses, discovers or has direct knowledge of an incident must complete an incident report before the end of the shift/workday. - Under-reporting or failure to report a known incident is not acceptable. - An “incident” is an unanticipated event resulting in, or nearly causes, a negative impact on patient care. Any harm caused can be temporary, long-term, or permanent and range in severity from no obvious or significant injury, up to death. Although requested, the hospital failed to present incident reports for 20 patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) related to the hard reset/seclusion. Review of Patient #14’s medical record, dated 11/01/25, showed: - He was a 15-year-old admitted to the hospital with recurrent and severe MDD without psychotic features (characterized by defective or lost contact with reality). - On 11/13/25 at 12:54 PM, the patient complained of a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) of seven to his right hand. A narrative note showed the patient hit the wall in his room when he was mad. - On 11/15/25, the x-ray results showed right fourth and fifth finger fractures (break in a bone). Review of the hospital’s document titled, “Incident Report Form 5076,” dated 11/15/25, showed an incident report for Patient #14 was completed two days after the event. During an interview on 03/25/26 at 2:07 PM and 03/26/26 at 9:15 AM, Staff K, Quality Director, stated that there was no incident report completed at the time of Patient #14’s injury. There were several failures related to that event, including the completion of the incident report. During a telephone interview on 04/15/26 at 10:00 AM, Staff ZZ, Physician, stated that he expected incident reports to be completed for all seclusion/restraint and self-harm events. Review of the undated Occupational Safety and Health Administration (OSHA) guidelines showed eating and drinking in work areas where blood or other potentially infectious materials may contaminate work surfaces, or the food itself, is prohibited. Although requested, the hospital failed to provide a policy directing staff to appropriate areas for food and drink consumption. Observation with concurrent interview on 03/25/26 at 1:25 PM, on the Three South Unit, showed two staff members eating and drinking at the folding tables in the milieu. Staff A stated that it was acceptable if the staff were not able to get a break. Observation on 03/30/26 at 2:00 PM, on the Four South Unit, showed Staff BB had a drink and sandwich in her hand while observing patients. Observation on 03/31/26 at 9:00 AM, on the Four South Unit, showed Staff F sitting at the nurses’ station eating a breakfast burrito. During an interview on 04/04/26 at 4:45 PM, Staff K, Quality Director, stated that there were designated locations for drinks. In general, the clinical staff did not have a formal infection prevention policy due to a history of noncompliance. The hospital followed the Centers for Disease Control (CDC) and Occupational Safety and Health Administration (OSHA) guidelines. Review of the hospital’s policy titled, “Patient/Resident Tray, Delivery of,” effective 02/2026, showed trays were to be passed to patients/residents on the unit within 10 minutes of arrival on the unit. Review of the hospital’s undated document titled, “Lakeland Behavior Health System Four South,” showed breakfast was served at 6:45 AM. Observation on 03/31/26 at 7:15 AM, on the Four South Unit, showed tables set up in the center of the milieu with 20 breakfast trays sitting on the tables. Each breakfast tray contained a carton of milk, orange juice, biscuits and gravy and a banana. At 08:15 AM, the trays were still sitting on the tables unattended. During an interview on 03/31/26 at 08:15 AM, Staff EE stated the kids eat when they decide to get up and there was no real schedule they went by. The kids were still asleep and had just started to wake up. Breakfast trays were usually delivered at 6:30 AM. During a concurrent observation and interview on 03/31/26 at 8:30 AM, Staff F stated that the food trays were originally dropped off by dietary around 6:30 AM. He stated this was not satisfactory, there had been a change in the schedule and “obviously it was not communicated to dietary.” He then instructed staff to throw away all the perishable items and new food trays were ordered. The trays had been sitting on the table for approximately two hours and had not been addressed until the surveyor began to ask questions. During an interview on 03/31/26 at 10:50 AM, Staff T stated that he expected breakfast to be served when it was hot. The early breakfast time for the Four South Unit was “horrible” because the patients were all asleep. He expected the patients to be woken up for medications and breakfast. During an interview on 04/01/26 at 12:03, Staff RR, Risk Management Director, stated that the unit manager was to ensure the unit schedule was followed. It was identified last week in leadership rounds that the schedule on the Four South Unit related to breakfast was wrong. Review of the hospital’s policy titled, “Multidisciplinary Treatment Plan, effective 03/2026, showed all disciplines are responsible for adding any new problems (including medical issues) identified to the patient’s problem list. Review of Patient #14’s medical record, dated 11/01/25, showed on 11/15/25, his x-ray results indicated his right fourth and fifth finger were fractured (break in a bone). His hand injury was not documented on the plan of care or included in his treatment plan. There was no medical diagnosis listed on his discharge summary dated 11/26/25. During a telephone interview on 04/15/26 at 10:00 AM, Staff ZZ, Physician, stated that he expected a medical diagnosis that needed follow-up to be placed on the patient’s treatment plan. It would have been a good idea to include the hospital acquired fracture on Patient #14’s treatment plan. During an interview on 03/25/26 at 10:00 AM, Staff A stated that Patient #14’s wrist injury should have been on his treatment plan. Anything medical should be included on the treatment plan and it was best practice for nurses to include injuries on the patient’s plan of care. 48359”

“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: 47504 Based on interview, record review, video review and policy review the hospital failed to recognize, report and investigate allegations of physical, verbal, and sexual abuse of six current patients (#34, #51, #56, #57, #60 and #62) of six patients interviewed. Review of the hospital’s policy titled. “Patient Abuse and Neglect,” last 01/2023, showed: - Patients are not to be mistreated or abused physically, verbally, psychologically or sexually while under our care. - Patient neglect is prohibited. - Any employee found guilty of mistreating, abusing or neglect of a patient will be subject to disciplinary action up to and including termination. - Patient abuse is strictly prohibited and will not be tolerated. Examples of patient abuse include but are not limited to striking a patient; using excessive force in restraining a patient; rough handling of the patient; teasing, taunting or ridiculing a patient; speaking inappropriately with a patient and threatening a patient. - Neglect would be failing to provide for the patient’s basic emotional or physical needs or failing in any way that would endanger the patient’s emotional or physical well-being. - Failing to be fully engaged in promoting patient treatment plans would also be considered neglect. -Upon investigation and after an assessment of the findings, a final determination should be made by the Senior Facility Leader and senior management. - Findings of patient abuse will be considered a violation of the standards of conduct and subject to immediate termination. - Upon the discretion of the facility and in accordance with applicable state or Federal requirements, such violations may be reported to the employee’s state licensing agency and/or law enforcement agencies. Review of the hospital’s policy titled, “Workplace Violence Prevention (WVP),” dated 04/2025, showed: - The goal is to protect patients, employees, visitors and the public. - Staff are trained to recognize and respond effectively to violent actions and aggressive behaviors, and to deter escalation. - WVP incidents include those in which an individual commits assault, engages in harassing or intimidating behaviors, or credibly threatens the personal safety of employees, patients, visitors or vendors. - Examples of WVP include credible threats of violence; harassing behaviors such as stalking, obscene or disturbing messages, intimidating gestures, using a threatening posture, close finger pointing; property damage, such as broken doors or shattered glass; acts of unmanageable behavior, causing damage to property or resulting in injury, or throwing or breaking objects; assaultive actions such as intentionally ejecting bodily fluids (spitting) towards others; physical confrontations including striking, shoving, choking, kicking, tackling, collar-clothing grabbing, binding hands or feet, or other skin to skin contact and interaction; utilizing sharp objects as a weapon; violating physical boundaries such as sexual advances, body exposure, sexual activity, or molestation. - Staff should identify escalating behaviors, facilitate de-escalation, listen, provide empathetic support, and work as a team to de-escalate the individual. Professional, thoughtful, and empathic interaction with all individuals whose behavior is escalating is paramount during this process. - All staff members are responsible for using safe work practices, for following all directives, policies and procedures and for assisting in maintaining a safe and secure work environment. - The hospital’s Leadership Team will evaluate the performance of staff related to compliance with safety measures, provide training and/or counseling to staff whose performance is deficient, and discipline staff for failure to comply with safety and security practices. - Abuse and threats are not tolerated. WVP events will be tracked and trended. Review of an undated and untitled hospital document showed: - Patient #36 was admitted on 03/29/26 and was discharged on 03/31/26 against medical advice (AMA) for safety concerns. - Patient #51 was admitted on 03/27/26 and was discharged on 03/31/26 AMA for safety concerns. - Patient #55 was admitted on 03/27/26 and was discharged on 03/31/26 AMA with no reason listed. - Patient #33 was admitted on 03/29/26 and was discharged on 04/02/26 AMA with reason listed as grandchild. Review of Patient #34’s medical record dated 03/13/26, showed she was a 14-year-old who was admitted on 03/13/26 at 3:40 PM, for suicidal ideation (SI, thoughts of causing one’s own death) and was diagnosed with Major Depressive Disorder (MDD, a mental health condition that causes persistently low mood and loss of interest in activities that once brought joy). During an interview on 03/31/26 at 9:00 AM, Patient #34 stated that she had thoughts of self-harm (behavior that is harmful or potentially harmful to oneself) and talked to Staff CC. Staff CC laughed at her and told her to go back to her room. Staff CC yelled and cussed at the patients on the Four South Unit. Staff M did not respond to her asking for help. She requested a nurse, Staff M came to her room, and she told Staff M she was not doing good, was thinking about her trauma, she had been locked in her room for four days and that caused her to want to self-harm. Staff M, told her “You don’t know what trauma is, you don’t know what abuse is, you’re just having a panic attack.” She stated she was having a panic attack due to being on a hard reset and was not allowed to leave her room for the last four days. Staff M left her room. She did go and confront her at the nurse’s station and was told that she would just tell the Nurse Practitioner (NP, a nurse with advanced clinical education and training) that he needed to extend her stay. She stated that Staff MM called her “Rapunzel” and told her she looked like a “fidget spinner.” On 03/30/26 in the late afternoon, all the girls from the Four South Unit were allowed to come out and sit on the floor in the center of the milieu. When the girls were told they had to return to their rooms again the girls went on strike against the staff and fights broke out. The police department was notified and responded to the unit. She stated that she witnessed Patient #50 being taken to the seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) room for fighting. She stated that she was left alone in the seclusion room with no one observing her. She watched her through the window when she saw her tie her bra around her neck. She told Staff OO and was told to shut up and get back. She stated that Patient #50 attempted to tie a sock around her neck over the weekend and should not have been left alone. She stated that the nurses ran into the seclusion room and got the bra from around her neck. She stated that Staff II went into the seclusion room and jerked her pants down and gave her a shot and removed all her clothing. Patient #50 was left lying in the seclusion room naked with no clothes on. She stated that Patient #50 did not do anything wrong at the time of the injection and thought that Staff II was very rough and inappropriate at the time. She said no one was at the door making observations, she was left unattended. She stated that the same evening she witnessed Staff II and a big group of staff go into Patient #57’s room and gang up on Patient #56, Patient #57 and Patient #62. She stated that Staff II jumped on Patient #56 and took her down to the floor, she was in a hold and they gave her a shot of medication. The staff were yelling, screaming and cussing at everyone that night. She stated that after the incident with Patient #56, Patient #57 was calm and not doing anything in her room by herself and Staff OO went in and attempted to give her a shot. She was crying and begging the nurse not to give it to her. She stated that Staff JJ came onto the unit and heard the noise and went down to Patient #57’s room and stopped them from giving her a shot. “They are abusing us daily.” She stated that she requested to call her mother, she felt unsafe and was denied a phone call on 03/30/26. Patient #34 was discharged on 3/31/26 at 6:46 PM. Review of Patient #51’s medical record, dated 03/27/26, showed she was a 12-year-old who was admitted for SI with a plan. She was diagnosed with MDD and had a history of self-harm. During an interview on 03/31/26 at 9:30 AM, Patient #51 stated Staff CC yelled and cussed at the patients. She alleged there were several employees that verbally abused them. Staff overused their power and abused all of the kids on the night of 03/30/26. Patient #50 was left in seclusion by herself and tried to kill herself. Staff II attacked Patient # 56 for no reason, when she was being quiet in her room. After they took Patient #56 down, they attacked Patient #57 and tried to give her a shot. Someone came in and stopped them from doing it. The patients were all in their rooms not doing anything. Review of hospital document titled, “Report of Discharge Against Medical Advice,” dated 03/31/26 at 7:13 PM, showed that Patient #51 called her mother due to escalations on the unit on 03/30/26, telling her that she felt unsafe at the hospital. Review of hospital video dated 03/30/26, from the camera in Patient #57’s bedroom showed: - At 7:24 PM, three patients (#56, #57, and #62) enter Patient #57’s room. They are standing and appear to be talking to each other, and a staff member is standing at the door talking to them. - At 7:26 PM, the staff member leaves the doorway. Only shoes are visible in the doorway, there is no way to determine which staff member is there. - At 7:28 PM, the three girls are calmly sitting on a bed talking to each other. There is no imminent risk of danger at this time. - At 7:33 PM, nine staff members enter the room at one time and stand over the girls while they are sitting on the bed. There appears to be a conversation between the staff members and the three patients but there is no audio. There is no imminent risk of danger. - At 7:34 PM, Staff II initiates a takedown of Patient #56 while she is sitting on the bed. Staff II was the first staff member to engage, followed by the other staff. - At 7:35 PM, Patient #57 is sitting on her bed. She walks to the door and then paces around her room. - At 7:37 PM, she takes a stuffed animal and hugs it while sitting on her bed. - At 7:44 PM, Patient #57 gets up and walks to the top of her bed in the far corner of the room. Staff members are at the door. - At 7:50 PM, Patient #57 appears to be pleading with her hands out while in the corner of the room. Staff OO enters the room with a syringe in her hand; Patient #57 goes down in a fetal position in the corner of the room. She continues to stay in the fetal position in the corner of the room. - At 7:56 PM, Patient # 57 runs to the bathroom crying. Staff OO follows her into the bathroom and directs two BHT’s to the bathroom. - At 7:59 PM, Staff OO briefly comes out of the bathroom and sits on the bed. She then re-enters the bathroom. Three staff members are in the bathroom; there is no video from inside the bathroom, however you can see the bathroom door moving. - At 8:00 PM, Staff JJ enters the room and goes into the bathroom. Staff OO then leaves the room. - At 8:02 PM, the remaining BHT’s leave the room. - At 8:06 PM, a staff member brings Patient #57 a cup of water and all of the staff members exit the bathroom with Patient #57. - At no time during this event does Patient #57 display any threatening behavior. There is no imminent risk of danger. Review of hospital video dated 03/30/26, from the camera outside of Patient # 57’s room shows Patient #57 was being held down on the ground. Review of Patient #56’s medical record dated 03/28/26, showed she was a 15-year-old who was admitted for homicidal ideation (HI, thoughts or attempts to cause another’s death), defiance, elopement (when a patient makes an intentional, unauthorized departure from a medical facility) and self-harm. She was diagnosed with disruptive mood dysregulation disorder (DMDD, condition of extreme irritability, anger, and frequent, intense temper outbursts). During an interview on 03/31/26 at 9:45 AM, Patient #56 stated she had been on a lockdown since she arrived. She had asked staff numerous times why she was on a lockdown and confined to her room. The patients were allowed to come out at times, but when Staff CC was present on the unit, Staff CC ran the show. She yelled and cussed at the patients and would get her “riled up.” On the night of 03/30/26, Patient #56 was in the milieu. She admitted that she did get into a fight with another girl but walked away and tried to settle herself down. She was sitting on a bed talking to other girls when several staff members came and jumped on her. “I was arguing but I had been locked up since I arrived on the unit and we were not treated fairly. I was drug down onto the floor and out in the hall and was given a shot. Staff II verbally, physically and sexually assaulted me. He grabbed my boob on purpose and squeezed as hard as he could when he took me down on the bed.” Review of Patient #57’s medical record, dated 03/25/26, showed she was a 15-year-old who was admitted for homicidal ideation (HI, thoughts or attempts to cause another’s death) and was diagnosed with DMDD). She had a history of Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring because of injury or severe psychological shock) and a traumatic history of being locked in a room, sex trafficked and injected with various drugs. During an interview on 03/31/26 at 9:30 PM, Patient #57 stated that on 03/30/26 the patients had been allowed to go out to the milieu after being stuck in their rooms for 72 hours. The girls started to riot, and fights broke out. She admitted to fighting with another girl. She removed herself out of the situation and went to her room to calm down. Some girls followed her into her room where they were sitting on the bed not doing anything. A big group of staff entered her room and attacked Patient #56, pinning her down for no reason. Afterwards, she was sitting on her bed processing everything on her own when Staff OO came in with a shot in her hand. She cried and begged Staff OO to not to give her the shot and asked for a pill instead. Patient #57 had previously been locked in a room, held down and given shots of drugs. She had been forced to have sex with people she didn’t know. She panics when people move towards her with shots in their hand. She had not been doing anything to deserve that shot. She ran into the bathroom to try to get away and the staff ran in after her. Staff OO was trying to pull my pants down, and Staff MM was holding my feet and legs down. She began throwing up and the nurse pushed her head down into the toilet. A social worker came into the room and yelled at the staff to stop. The SW sat with Patient #57 in the bathroom and helped her calm down. The SW got them to give her a pill instead, which was what she had originally begged for instead of the shot. “This was traumatizing,” to her. She asked, “Why do people treat others this way?” She indicated, she “had been through so much in life.” “We’re here for help and the staff yell and cuss at us. They laugh at people and call them names; they are like bullies.” During an interview on 03/31/26 at 4:10 PM, Staff KK, stated when she entered Patient #57’s room, the patient was calm. The nurse stated, “they were past the talking point, and it was time to go hands on.” Staff KK felt the nurse’s direction to go hands on was “abusive.” The nurse told Staff MM, to drag Patient #57 out of the bathroom. Staff KK stated they could not drag her, and Patient #57 did not fight when they went hands on. “There was too much chaos and no lead to tell us what to do.” During an interview on 03/31/26 at 4:27 PM, Staff MM, stated that he got into Patient #57’s room late and the patient was agitated with the other staff members in the room. He was told by Staff OO, that no BHA could try to de-escalate Patient #57. When Staff JJ, entered the room “we were just following orders.” The patient’s behavior did not justify hands on. He felt there was an opportunity to verbally de-escalate Patient #57. The patient was escalated by the pending injection because of her traumatic history. He stated that Staff OO overstepped at times and went straight to yelling. He observed another patient telling Staff OO she was having a panic attack and Staff OO responded by telling the patient they were okay. The patient felt disregarded. He stated, “Nurses need to better assess situations before making a hands-on decision.” Review of Patient #60’s medical record, dated 03/25/26, showed she was a 13-year-old who was admitted being placed into state custody due to parental neglect. She was admitted for self-harm, SI without a plan and was diagnosed with MDD and PTSD. During an interview on 03/31/26 at 9:45 AM, Patient #60 stated that she witnessed abuse last night on 03/30/26 by staff to other girls on the unit. Review of Patient #62’s medical record, dated 03/26/26, showed she was a 15-year-old who was admitted for SI and self-harm (behavior that is harmful or potentially harmful to oneself). She was diagnosed with disruptive mood dysregulation disorder (DMDD, condition of extreme irritability, anger, and frequent, intense temper outbursts). During an interview on 03/31/26 at 10:00 AM, Patient #62 stated she had witnessed several events that involved multiple staff members abusing some girls. She stated that Staff II and Staff OO were the primary staff involved. There was another nurse too, but she could not recall her name. Staff members yell and cuss at the patients whenever they want. Staff CC always yells and cusses at them. “She bosses everyone around and tells the nurses what to do. She thinks she is in charge. We (the patients) have the right to be treated respectfully; the staff instigate things by calling us names and cussing at us, then we get mad and end up in trouble. If the staff talked to me differently, I wouldn’t overreact.” During an interview and concurrent video review, on 04/01/26 at 12:03, Staff RR, Risk Management Director, stated that he definitely had a lot of questions about the content of the videos he reviewed from Patient #57’s room. He questioned why the police were called twice. He admitted that Patient #56 and Patient #57 were not presenting an imminent risk of harm when the staff members went hands on. The eight staff members in Patient #57’s room were a “show of force” to patients. The staff members went hands on because a patient postured. A patient would need to be “coming at me before I would go hands on or take a patient down.” There was no immediate risk at that time. The video showed the patients were all sitting on the bed. The staff lost control of the milieu on the unit and did not do the right things to get control back. Milieu management should be a collaboration with the charge nurse and the BHA’s and it is very important. Some of the BHT leads are very strong. In regard to the milieu of the Four South Unit over the weekend, he did not observe any organization or collaboration from the video of the events. During an interview on 04/01/26 at 4:50 PM, Staff V stated that he identified Staff II as the staff member that initially went hands on with Patient #56. He questioned why eight staff members were in Patient #57’s room. During an interview on 03/31/26 at 10:50 AM, Staff T stated that he was not surprised that Staff CC was accused of verbal abuse. She was strict with the patients, and should collaborate with the other nursing staff, and not make all of the unit’s decisions. Abuse allegations were to be immediately reported to the supervisor. Any staff member involved was to be removed from patient care. A full unit hard reset was easier when there are staffing issues and they are not okay. He was made aware of the full unit room restrictions on the morning of 03/30/26. The restrictions were removed that evening, and the patients began to riot. The 2.5 days of restrictions could have something to do with the riot. The full unit hard reset over the weekend should not have happened. A full unit hard reset was not therapeutic, especially when the patients were not being offered therapy. During an interview on 03/31/26 at 3:25 PM, Staff JJ, stated that the nurses on the Four South Unit talked terrible to the patients. Staff M, told a patient her trauma was not real. Staff CC, was rude, angry and did not accept responsibility. He informed Staff JJ, CNO, and was told he “was going to work on it.” During an interview on 04/01/26 at 9:00 AM, Staff SS, stated that he has heard staff members, mostly BHA’s, belittle the patients. He reported this concern to Staff T. Staff CC, could get “pretty abrasive.” She worked independently without provider input. He was not surprised the BHA’s went hands on at the RN’s direction unnecessarily. He believed restraints could be avoided, but the staff engaged in a power struggle. De-escalation required work and effort, it was easier to shove a patient into seclusion. Patients needed to interact and engage in therapy. This was a common concern for him for years. He stated the girls had been on hard reset over the weekend and the nursing staff tried to initiate another hard reset the evening of 03/30/26, but he said no. The patients were hospitalized for treatment. During an interview on 03/31/26 at 1:15 PM, Staff HH stated that she believed the hospital had a pattern of abuse and she escalated her concern to the unit Managers and the CNO. When she reported her concerns for abuse, the CNO’s response was to re-educate the staff, there was no coaching or counseling for specific staff. She felt no one listened to her and nothing was really done when allegations were substantiated. “Staff P is super mean and works on several units. Staff QQ is so mean to the patients. Staff II is terrible and had to be transferred because he was worse with the kids than the adults. It doesn’t surprise me at all that there are complaints about him. Staff CC believes she is in control of everything. She doesn’t listen to the kids and doesn’t let them do anything. Staff G is mean and aggressive with the elderly patients. It is just not okay to talk to patients that way.” During an interview on 04/15/26 at 10:00 AM, Staff YY stated “yelling and cussing at patients was not the best practice and that it should be considered verbal abuse.” “Staff members who had allegations against them should all be investigated. If substantiated, they should be removed from patient care.” He did recall a time he witnessed a nurse yelling at a patient and went directly to the CNO and discussed the actions that he witnessed. He stated, “the employee was still currently employed, the CNO should be aware of all allegations of abuse and ensure they are investigated.” He stated yelling only escalates these patients. He was not completely aware of the Four South Unit’s incidents that occurred on 03/30/26. He was not aware the unit had been placed on a hard reset for three days. When eight staff members went into Patient #57’s room, he would consider that to be a show of intimidation if there was no immediate danger. He had not reviewed the video and was unaware this happened. He stated that patients have discussed abuse allegations against staff, and he instructed them to file a grievance. He stated, “I have been told by patients that their grievances are not being investigated, and I am sure that they are not all being investigated.” Review of Staff II’s personnel file showed: - On 08/2023, he received a written warning for arguing with other staff members. - On 04/2024, he received a final written warning for yelling and cussing at children. - On 01/13/26, he received a written warning for verbal abuse. During an interview on 04/15/26 at 2:50 PM, Staff SS stated that Staff II had been suspended pending the investigation regarding Patient #56. He stated they determined the allegation of abuse was not abuse. It was just an improper takedown. He was re-educated and given a written warning. This was Staff II’s fourth written warning. This would total two additional written warnings following the final written warning that was issued on 01/2024. Staff members who were identified with alleged abuse were not immediately removed from patient care until the State Agency began to investigate the complaints from the Four South Unit. 48359”

“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: 47504 Based on interview, record review and policy review the hospital failed to follow their policy and ensure all patients placed in restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) had a physician order that was signed within 24 hours for 20 current patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) and four discharged patients (#63, #67, #68 and #71) of 30 patient’s medical records reviewed. This failure had the potential to affect all patients placed in restraints or seclusion. Findings included: Review of hospital document titled, “Seclusion/Restraint: Acute (sudden onset) and Sub-Acute Services,” effective 11/2025, showed: - A seclusion was the involuntary confinement of a person in a room or an area where the person is alone and physically prevented from leaving. - A restraint included a physical restraint, chemical restraints (a form of medical restraint in which a drug is used to restrict the freedom of movement of a patient) or mechanical restraint. - The nurse will ensure the nursing supervisor/nurse manager/unit manager are notified and will contact the provider for orders while the emergency safety intervention is being initiated by staff or immediately after the emergency safety situation ends. - The attending physician should be notified with the date and time the physician was notified. - The initial order may not exceed two hours for ages nine to 17. - The provider should be contacted for renewal of orders when the restriction is needed beyond the time frames specified for the initial order. - The provider will write orders or give telephone/verbal orders for seclusion or restraints and sign them within 24 hours. Review of Patient #63’s medical record, dated 03/13/26, showed: - On 03/13/26 at 5:49 PM, he was placed in a physical restraint and given a chemical restraint. - At 5:57 PM, the order was received from the physician. - On 03/16/26 at 7:10 AM, the restraint orders for the physical and chemical restraint were signed by the physician. This order was not signed within 24 hours. Review of Patient #67’s medical record, dated 12/20/25, showed at 1:03 AM, an order was received from the physician to place Patient #67 in seclusion and to give a chemical restraint. The order was not signed by the physician until 12/22/26 at 9:50 AM. This order was not signed within 24 hours. Review of Patient #68’s medical record, dated 12/14/25, showed at 6:51 PM, an order was received from the physician to place Patient #68 in a physical, administer a chemical restraint and placed them in seclusion. These orders were not signed until 12/15/26 at 10:37 PM, outside the 24-hour window. Review of Patient #71’s medical record, dated 01/02/26, showed at 11:34 PM, Patient #71 was placed in a physical restraint, given a chemical restraint and placed in seclusion. There was no physician order for physical restraint or seclusion. The concurrent observation and review of 20 patient (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) medical records, on 03/30/26 at 2:30 PM, showed all patients were placed on a hard reset and confined to their bedrooms on 03/28/26, 03/29/26 and 03/30/26. There were no physician orders for these days of seclusion. The concurrent observation and review of Patient #50’s medical record on 03/30/26 at 2:30 PM, showed Patient #50 was placed in a physical restraint, given a chemical restraint and then placed in seclusion. There was no physician order for the physical restraint or seclusion. During an interview on 03/26/26 at 10:00 AM and 03/31/26 at 10:50 AM, Staff T stated the expectation was for a provider to enter an order for a hard reset with documentation of the indication of need. He preferred patients to reset daily when indicated. An order needed to be written for individualized room restrictions, restraints and seclusion. During an interview on 04/01/26 at 9:00 AM, Staff SS, NP, stated that all seclusions should have an order from a provider. During an interview on 04/02/26 at 10:30 AM, Staff A stated that all restraints and seclusions should have a physician order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy reviews, the hospital failed to follow their policy and ensure patients placed in restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) or seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) had documented initiation and discontinuation times for 20 current patients of (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) of 20 patients observed and medical records reviewed. This placed all patients placed in restraints or seclusion at the risk of harm. Findings included: Review of the hospital’s policy titled, “Seclusion/Restraint: Acute and Sub-Acute Services,” effective 11/2025, showed the nurse will document the date and time in the appropriate places. Review of the hospital’s undated document titled, “Seclusion/Restraint One Hour Face to Face Assessment,” directed staff to document the intervention date and time, along with the need to continue or discontinue the restraint or seclusion. On 03/30/26 at 2:30 PM, during concurrent observation and review 20 patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, 55, #56, #57, #58, #59, #60, #61 and #62) medical records showed each patient was placed on a hard reset and confined to their bedrooms on 03/27/26, 03/28/26 and 03/30/26. There was no documentation of the initiation time or discontinuation time for these days of seclusion. During a telephone interview on 04/15/26 at 10:00 AM, Staff ZZ, Physician, stated that he expected all staff members to follow all of the hospital’s policies and procedures. He stated that he expected documentation of restraint/seclusion initiation and discontinuation times, and for them to be discontinued as soon as possible.”

“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: 47504 Based on observation, interview and policy review, the hospital failed to follow the policy for safety observations for 20 current patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) of 20 patients observed and medical records reviewed. Review of the hospital’s policy titled, “Seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving)/Restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head): Acute (sudden onset) and Sub-Acute Services,” effective 11/2025, showed: - Respirations will be assessed and recorded every 15 minutes while the patient is in seclusion or restraint. - The Nurse will assign a staff member to monitor the patient continuously and document at least every fifteen minutes for all episodes of seclusion. - A staff member will interact at least every fifteen minutes with the patient during the restriction in order to assess the patient’s physical and emotional status. - The Nurse will ensure the patient/resident is removed from seclusion or restraint as soon as they are no longer a danger to self or others. On 03/30/26 at 2:30 PM, during concurrent observation and review of 20 patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) medical records, showed each patient was placed in a hard reset and could not leave their rooms on 03/27/26, 03/28/26 and 03/30/26. There were no nursing assessments indicating that patients were in a hard reset/seclusion. There was no documentation indicating the nurse had assigned a staff member to monitor each patient continuously for all episodes of the hard reset/seclusion. None of the patients had their respirations assessed during these events. During a telephone interview on 04/15/26 at 10:00 AM, Staff ZZ, Physician, stated that he expected all staff to follow the hospital’s policies and procedures. He expected continuous one-to-one (1:1, continuous visual contact with close physical proximity) observation while patients were restrained/secluded.”

“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: 47504 Based on interview, record review and policy review the hospital failed to follow their policy to ensure a qualified staff member completed a face-to-face (a qualified staff members evaluation of a patient in restraints) within one hour of the initiation of a restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) or seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) for 20 current patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) and 11 discharged patients (#3, #63, #64, #65, #66, #67, #68, #69 #70, #71 and #72) medical records reviewed out of 31 total patients reviewed. Findings included: Review of hospital document titled, “Seclusion/Restraint: Acute (sudden onset) and Sub-acute Services, effective on 11/2025, showed: - If the registered nurse (RN) who completes the one-hour post restraint face-to-face assessment has not been involved in determining the need for seclusion or restraint (including chemical restraints [a form of medical restraint in which a drug is used to restrict the freedom of movement of a patient] ), initiation of a therapeutic hold (treatment technique in which a violent patient is physically contained by people) or seclusion, or attempting to process or deescalate the patient, they are not considered directly involved in the seclusion/restraint intervention. This RN may fairly assess the situation and be the leader for the staff/supervision/administration debriefing. - A provider or qualified RN will complete a face-to-face evaluation within one hour of initiation of any seclusion or physical/chemical restraint. - The nurse should document the patient’s immediate situation, their reaction to the intervention, the patient’s medical and behavioral condition, and the need to continue or terminate the restraint or seclusion. Review of Patient #3’s medical record showed restraints were initiated on 11/08/26 at 7:00 PM, by Staff AAA, RN. A face-to-face was completed at 9:26 PM by the same nurse. The face to face was completed one hour and 26 minutes late. Review of Patient #63’s medical record showed restraints were initiated on 03/13/26 at 5:49 PM, by Staff XX, RN. A face-to-face was completed at 6:00 PM by the same nurse. On 03/26/26, Staff XX completed face-to-face training, 13 days after she completed Patient #63’s face-to-face. Review of Patient #64’s medical record showed restraints were initiated on 03/07/26 at 2:00 PM, by Staff S, RN. A face-to-face was completed at 2:40 PM by the same nurse. Review of Patient #65’s medical record showed restraints were initiated on 09/08/25 at 2:37 PM, by Staff P, RN. A face-to-face was completed at 2:50 PM by the same nurse. At 7:36 PM, restraints were initiated by Staff YY, RN. A face-to-face was completed at 7:50 PM by the same nurse. Review of Patient #66’s medical record showed restraints were initiated on 01/05/26 at 8:25 PM, by Staff ZZ. A face-to-face was completed at 9:05 PM by the same nurse. Review of Patient #67’s medical record showed restraints were initiated on 12/20/25 at 1:03 AM, by Staff BBB, RN. A face-to-face was completed at 2:03 PM by the same nurse. Review of Patient #68’s medical record showed restraints were initiated on 12/14/25 at 6:51 PM, by Staff S, RN. A face-to-face was completed at 7:50 PM by the same nurse. Review of Patient # 69’s medical record showed restraints were initiated on 02/23/26 at 2:00 PM, by Staff II, Nurse Supervisor. A face-to-face was completed at 3:00 PM, by the same nurse. Review of Patient #70’s medical record showed restraints were initiated on 01/26/26 at 11:34 PM, by Staff BBB, RN. A face-to-face was completed at 12:30 AM by the same nurse. Review of Patient #71’s medical record showed restraints were initiated on 01/30/26 at 1:48 AM, by Staff CCC, RN. A face-to-face was completed at 2:00 AM by the same nurse. On 03/30/26 at 2:30 PM, during concurrent observation and review 20 patients (#11, #29, #33, #34, #35, #36, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) medical records showed on 03/28/26, 03/29/26 and 03/30/26 all patients on the Four South Unit were placed on a hard reset. There was no face-to-face documentation for these hard resets/seclusions. During an interview on 04/02/26 at 10:30 AM, Staff A stated that all restraints and seclusions must have a face-to-face. During an interview on 04/02/26 at 12:30 PM, Staff GG, Chief Nursing Officer (CNO), stated that the same nurse could initiate the restraint, do the face-to-face and the debriefing of the patient. I asked him who was making the decision to place the patient in the restraint, and he stated the nurse was. Upon review of the policy, he acknowledged that the same nurse could not complete both.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(vii) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (vii) The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification. This Standard is not met as evidenced by: 47504 Based on interview and personnel file review, the hospital failed to ensure that all staff were trained on a periodic basis in first aid related to restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) for 14 staff members (C, F, J, M, O, P, CC, EE, FF, II, NN, QQ, WW, and XX ) of 14 personnel files reviewed. This failure had the potential to result in serious injury or death to patients who required restraints in the hospital. Findings included: Although requested, the hospital failed to present a policy in relation to first aid restraint training requirements. Review of Staff C’s, RN, personnel file showed she had no restraint first aid training. Review of Staff F’s, RN, personnel file showed she had no restraint first aid training. Review of Staff J’s, Registered Nurse (RN), personnel file showed she had no restraint first aid training. Review of Staff M’s, RN, personnel file showed she had no restraint first aid training. Review of Staff O’s, Behavior Health Assistant (BHA), personnel file showed she had no restraint first aid training. Review of Staff P’s, RN, personnel file showed she had no restraint first aid training. Review of Staff CC’s, BHA, personnel file showed she had no restraint first aid training. Review of Staff EE’s, RN, personnel file showed she had no restraint first aid training. Review of Staff FF’s, RN, personnel file showed she had no restraint first aid training. Review of Staff II’s, Nursing Supervisor, personnel file showed he had no restraint first aid training. Review of Staff NN’s, Intake Counselor, personnel file showed she had no restraint first aid training. Review of Staff QQ’s, RN, personnel file showed she had no restraint first aid training. Review of Staff WW’s, RN, personnel file showed she had no restraint first aid training. Review of Staff XX’s, RN, personnel file showed she had no restraint first aid training. During an interview on 03/27/26 at 2:25 PM, Staff K, Quality Director, stated that there was no restraint first aid training for the staff on the acute care side of the hospital. He believed that was only a requirement for the residential care staff. 48359”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 47504 Based on observation, interview and personnel file review, the hospital failed to ensure that seven nurses (Staff F, J, M, EE, FF, XX and WW) were orientated and had verified competency in the patient care they provided of nine nurse personnel files reviewed. This failure could place all patients at risk for their safety. Findings included: Although requested, the hospital failed to present a policy related to staff orientation and competency. Review of Staff F’s, Temporary RN, personnel file showed he did not complete his unit-specific competency checklist. His hire date was 01/20/26. Observation on 03/23/26 at 4:00 PM, on the Four South Unit, showed Staff F, Temporary RN, worked independently to provide patient care. Review of Staff J’s, Temporary RN, personnel file showed she completed her unit-specific competency checklist on 03/25/26, after observation of her working independently. Her hire date was 02/02/26. Observation on 03/24/26 at 9:00 AM, on the Four South Unit, showed Staff J, Temporary RN, worked independently to provide patient care. Although requested, the hospital failed to present a document related to the work schedule for Staff M, Licensed Practical Nurse (LPN). Review of Staff M’s, LPN, personnel file showed she did not complete her unit-specific competency checklist. Her hire date was 08/18/25. Although requested, the hospital failed to present a document related to the work schedule for Staff EE, Registered Nurse (RN). Review of Staff EE’s, RN, personnel file showed she did not complete her unit-specific competency checklist. Her hire date was 01/20/26. Review of Staff FF’s, Temporary RN, personnel file showed he did not complete his unit-specific competency checklist. His hire date was 01/19/26. Observation on 03/31/26 at 8:00 AM, showed staff FF, on the Three South Unit, Temporary RN, worked independently to provide patient care. Review of Staff XX’s, Temporary RN, personnel file showed she did not complete her unit-specific competency checklist. Her hire date was 01/20/26. Observation on 04/07/26 at 1:45 PM, on the Four South Unit, showed staff XX, Temporary RN, worked independently to provide patient care. Review of the hospital’s document titled, “Timesheet,” dated 02/16/26 through 04/04/26, showed Staff WW, Temporary RN, began working independently on 03/15/26. Review of Staff WW’s, Temporary RN, personnel file showed she did not complete her unit-specific competency checklist. Her hire date was 02/16/26. During an interview on 03/26/26 at 11:06 AM and 04/01/26 at 4:50 PM, Staff V, Human Resources Director, stated that the newly hired temporary staff hiring process mimicked the permanent staff hiring process. Each temporary staff member received 40 hours of in-class general hospital orientation and then could have up to two weeks of shadowing to learn the skills. The hospital preferred psychiatric (relating to mental illness) experience but had hired new graduates. All temporary staff received the same orientation, experienced or not. Competency was validated through a “competency packet.” The packet required 36 to 40 hours for a nurse to complete. He agreed staff should not work independently before their competency packet was completed. He stated that the hospital had an opportunity for improvement related to unit specific orientation. He agreed there weren’t checklists in the personnel files. The unit specific orientation completion checklist was used to verify staff competencies. He assumed the staff members whose personnel files were reviewed were all working independently. During an interview on 03/31/26 at 10:50 AM, Staff T stated that new hires were given two weeks of shadowing. He did not expect staff to complete the unit specific orientation checklist prior to working independently. He asked the new staff member if they felt confident providing care if their checklist was not completed. He “did not like the process.” He believed some of the new staff were nervous and the Behavioral Health Assistants (BHAs) were making unit decisions, instead of the nurses. 48359”

“LICENSURE OF NURSING STAFF CFR(s): 482.23(b)(2) The nursing service must have a procedure in place to ensure that hospital nursing personnel for whom current licensure is required have a valid and current licensure. This Standard is not met as evidenced by: 48359 Based on interview and document review, the hospital failed to ensure staff had the required certification and licensure for two staff members (NN and P) of 14 personnel files reviewed. Review of the hospital’s policy titled, “Workplace Violence Prevention,” effective 04/2025, showed training for all employees with respect to workplace security, situational awareness, workplace violence and behavioral de-escalation techniques shall be provided to all staff including managers and supervisors, upon hire and with refresher training required annually. Handle With Care (HWC, a trauma-informed behavior management program focusing on verbal de-escalation and safe physical intervention for healthcare) was the program provided. Review of the hospital’s document titled, “Admissions Counselor Job Description,” dated 04/01/22, showed Education/Experience/Skill Requirements included: - A bachelor’s degree in the social services field was required. - A master’s degree in a social services field (psychology, counseling, social work, sociology, health administration or nursing) or Registered Nurse (RN) was preferred. - License/Designation/Certification Requirements included current licensure. Review of Staff NN’s, Intake Counselor, personnel file on 04/02/26, showed on 11/07/25, her RN license was revoked. On 03/25/26, her HWC certification expired. Review of Staff P’s, RN, personnel file on 04/02/26, showed on 03/27/26, her HWC certification expired. During an interview on 04/01/26 at 4:50 PM, Staff V, Director, stated that Staff NN’s, Intake Counselor, education and licensure did not meet her job requirements. He would be unable to place her into the Intake Counselor’s job role if he independently made the decision and HWC certification was required annually for all staff. During an interview on 04/01/26 at 2:00 PM, Staff K, Quality Director, stated that Staff NN’s, Intake Counselor, promotion was approved by the prior Chief Executive Officer (CEO) which was based on her previous experience as an intake coordinator which was a clinical role. Her current position was to perform clinical assessments and “all of the above.””

“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: 48359 Based on interview, record review and policy review, the hospital failed to ensure that the Chief Nursing Officer (CNO) provided adequate oversight and supervision of nursing personnel when the staff failed to assess and communicate patient medical concerns for three current patients (#29, #30 and #31) and four discharged patients (#14, #26, #28 and #37) of nine medical records reviewed with medical complaints. Findings included: Although requested, the hospital failed to present a policy related to medical care and medical book documentation. Review of the hospital’s policy titled, “Self-Injurious (behavior that is harmful or potentially harmful to oneself) Behavior/Prevention: Early Identification, Observation, Response and Notification,” effective 06/2025, showed non-suicidal (to cause one’s own death) self-injury (NSSI) is when a patient deliberately causes injury to him/herself without intent to die. Nursing staff is to contact the attending provider to discuss/communicate risks and obtain orders for NSSI behavior precautions. Review of the hospital’s policy titled, “Critical Values,” effective 05/2025, showed: - A critical test result was a test result that is beyond the normal variation whose values reflect an emergent situation including laboratory and imaging services. - The Registered Nurse (RN) will notify the provider within 30 minutes of receipt of the results. - The RN will document the date and time the provider was notified in the progress notes. Review of Patient #14’s medical record, dated 11/01/25, showed: - He was 15 years old. - On 11/13/25 at 12:54 PM, he complained of a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) score of seven to his right hand. A narrative note showed he hit the wall in his room when he was madand would be seen by the medical provider. - The provider was not notified of the NSSI. - On 11/14/25 at 3:24 PM, an x-ray (test that creates pictures of the structures inside the body-particularly bones) of his right wrist was ordered. - On 11/15/25, the x-ray results showed right fourth and fifth finger fractures (break in a bone). - At 4:55 PM, Staff S, RN, initialed the x-ray report. The provider was not notified of the test results. Review of the hospital’s document titled, “Medical Practitioner Consult Log,” dated 03/23/26, showed three patients (#29, #30 and #31) pierced their noses with an earring. Review of the hospital’s policy titled, “Employee Injuries,” effective 06/2024, directed staff to: - Determine if the injury is a blood-borne pathogen (infectious microorganisms [organisms, such as bacteria, too small for the naked eye], such as viruses or bacteria, carried in human blood and bodily fluids that can cause serious or fatal diseases in humans) exposure (needle stick, an injury creating an opportunity for exposure to blood or body fluids). - If so, facilitate post-exposure testing on the patient for any suspected exposure. - Primary Care Provider orders include human immunodeficiency virus (HIV, virus that attacks the cells that help the body fight infection) and hepatitis B and C (inflammation of the liver. The various forms of viral hepatitis are named after different letters of the alphabet) testing. Review of the hospital’s policy titled, “Assessment and Reassessment,” effective 08/2025, showed each patient is reassessed as necessary based on the patient’s plan for care or change in their condition. Review of Patient #29’s medical record, dated 03/19/26, showed: - She was 12 years old. - On 03/23/26 at 11:59 AM, a nursing note showed she and her peers hid an earring in headphones and a stress ball. The girls attempted to give each other piercings with it. The contraband (items that are illegal, forbidden, or that can be used to harm self or others) was confiscated. - There was no nursing reassessment based on the patient’s change in condition due to the nose piercing. Review of the hospital’s document titled, “Incident Report (a staff report of an unexpected occurrence) Form-1281,” dated 03/23/26, showed Patient #29 and her peers had pierced their noses with an earring and put studs in them. At 5:55 PM, the provider was notified, five hours and 56 minutes after the event occurred. Review of Patient #30’s medical record, dated 03/13/26, showed: - She was 15 years old. - On 03/23/26 at 11:58 AM, a nursing note showed she and her peers were hid an earring in headphones and a stress ball. They attempted to give each other nose piercings with it. The contraband was confiscated, wound sites were cleansed and the patients were placed in the medical book. - There was no nursing reassessment based on the patient’s change in condition due to the nose piercing. Review of the hospital’s document titled, “Incident Report Form-1279,” dated 03/23/26, showed Patient #30 and her peers had pierced their noses with an earring and put studs in them. At 5:55 PM, the provider was notified, five hours and 57 minutes after the event occurred. Review of Patient #31’s medical record, dated 03/14/26, showed: - She was 13 years old. - On 03/23/26 at 11:52 AM, a nursing note showed she and her peers hid an earring in headphones and a stress ball. They attempted to give each other a nose piercing with it. The contraband was confiscated. The sites were cleansed, and the patients were placed in the medical book. - There was no nursing reassessment based on the patient’s change in condition due to the nose piercing. Review of the hospital’s document titled, “Incident Report Form-1280,” dated 03/23/26, showed Patient #31 and her peers had pierced their noses with an earring and put studs in them. At 5:55 PM, the provider was notified, six hours and three minutes after the event occurred. During an interview on 03/23/26 at 4:00 PM, Staff F stated that some of the girls had pierced their noses with a peer’s earring that was hidden in headphones earlier in the day. The piercings were removed and discarded. The insertion sites were cleansed, and the girls were entered into the “medical book” to be evaluated by the medical doctor. Review of the hospital’s document titled, “Medical Practitioner Log,” dated 03/01/26, showed Patient #28 had a low blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) since 02/26/26. His lowest BP was 88/55 and his lowest heart rate (HR, the number of times the heart beats within a certain time period, normal pulse/heartbeats for adults range from 60 to 100 per minute) was 58. He took Losartan (a medication used to treat high blood pressure) and Lopressor (a medication used to treat high blood pressure and chest pain) twice daily. Perhaps adjust the dosing or discontinue one of the BP medications. Review of the hospital’s policy titled, “Medication Administration,” dated 06/2024, directed staff to not administer medications that exceed the parameters specified in appropriate medication literature without first consulting the provider and document such consultations in the progress notes. Nurses will notify the provider when medication parameters were not provided by the provider in the order. Review of Patient #28’s medical record, dated 02/26/26, showed: - He was 75-years old. - On 02/28/26 at 8:19 AM, his BP was 88/55 and his HR was 58. He was given Losartan 100 mg and Lopressor 50 mg. - At 5:07 PM, his HR was 58. He was given Lopressor 50mg. - No order parameters were written for the medications. - There was no nursing documentation of provider notification other than the medical book. During an interview on 04/01/26 at 9:00 AM, Staff TT, Pharmacist, stated that the hospital was working on developing parameters for some medications, but he was not aware there were not parameters for Lopressor and Losartan. After review of Patient 28’s vital signs (VS, measurements of the body’s most basic functions) he stated that the medication should not have been administered. He expected all nurses to have basic knowledge of medication administration. He stated that the hospital had opportunities to mitigate patient harm. Review of the hospital’s document titled, “Medical Practitioner Log,” dated 03/04/26, showed Patient #26 complained of chest pain with a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) score of seven, and her left arm felt heavy. Review of Patient #26’s medical record, dated 03/02/26, showed: - She was 35-years old. - There was no provider progress note, or orders related to her complaint of chest pain. - There was no nursing reassessment related to the patient’s complaint of chest pain - There was no nursing documentation of provider notification other than the medical book. During an interview on 03/27/26 at 10:00 AM, Staff T stated that he did not expect a complaint of chest pain to be written in the medical book. He expected a phone call to inform the medical provider of the patient’s situation. He stated that there were no “clear guidelines” to direct nursing on what was and was not appropriate for the medical book. Review of the hospital’s document titled, “Medical Practitioner Log,” dated 03/21/26, showed patient #37 complained of a fall on her left knee with a pain scale assessment score of 10. Review of Patient #37’s medical record, dated 02/27/26, showed: - She was 12 years old. - There was no provider progress note, or orders related to her complaint of knee pain. - There was no nursing reassessment related to the patient’s complaint of knee pain. - There was no nursing documentation of provider notification other than the medical book. During a telephone interview on 04/15/26 at 10:00 AM, Staff ZZ, Physician, stated that he expected staff to follow all hospital policies and procedures. He expected a change in condition to be immediately reported to the providers. A complaint of chest pain should not have been placed in the medical book. The medical books were something that had been in use prior to the use of the electronic medical record. He was not fond of a process where the books were only checked once in a while. Providers needed to be contacted rather than having the complaints written in a book. He was pleased the survey had observed this practice because he thought it was a very dangerous practice. During a telephone interview on 04/15/26 at 9:45 AM, Staff GG, CNO, stated that he had full oversight of the nursing and behavioral health aids. He expected staff to follow all hospital policies and procedures. During an interview on 03/27/26 at 10:00 AM, Staff T stated that when a Nurse Practitioner (NP, a nurse with advanced clinical education and training) was notified of a medical complaint their typical response was to “write it in the medical book, unless it was an urgent concern.” Urgent concerns were sent out to the local Emergency Department (ED). The medical provider typically rounded on each unit daily between 2:30 PM and 4:00 PM. Staff T stated that he had issues with the medical providers failing to document in the medical record. He stated that when a complaint was written in the medical book the medical provider would “just scratch through it and not see the patient.” During an interview on 03/26/26 at 2:07 PM, Staff K, Quality Director, stated that when a patient complaint was not urgent that complaint was entered into the medical book. There was no expectation for a provider to evaluate the patient’s complaint. The provider usually saw the patient “within a couple of days.” The expectation was for the medical provider to review the book every day but that did not always happen. It depended on the “assertiveness of the nurse.” He stated that the hospital had “opportunities” with the medical providers.”

“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: 48359 Based on observation, interview and personnel file review, the hospital failed to ensure that seven nursing staff (F, J, M, EE, FF, XX, and WW) of nine nurses’ personnel files reviewed were orientated with verified competency in the patient care they provided. This failure could place all patients at risk for their safety. Findings included: Although requested, the hospital failed to provide a policy regarding staff orientation and competency. Observation on 03/23/26 at 4:00 PM, showed Staff F, Temporary Registered Nurse (RN), worked independently to provide patient care. Review of Staff F’s, Temporary RN, personnel file showed he did not complete his unit-specific competency checklist. His hire date was 01/20/26. Observation on 03/24/26 at 9:00 AM, showed Staff J, RN, worked independently to provide patient care. Review of Staff J’s, RN, personnel file showed on 03/25/26, she completed her unit-specific competency checklist after observation of her working independently. Her hire date was 02/02/26. Review of the hospital’s document titled, “Timesheet,” dated 08/23/25 through 04/04/26, showed Staff M worked independently beginning 09/20/25. Review of Staff M’s, Licensed Practical Nurse (LPN), personnel file showed she did not complete her unit-specific competency checklist. Her hire date was 08/18/25. Review of the hospital’s document titled, “Timesheet,” dated 01/20/26 through 04/04/26, showed Staff EE worked independently beginning 02/13/26. Review of Staff EE’s, RN, personnel file showed she did not complete her unit-specific competency checklist. Her hire date was 01/20/26. Observation on 03/31/26 at 8:00 AM, showed staff FF, Temporary RN, worked independently to provide patient care. Review of Staff FF’s, Temporary RN, personnel file showed he did not complete his unit-specific competency checklist. His hire date was 01/19/26. Observation on 04/02/26 at 2:45 PM, showed staff XX, Temporary RN, worked independently to provide patient care. Review of Staff XX’s, Temporary RN, personnel file showed she did not complete her unit-specific competency checklist. Her hire date was 01/20/26. Review of the hospital’s document titled, “Timesheet,” dated 02/02/26 through 04/04/26, showed Staff WW, Temporary RN, worked independently beginning 02/20/26. Review of Staff WW’s, Temporary RN, personnel file showed she did not complete her unit-specific competency checklist. Her hire date was 02/16/26. During a telephone interview on 04/15/26 at 10:00 AM, Staff ZZ, Physician, stated that he was not surprised staff had not completed their competency checklists prior to working independently. The competencies should be completed and verified prior to working independently. Each staff member was to have a full orientation. During an interview on 03/26/26 at 11:06 AM and 04/01/26 at 4:50 PM, Staff V, Human Resources Director, stated that the newly hired temporary staff hiring process mimicked the permanent staff process. Each temporary staff member received 40 hours of in class, general hospital orientation and then could have up to two weeks of shadowing to learn skills. There was also electronic education. The hospital preferred psychiatric (relating to mental illness) experience but had hired new graduates. All temporary staff received the same orientation, experienced or not. All staff received Handle with Care (HWC, a trauma-informed behavior management program focusing on verbal de-escalation and safe physical intervention for healthcare) training prior to their engagement in restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head). Competency was validated through a “competency packet,” which each staff member had 60 days to complete. The packet took 100 hours for a Behavioral Health Aid (BHA) to complete and 36 to 40 hours for a nurse to complete. He agreed staff should not work independently before the competency packet was completed. He stated that the hospital had an opportunity with unit specific orientation. He agreed the checklists were not in the personnel files. He assumed the staff members whose personnel files were reviewed all worked independently. He agreed that unit specific orientation checklist completion verified staff competency. The hospital required annual HWC certification and staff members with expired certification should be removed from patient care. During an interview on 03/31/26 at 10:50 AM, Staff T, Manager, stated that new hires were given two weeks of shadowing and then 60 days to complete the unit specific orientation checklist. He did not expect staff to complete the unit specific orientation checklist prior to working independently. He asked the new staff member if they felt confident if the checklist was not completed. He stated that he “did not like the process.” He believed some of the new staff were nervous and the BHAs made the unit decisions.”

“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: 47504 Based on observation, interview, record review and policy review, the hospital failed to follow their policies for medication administration for 10 current patients (#3, #10, #11, #29, #38, #49, # 51, #55, #56 and #61 ) of 19 patients observed and 12 current patients (#11, #29, #34, #35, #50, #52, #56, #57, # 60, #61, #62 and #74) of 17 medical records reviewed. These failures had the potential to result in serious injury to patients and/or staff. Findings included: Review of the hospital’s policy titled, “Medication Administration,” dated 06/2024, showed: - Nurses will check medications to be administered against the medication administration record (MAR) to ensure the correct patient, correct medication, correct dose, correct route, correct time of administration, correct documentation and correct education. - Medications must be administered within an hour before or after the specified time of administration to be considered “correct.” - Identify the patient/resident receiving medication by using at least two patient identifiers (i.e. check the patient/resident photo in the MAR, check wristband, ask patient for birth date, etc.). If necessary, other staff members familiar with the patient may verify identification. - Do not administer any medication which the parent/guardian (the person appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves) has not yet given consent to administer, unless the patient/resident presents an imminent danger to himself/herself, or others and the provider has ordered medications to be given involuntarily. The guardian is to be notified as soon as possible after the first dose is given and consent obtained for subsequent doses. - Nurses will report errors in administration of medication immediately to the provider and send an incident report to Process Improvement/Risk Management. Review of the hospital’s policy titled, “Identification, Patient,” dated 05/2025, showed: - Two unique identifiers will be used to reconfirm patient identification prior to every instance of administering medications. - The patient’s full name and date of birth on the identification band will be checked against the identifiers on the medical record to ensure proper identification. - All staff will compare the patient’s two identifiers for medication administration with the information that appears on the patient’s identification band prior to providing the care, treatment or service. Although requested, the hospital failed to provide a work order for the Two Northeast Unit barcode scanner. Observation with concurrent interview on 10/25/26 at 10:45 AM, showed Staff P attempted to administer medications to Patient #3 without scanning the patient’s identification band. Staff A, Supervisor, interrupted the medication administration process and rearranged the laptop computer with the barcode scanner and attempted to scan Patient #3’s identification band, the barcode was missing on the patient’s identification band. Staff A proceeded to scan the patient’s label at the nurses’ station. Staff P stated that the barcode scanner had been broken since 01/2026, and a work order had been entered. Observation with concurrent interview on 03/24/26 at 9:00 AM, showed Staff J scanned a patient label at the nurses’ station, scanned three oral medications, placed the medications in a medication cup, walked to Patient #10’s room and administered the medication without using two patient identifiers. At 9:10 AM, Staff J scanned a patient label at the nurses’ station, scanned three oral medications, placed the medications in a medication cup, walked to Patient #11’s room and administered the medication without using two patient identifiers. Staff J stated that the unit did not have a workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient) to scan identification bands for medication administration for patients on room restrictions. She agreed she did not verify the patient’s identification prior to the medication administration. Observation with concurrent interview on 03/31/26 at 7:35 AM Staff D co-signed a pharmacy unconfirmed medication for Patient #38 without observing the medication administration. Staff D stated that she did not witness the administration, but the computer showed the medication was scanned. During an observation on 03/31/26 at 7:31 AM, Staff EE scanned Patient #49’s label placed on a sheet of paper with each patient’s label at the nurses’ station and scanned three oral medications. Staff EE asked the patient her last name and date of birth, she did not have an identification band. During an observation on 03/31/26 at 7:37 AM, Staff EE scanned Patient #55’s label placed on a sheet of paper with each patient’s label at the nurses’ station and scanned one oral medication. Staff EE asked the patient her last name and date of birth, she did not have an identification band. During an observation on 03/31/26 at 8:29 AM, Staff EE scanned Patient #56’s label placed on a sheet of paper with each patient’s label at the nurses’ station and scanned two oral medications. Staff EE asked the patient her last name and date of birth, she did not have an identification band. During an observation on 03/31/26 at 8:45 AM, Staff EE scanned Patient #51’s label placed on a sheet of paper with each patient’s label at the nurses’ station and scanned three oral medications. Staff EE asked the patient her last name and date of birth, she did not have an identification band. During an observation on 03/31/26 at 8:52 AM, Staff EE scanned Patient #61’s label placed on a sheet of paper with each patient’s label at the nurses’ station and scanned three oral medications. Staff EE asked the patient her last name and date of birth, she did not have an identification band. During an observation on 03/31/26 at 8:55 AM, Staff EE scanned Patient #29’s label placed on a sheet of paper with each patient’s label at the nurses’ station and scanned one oral medication. Staff EE asked the patient her last name and date of birth. She did not have an identification band. During an observation on 03/31/26 at 5:52 PM, Staff EE administered clonidine (medication used to lower high blood pressure and heart rate) to Patient #61 without assessment of her blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) or heart rate (HR, the number of times the heart beats within a certain time period) prior to the administration. Patient #61’s MAR showed clonidine was to be held for a BP between 90/60 and 120/80 or a HR less than 60. Review of Patient #11’s medical record, dated 01/29/26, showed: - She was 17 years old. - On 02/06/26 at 8:51 AM, 02/07/26 at 8:16 AM, 02/15/26 at 8:11 AM, and 02/16/26 at 8:22 AM, one oral medication was given without consent. Consent was obtained on 02/23/26. - No incident reports were completed. - On 02/12/26 at 6:49 PM, four oral medications were administered one hour and 49 minutes after the scheduled time. - On 02/23/26 at 9:38 AM, four oral medications were administered one hour and 38 minutes after the scheduled time. - On 02/26/26 at 6:28 PM, four oral medications were administered one hour and 28 minutes after the scheduled time. - On 03/07/26 at 6:07 PM, three oral medications were administered one hour and seven minutes after the scheduled time. - On 03/23/26 at 9:14 AM, four oral medications were administered one hour and 14 minutes after the scheduled time. Review of Patient #29’s medical record, dated 03/16/26, showed she was 12 years old. On 03/24/26 at 9:11 AM, one oral medication was administered one hour and 11 minutes after the scheduled time. Review of Patient #34’s medical record, dated 03/13/26, showed: - She was 14 years old. - On 03/23/26 at 8:56 PM, one oral medication was administered without consent. - An incident report was not completed. - On 03/31/26 at 9:02 AM, two oral medications were administered one hour and 2 minutes after the scheduled time. Review of Patient #35’s medical record, dated 03/23/26, showed she was 13 years old. On 03/30/26 at 9:44 PM, one oral medical was administered one hour and 44 minutes after the scheduled time. Review of Patient #50’s medical record, dated 03/28/26, showed: - She was 16 years old. - On 03/28/26 at 9:04 PM, Zyprexa (medication used to treat mental disorders) intramuscularly (IM, within the muscle) was ordered and administered one time for agitation. - On 03/30/26 at 8:05 PM, two scheduled oral medications and one as needed medication were administered without guardian consent. Consent was obtained on 04/02/26. - On 04/03/26 at 12:35 PM, Zyprexa IM was ordered and administered one time for agitation. - The guardian was not notified, and consent was not obtained after the medication was administered. - No incident reports were completed. Review of Patient #52’s medical record, dated 03/30/26, showed: - She was 13 years old. - On 03/30/26 at 7:18 PM, one oral medication was administered without consent. Consent was obtained on 04/02/26. - An incident report was not completed. Review of Patient #56’s medical record, dated 03/28/26, showed, - She was 15 years old. - On 04/02/26 at 9:13 PM, one oral medication was administered, one hour and 13 minutes after the scheduled time. - On 04/06/26 at 9:11 AM, one oral medication was administered, one hour and 11 minutes after the scheduled time. Review of Patient #57’s medical record, dated 03/25/26, showed she was 15 years old. On 03/31/26 at 9:10 AM, three oral medications were administered, one hour and 10 minutes after the scheduled time. Review of Patient #60’S medical record, dated 03/25/26, showed she was 13 years old. On 03/31/26 at 9:10 AM, one oral medication was administered, one hour and 10 minutes after the scheduled time. Review of Patient #61’s medical record, dated 03/17/26, showed: - She was 14 years old. - On 03/23/26 at 9:13 PM, one oral medication was administered, one hour and 13 minutes after the scheduled time. - On 04/02/26 at 9:30 AM, four oral medications were administered, one hour and 30 minutes after the scheduled time. Review of Patient #62’s medical record, dated 03/16/26, showed she was 15 years old. On 03/30/26 at 9:03 AM, one oral medication was administered, one hour and three minutes after the scheduled time. Review of Patient #74’s medical record, dated 05/22/25, showed: - She was 12 years old. - On 05/30/25 at 6:57 PM, two oral bedtime medications were administered, one hour and three minutes before the scheduled time. - On 06/16/25 at 9:38 PM, one bedtime medication was administered, one hour and 38 minutes after the scheduled time. - On 07/06/25 at 6:45 PM, one oral medication was administered, one hour and 15 minutes before the scheduled time. During a telephone interview on 04/15/26 at 9:45 AM, Staff GG, Chief Nursing Officer (CNO), stated that he expected staff to follow all hospital policies and procedures. He expected medications to be administered within 60 minutes of the scheduled time. He expected medications were not given if consent was not obtained. He expected consent was obtained for emergency medications after the first dose. He expected documentation of attempts to obtain medication consent. He expected incident reports to be written for all medication errors. He was surprised to learn that medications were given without consent and no incident reports were written. He expected patients to be identified with two patient identifiers and their identification band. During an interview on 04/01/26 at 9:00 AM, Staff SS, Nurse Practitioner (NP), stated that patients were given the wrong medications or given medications without consent so many times it was impossible to remember, and it just kept happening. Patients were given medications without consent for three to four weeks in a row. Medications were overridden without double checking. During an interview on 04/01/26 at 9:00 AM, Staff TT, Pharmacist, stated that he expected all nurses to have basic knowledge of medication administration. He stated that the hospital had opportunities to mitigate patient harm. During an interview on 03/24/26 at 10:27, Staff K, Quality Director, stated that the WOW on the Four South Unit was recently replaced but had not been assembled and staff did not know how to use it. During an interview on 03/31/26 at 8:15 AM, Staff FF stated that sometimes when a medication was scanned it did not register. Once the medication was opened the barcode was destroyed. Staff would pull another medication from the medication dispensing machine and scan the unopened medication, administered the previously opened medication and returned the unopened medication to the medication dispensing machine. 48359”

“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: 47504 Based on observation, interview and policy review, the hospital failed to ensure: - Staff performed hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) when providing care for 14 patients (#4, #6, #7, #8, #9, #10, #11, #12, #13, #20, #37, #38, #39 and #40) of 17 patients observed. - Staff prepared a clean work surface prior to performing patient care for 14 patients (#4, #6, #7, #8, #9, #10, #11, #12, #13, #20, #37, #38 #39, and #40) of 17 patients observed. - Food items located in the kitchen refrigerator, kitchen freezer and the dry goods area were properly dated. - Expired food items were removed from the kitchen refrigerator. - Surfaces and equipment in the kitchen were properly cleaned. - The dairy cooler temperature was maintained. - Frozen meat was properly thawed out in the refrigerator. - Prepared leftover foods were properly labeled, dated and stored in the refrigerator or freezer within 30 minutes of being serving. These failures had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The hospital census was 76. The severity and cumulative effects of these systemic practices resulted in the hospital’s non-compliance with 42 CFR 482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs and resulted in the hospital’s failure to ensure quality health and safety. Refer to A-0749 for details.”

“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: 47504 Based on observation, interview and policy review, the hospital failed to ensure: - Staff performed hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) when providing care for 14 patients (#4, #6, #7, #8, #9, #10, #11, #12, #13, #20, #37, #38, #39 and #40) of 17 patients observed. - Staff prepared a clean work surface prior to performing patient care for 14 patients (#4, #6, #7, #8, #9, #10, #11, #12, #13, #20, #37, #38 #39, and #40) of 17 patients observed. - Food items located in the kitchen refrigerator, kitchen freezer and the dry goods area were properly dated. - Expired food items were removed from the kitchen refrigerator. - Surfaces and equipment in the kitchen were properly cleaned. - The dairy cooler temperature was maintained. - Frozen meat was properly thawed out in the refrigerator. - Prepared leftover foods were properly labeled, dated and stored in the refrigerator or freezer within 30 minutes of being serving. These failures had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. Review of the hospital’s policy, “Food Preparation,” dated 06/2024, showed: - Food would be properly handled to protect patients/residents from contamination. - Frozen foods, such as meat, would be thawed in the refrigerator, not at room temperature. - Foods would be stored in the refrigerator in a shallow, covered container, labeled and dated. - Pre-portioned desserts, salads, meats, sandwiches and cold foods would be stored in the refrigerator at 41 degrees Fahrenheit or lower until served. Review of the hospital’s policy titled, “Tray Audits,” dated 06/2024, showed: - Tray audits were performed to ensure safe food temperatures and infection control standards. - The dietitian or designee should perform at least one test tray audit weekly. - Cold foods were maintained at a temperature of 41 degrees F or less and hot foods were maintained at a temperature of 140 degree or greater. Review of the hospital’s policy titled, “Cleaning Procedures, Dietary 10.3.2,” revised on 06/2024 showed the nutrition service manager was to assign the responsibility of cleaning duties to kitchen staff and monitor compliance with the cleaning schedule. Staff were to clean and sanitize all workstations with an approved detergent and sanitizer, at a minimum of every four hours, or more frequently when needed. Review of the hospital’s policy titled, “Food Storage,” dated 06/2024, showed: - Food was stored in sealed containers, at appropriate temperatures to maximize shelf life. - Broken lots of bulk staples were stored in containers with tight fitting covers. - Kitchen staff should inspect the cleanliness of the area on a regular basis. Inspect the food storage area for bulging or broken containers, for spilled, spoiled or infected food, keeping the area clean and organized. Any spilled, spoiled or infected food should be immediately removed, and the area thoroughly cleaned. - The nutritional service manager should ensure that refrigeration units maintain a temperature at 34 to 40 degrees F. During concurrent observation and interview on 04/15/25 at 2:15 PM, with Staff T, Kitchen Supervisor and Staff S, Operations Manager, in the cafeteria and kitchen, showed: - The cafeteria’s milk cooler, contained 31 boxes of expired apple juice. Staff S stated that Hyland dairy staff check the cooler when they make deliveries. He was unaware if any other staff checked the coolers for expired product. He depended on Hyland dairy delivery staff. - One pack of opened flour tortillas on the countertop without an opened date or expiration date. - A large plastic container labeled parfait toppings that contained a large jug of Smucker’s raspberry syrup, one large jug of chocolate syrup, one plastic container labeled Heath bar, one plastic container labeled coconut, one plastic container labeled granola, one plastic container of M & M candy and one plastic container of chocolate chips on the counter. None of the containers were labeled with an opened or expiration date. The containers were dirty and had dried syrup on their exteriors. - One opened loaf of bread without an opened or expiration date. - Three individual sized cartons of soy milk that were warm to touch. Staff T stated they needed to be placed back into the cooler. She was unaware of how long they had been sitting out, so they should be discarded. - On the counter by the large stove, there was a large box that contained 20 closed boxes of baking soda and one opened box. It had a large water like stain on 75% of the large box. There was one opened box of baking soda that had spilled out inside the on top of the other boxes of baking soda that was dried on the boxes. The opened baking soda was without an opened date or expiration date. - Multiple containers of seasonings and dry goods located on a shelf near the stove. One large plastic container of oregano seasoning dated 11/16, an undated open taco seasoning box, one undated open box of country gravy mix, one undated open box of corn starch, two undated opened boxes of spaghetti noodles, one undated open box of pancake mix, and one unlabeled open box of brown sugar. - Two fryers containing dark brown grease, with lots of sediment within in them. The exterior of both fryers was covered in dried grease. Staff S stated that the grease was changed every two weeks and that the fryers were to be cleaned daily. Staff T agreed that the fryers appeared dirty and looked like they were not cleaned on a regular basis. - Located above the stove were undated, open containers of cinnamon, soy sauce, steak seasoning, and garden seasoning. - The freezer contained unlabeled, open bags of chicken nuggets and chicken patties laying on a shelf. The individual chicken patties were covered with an iced coating. - The cooler contained unlabeled, open bags of hamburger buns, hot dog buns, garlic bread, cookies, brownies, muffins, and plastic bags of vegetarian chicken, dated 1/25, with an iced coating on the patties. Staff T was unaware of how long the open vegetarian chicken could be stored in the plastic bags. - The fruit and vegetable cooler contained unlabeled, open boxes of celery, lettuce, tomatoes, and a plastic container of crushed berries. - The dairy cooler contained unlabeled, opened bundle of plastic wrapped sliced American cheese, an open jug of lime juice, two undated, open packages of sliced provolone cheese, an open, expired tub of blue cheese, four expired individual packs of sugar-free Jello, and two unlabeled, open jugs of barbeque sauce. - The meat and egg cooler contained an open, expired package of bologna, dated 03/18/25, an undated, open carton of Almond milk, an undated, open jug of liquid eggs and an open carton of soy milk without a lid, which leaked onto the cooler floor. The milk was no longer liquid but was a sticky film which covered the majority of the cooler floor. - Shelves outside of the coolers contained four boxes of frozen pork chops being thawed at room temperature. Staff T was unaware guidelines for thawing frozen meats. She did not know how long the pork chops had been sitting out to thaw. Staff routinely thaw frozen meats for the next meal outside of the coolers. - The dairy cooler did not have a functional thermostat, and temperatures were not being monitored. During an interview on 04/15/25 at 2:15 PM, Staff T, Kitchen Supervisor, stated that boxes and packages of food were to be labeled with the date they were received from the supplier and the manufacturer’s expiration date. The hospital did not have a standardized protocol directing staff on how to label food items once they were removed from their original boxes or packages. Refrigerated, multi-serving foods and drinks expired five days after they were opened. She did not know how kitchen staff would be aware the opened or expiration dates. There was no guidance on how items were to be labeled once opened. Kitchen staff were required to obtain food handlers certification. Her certification had been expired for several years. No one monitored staff certification. Review of the hospital document titled, “Nutrition Department Master Cleaning Schedule,” showed all equipment, counters, dishes, and pots and pans were to be cleaned on a daily basis and checked off. Documents for the months of January 2025, February 2025, March 2025, and the current month of April 2025, were blank, indicating that cleaning was not completed. During an interview on 04/15/25 at 4:30 PM, Staff S, Operations Manager, stated that he recently became the manager. He was unaware that the daily cleaning checks for equipment and workstations had not been completed for four months, that staff were required to have food handler certification, or which staff members had current certification. He did not know the policy for labeling and dating opened food items. The fryer grease was supposed to be changed out every two weeks, but the staff member that had been doing that quit his job. None of the other staff knew how to change out the grease. He was unaware that the freezer did not have a temperature gauge on it. Review of the hospital’s policy, “Standard Precautions,” dated 04/2024, showed hand hygiene was the best way to prevent the spread of infection and should be performed before and after every patient contact. All surfaces and reusable equipment should be properly cleaned utilizing hospital-grade disinfectant cleaners prior to use on another patient. Observation on 04/14/25 at 2:35 PM, Three North, showed Staff Z, RN, place Patient #7 in the seclusion room for disruptive behavior. She then obtained an order for an as needed medication, removed a Thorazine 50 mg vial from the medication dispensing cabinet, and place it on the countertop of the nursing station desk. Staff Z withdrew the medication from the vial using a syringe, placed the syringe on the countertop of the nursing station desk, applied gloves and administer the medication to Patient #7. Staff Z failed to perform hand hygiene after her initial contact with Patient #7, prior to removing the medication from the medication dispensing cabinet, or before applying gloves for administration. Observation on 04/15/25 at 8:08 AM, Three North, showed Staff Z, RN, failed to perform hand hygiene prior to removing medication from the medication dispensing cabinet for Patient #12. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #12. Hand hygiene was not performed prior to the administration of the medication. Observation on 04/15/25 at 8:12 AM, Three North, showed Staff Z, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #20. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #20. Hand hygiene was not performed prior to administration of the medication. Observation on 04/15/25 at 8:15 AM, Three North, showed Staff Z, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #37. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #37. Hand hygiene was not performed prior to administration of the medication. Observation on 04/15/25 at 8:19 AM, Three North, showed Staff Z, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #6. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #6. Hand hygiene was not performed prior to administration of the medication. Observation on 04/15/25 at 8:26 AM, Three North, showed Staff Z, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #7. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #7. Hand hygiene was not performed prior to administration of the medication. Observation on 04/15/25 at 8:32 AM, Three North, showed Staff Z, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #8. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #8. Hand hygiene was not performed prior to administration of the medication. Observation on 04/15/25 at 8:35 AM, Three North, showed Staff Z, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #38. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #38. Hand hygiene was not performed prior to administration of the medication. Observation on 04/15/25 at 8:37 AM, Three North, showed Staff Z, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #39. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #39. Hand hygiene was not performed prior to administration of the medication. Observation on 04/15/25 at 8:40 AM, Three North, showed Staff Z, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #40. She prepared the medication on the countertop of the nursing station desk, without cleaning the surface. Staff Z obtained a glass of water from the sink and placed the medication and water on the countertop. She then administered the medication to Patient #40. Hand hygiene was not performed prior to administration of the medication. Observation on 04/15/25 at 8:42 AM, Three North, showed Staff AA, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #9. She prepared the medication on the top of the WOW at the nurse’s station, without cleaning the surface. Staff AA obtained a glass of water from the sink and placed the medication and water on the countertop of the medication window. She then administered the medication to Patient #9. Hand hygiene was not performed prior to administration of the medication. Observation on 04/15/25 at 8:44 AM, Three North, showed Staff AA, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #10. She prepared the medication on the top of the WOW at the nurse’s station, without cleaning the surface. Staff AA obtained a glass of water from the sink and placed the medication and water on the countertop of the medication window. She then administered the medication to Patient #10. Hand hygiene was not performed prior to administration of the medication. Observation on 04/15/25 at 8:49 AM, Three North, showed Staff AA, RN, did not perform hand hygiene prior to obtaining medication from the medication dispensing cabinet for Patient #11. She prepared the medication on the top of the WOW at the nurse’s station, without cleaning the surface. Staff AA obtained a glass of water from the sink and placed the medication and water on the countertop of the medication window. She then administered the medication to Patient #11. Hand hygiene was not performed prior to administration of the medication. During a concurrent interview and observation on 04/15/25 at 9:25 AM, Four South, showed Staff I, RN, obtained pain medication for Patient #4 from the medication dispensing cabinet and placed it on the medication cart surface, without cleaning the surface. She proceeded to transport the medication cart from the nursing station into Patient #4’s room to administer the medications. Patient #4 was restricted to her room due to vomiting. Hand hygiene was not performed prior to entering Patient #4’s room. After administering the medication, Staff I exited the room with the medication cart without performing hand hygiene. She returned the medication cart to the nursing station without cleaning the surface. Staff I stated that hand hygiene was to be performed before and after, any patient contact. The medication carts and other muti-patient use equipment was cleaned, once a shift or when needed. Observation on 04/16/25 at 8:20 AM, Four North, showed, Staff O, RN, removed Patient #13’s medication from the medication dispensing cabinet and placed it on the medication cart surface, without cleaning the surface. She proceeded to transport the medication cart to the patient and administered the medication. After administering the medication, Staff O returned the medication cart to the nurse’s station without cleaning the surface. During an interview on 04/16/25 at 1:00 PM, Staff R, Infection Control RN, stated that, hand hygiene was to be performed before and after, each patient contact. When a medication cart was taken into a patient’s room, the nurse was expected to sanitize the cart’s surface afterwards, per policy. All surfaces were to be cleaned prior to placing medications on top of them. The countertops and medication window surface should be cleaned after each patient. During an interview on 04/17/25, Staff CC, Director of Nursing (DON), stated his expectation was for staff to follow policy on hand hygiene and cleaning surfaces in between all patient care.”