Triangle Springs

“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: 50318 Based on facility policy review, medical record review, and staff interviews, the facility staff failed to complete a face-to-face assessment within one hour after a violent physical restraint and seclusion intervention for 1 of 3 patient restraint records reviewed (Patient #8). The findings include: Review of facility policy, “Seclusion and Restraint,” effective date 02/2026, revealed, “ ... Physician/Qualified Trained RN (Registered Nurse). Conducts an in-person, face-to-face assessment of patient in seclusion/restraint within one (1) hour of initiation and documents findings on the One Hour Face-to-Face Evaluation. The face-to-face evaluation is performed even in those situations where the person is released early (prior to one hour). The Evaluation incorporates the following: Reviews, with the staff, the physical and psychological status of the patient. Determines if seclusion/restraint requires continuation. Guides staff in identifying ways to assist patient in regaining control to promote discontinuation. Provides an order if not already completed. Contacts the attending Physician or designee to review evaluation of patient ...” Closed medical record review on 03/12/2026 for Patient #8 revealed a 20-year-old patient who was admitted under IVC (involuntary commitment) on 02/20/2026 for evaluation of mania (a state of abnormally elevated energy, mood, or irritability) and psychosis (a disconnection from reality, including hallucinations, delusions, and disorganized thinking) in the context of cannabis use. On 02/24/2026, an order for physical restraint and seclusion was placed (time not specified). The physical restraint started at 2115 and ended at 2135 (20 minutes total). Seclusion started at 2159 and ended at 2257 (58 minutes total). The rationale for intervention was selected as danger to others, as the patient was climbing over the nursing station. The summary of events leading to initiation of seclusion/restraint revealed, “Patient want to use phone to call police. Patient was informed that the police should not be called and that he is on phone restriction. The patient started looking for a phone that he can reach. When he did not see a phone, he jump on the nursing station and walked on the counter. Then he jump down and hold was initiated.” Seclusion and Restraint One Hour Face-to-Face Evaluation form was completed on 02/25/2025 at 0810 (10 hours and 55 minutes after the physical hold was initiated). A checkbox for “Completed within 1 hour of intervention” was selected as “No.” The description of the patient’s response to intervention revealed, “Patient was insightful and apologetic ...” and a checkbox was selected for “Patient already out of seclusion/restraint.” Record review failed to revealed documentation of a face-to-face evaluation within an hour by a Physician or qualified trained RN. Interview on 03/13/2026 at 1158 with Director #1 revealed RN #6 called NP #7 for a telephone order for Patient #8’s restraints on 02/24/2026 at 2122. Interview revealed Supervisor #5 initiated Patient #8’s physical hold. Director #1 revealed the patient was being monitored while in seclusion by Supervisor #4, which would have been during the one hour timeframe after the physical hold was initiated. Interview revealed the face-to-face documentation was not completed by Supervisor #5 until the next morning on 02/25/2026. Interview request on 03/12/2026 and 03/13/2026 with Supervisor #5 who performed the face-to-face for Patient #8 revealed the interview was not provided by the end of the survey.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 34065 Based on facility policies review, quality data review, and staff interviews, the facility staff failed to ensure accurate tracking and reporting of the patient safety quality data related to completion of kitchen food temperature logs, emergency crash cart checks, glucometer control checks, and medication refrigerator temperature logs for the patient care floors for 3 of 3 units toured. The findings included: Review of the facility’s policy titled “Temperature Documentation” with effective date of 03/2025 revealed “Policy: Temperatures of food and all hot/cold food storage locations will be documented on a daily basis to ensure the prevention of bacterial growth. Procedures: 1. The hot/cold food storage locations will be documented twice daily. The walk in and freezer will be checked twice daily. 2. Food temperatures on the serving line will be documented prior to each meal....4. Patient refrigerator temperatures will be documented daily.... The monthly safety inspection will check to make sure temperatures are being documented and are within the proper threshold.” Review on 03/11/2026 of “Quality Council-Dietary” data of “Temperature and Sanitation Logs are completed daily” revealed December 2025 as “100%” and “January 2026” as “100%.” Review on 03/11/2026 of “Cooler” temperature logs for the month of December 2025 revealed Nine (9) of 31 days without a documented temperature. Review on 03/11/2026 of “Lowboy Cooler #2” for the month of December 2025 revealed 24 of 31 days without a documented temperature. Review on 03/11/2026 of “Freezer” temperature logs for the month of January 2026 revealed 13 of 31 days with one missing temperature each day and 6 of 31 days without a documented temperature. Review revealed 28 of 28 days not documented temperatures for the Freezer for the month of February 2026. Review on 03/11/2026 of “Lowboy Freezer” for the month of January 2026 revealed 4 of 31days with no documented temperature and 7 of 31 days with one documented temperature. Review on 03/11/2026 of “Lowboy Freezer” temperature logs for the month of February 2026 revealed 5 of 28 days without documentation of the second temperature. Review revealed 96 undocumented Cooler/Freezer temperatures December 2025 through February 2026. Review on 03/11/2026 of “Food Holding Temperature Log” of Service Line revealed no temperatures for breakfast or lunch on 01/01/2026; no documented temperatures for lunch on 01/02/2026; no documented temperatures for lunch or dinner on 01/04/2026; no documented temperatures for breakfast or lunch on 01/06/2026; and no documented temperatures for breakfast or lunch on 01/07/2026. Review revealed no documentation provided for the remainder of the month of January 2026. Interview on 03/12/2026 at 1100 with Director #1 revealed the aggregated data had been sent to the quality department. Interview revealed the Quality department was not aware of the incomplete temperature logs. Interview on 03/13/2026 at 1300 with Administration #8 revealed the staff member was not aware of the inaccurate temperature logs and quality. Interview revealed the logs should be completed per the policy. 50318 2. Review of facility policy, “Emergency Cart,” effective date 05/2025, revealed, “ ... Procedures ... D. Items on the top of Emergency Cart (AED, Suction, and Oxygen) will be checked and recorded daily for functionality. 1. The AED (Automated External Defibrillator, a portable device to deliver an electric shock for cardiac arrest) will be checked daily per manufacturers recommended steps ... H. The Emergency Cart checklists are to be preserved for a period of 3 years for each cart.” Review on 03/10/2026 of Unit A’s emergency crash cart log for March 1-10, 2026 revealed the crash cart was not checked for 4 of 10 days. Review of February’s crash cart log revealed the crash cart was not checked for 7 of 28 days. Review on 03/10/2026 of Unit B’s emergency crash cart log for March 1-10, 2026 revealed the crash cart was not checked for 2 of 10 days. Review of February’s crash cart log revealed the crash cart was not checked for 6 of 28 days. Review on 03/10/2026 of Unit C’s emergency crash cart log for March 1-10, 2026 revealed the crash cart was not checked for 6 of 10 days. Review failed to reveal an emergency crash cart log for February 2026 (28 of 28 days). Interview on 03/10/2026 at 1420 with Director #1 revealed the Director was unable to locate the February 2026 emergency crash cart log from Unit C. Interview on 03/11/2026 at 1530 with Nursing Leader #3 revealed the House Supervisors were responsible for the logs on each unit (glucometer, medication fridge, and emergency crash cart). Interview revealed there was no current plan of communication to report if the logs were not being completed, but it should be communicated to the Nursing and Quality leaders. Interview revealed the Nursing Leader had concerns with the crash carts not being checked, and the Nurses needing to use the crash carts. Nursing Leader #3 revealed they were not measuring or monitoring the completion of the logs as there had been recent staff turnover in the Quality department. Interview revealed “a lot of things” were not being monitored or measured currently. Nursing Leader #3 revealed there was not a good knowledge base with the staff for monitoring or quality improvement, and the unit manager should be monitoring the logs on each unit. 3. Review of facility policy, “Glucometer/Blood Sampling-Capillary (Finger Stick),” effective date 01/2026, revealed, “... Procedure... 5. When in use, the blood glucose meter will be monitored nightly for control solution range accuracy. Control logs (waived testing) are maintained for two (2) years ...” Review on 03/10/2026 of Unit A’s glucometer control log for March 1-10, 2026 revealed no control test for 5 of 10 days. Review of February’s glucometer control log revealed control tests were not performed for 8 of 28 days. Review on 03/10/2026 of Unit B’s glucometer control log for March 1-10, 2026 revealed no control test for 5 of 10 days. Review of February’s glucometer control log revealed control tests were not performed for 11 of 28 days. Review on 03/10/2026 of Unit C’s glucometer control log for March 1-10, 2026 revealed no control test for 6 of 10 days. Review of February’s glucometer control log revealed control tests were not performed for 11 of 28 days. Review on 03/13/2026 of data of “Medication Room- Glucometer logs up to date (including crash cart)” revealed December 2025 as “100%” and January 2026 was blank with no percentage listed. February 2026 data was not available at the time of review. Interview on 03/11/2026 at 1530 with Nursing Leader #3 revealed the House Supervisors were responsible for the logs on each unit (glucometer, medication fridge, and emergency crash cart). Interview revealed there was no current plan of communication to report if the logs were not being completed, but it should be communicated to the Nursing and Quality leaders. Interview revealed the Nursing Leader had concerns with the crash carts not being checked, and the Nurses needing to use the crash carts. Nursing Leader #3 revealed they were not measuring or monitoring the completion of the logs as there had been recent staff turnover in the Quality department. Interview revealed “a lot of things” were not being monitored or measured currently. Nursing Leader #3 revealed there was not a good knowledge base with the staff for monitoring or quality improvement, and the unit manager should be monitoring the logs on each unit. 4. Review of facility policy, “Medication & Lab Specimen Refrigerator Temperatures,” effective date 01/2026, revealed, “... Procedures 1. All medication refrigerators will be monitored two (2) times per day by assigned licensed staff. Temperature readings will be recorded on the ‘Temperature Log’ specific to each individual device and include the date/time and initials of the person recording the temperature... 7. Completed temperature logs are to be maintained in the Nursing Department for 3 years unless state/local jurisdictions require a longer period.” Review on 03/10/2026 of Unit A’s medication refrigerator temperature log for March 1-10, 2026 revealed the temperatures were not recorded twice daily per policy for 6 of 10 days, and 3 of 10 days had no recorded temperatures. Review failed to reveal a temperature log for February 1-15, 2026 (15 of 28 days). Further review revealed for February 16-28, 2 of 13 days had no recorded temperatures, and only 2 of 13 days had twice daily recorded temperatures. Review on 03/10/2026 of Unit B’s medication refrigerator temperature log for March 1-10, 2026 revealed the temperatures were not recorded twice daily per policy for 7 of 10 days, and 2 of 10 days had no recorded temperatures. Review of February’s temperature log revealed only 3 of 28 days had twice daily recorded temperatures, and 11 of 28 days had no recorded temperatures. Review on 03/10/2026 of Unit C’s medication refrigerator temperature log for March 1-10, 2026 revealed the temperatures were not recorded twice daily per policy for 8 of 10 days, and 5 of 10 days had no recorded temperatures. Review of February’s temperature log revealed only 5 of 28 days had twice daily recorded temperatures, and 14 of 28 days had no recorded temperatures. Review on 03/13/2026 of “Quality Council-Infection Control” data of “Medication Room- Refrigerator logs are up to date” revealed December 2025 as “100%” and January 2026 as “50%.” February 2026 data was not available at the time of review. Interview on 03/11/2026 at 1530 with Nursing Leader #3 revealed the House Supervisors were responsible for the logs on each unit (glucometer, medication fridge, and emergency crash cart). Interview revealed there was no current plan of communication to report if the logs were not being completed, but it should be communicated to the Nursing and Quality leaders. Interview revealed the Nursing Leader had concerns with the crash carts not being checked, and the Nurses needing to use the crash carts. Nursing Leader #3 revealed they were not measuring or monitoring the completion of the logs as there had been recent staff turnover in the Quality department. Interview revealed “a lot of things” were not being monitored or measured currently. Nursing Leader #3 revealed there was not a good knowledge base with the staff for monitoring or quality improvement, and the unit manager should be monitoring the logs on each unit.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 50318 Based on policy review, observations, and staff interviews, the facility staff failed to monitor crash carts, blood glucose equipment, and medication storage equipment to ensure safety and quality for 3 of 3 units at the facility. The findings include: 1. Review of facility policy, “Emergency Cart,” effective date 05/2025, revealed, “ ... Procedures ... D. Items on the top of Emergency Cart (AED, Suction, and Oxygen) will be checked and recorded daily for functionality. 1. The AED (Automated External Defibrillator, a portable device to deliver an electric shock for cardiac arrest) will be checked daily per manufacturers recommended steps ... H. The Emergency Cart checklists are to be preserved for a period of 3 years for each cart.” Observation on 03/10/2026 at 1054 of Unit A revealed incomplete logs for February and March 2026 of emergency crash cart logs. Observation on 03/10/2026 at 1146 of Unit B revealed incomplete logs for February and March 2026 of emergency crash cart logs. Observation on 03/10/2026 at 1157 of Unit C revealed an incomplete log for March 2026 of the emergency crash cart. Observation revealed the emergency crash cart log was missing for February 2026. Review of Unit A’s emergency crash cart log for March 1-10, 2026, revealed the crash cart was not checked for 4 of 10 days. Review of February’s crash cart log revealed the crash cart was not checked for 7 of 28 days. Interview on 03/10/2026 at 1420 with Director #1 revealed the Director was unable to locate the February 2026 emergency crash cart log from Unit C. Interview on 03/11/2026 at 1450 with Supervisor #4 revealed the House Supervisors were responsible for checking the emergency crash cart. Interview revealed the Supervisor would typically do a “basic” check, to ensure the supplies were there such as the oxygen tank and AED, but the AED was not tested daily. The Supervisor revealed that they “do the best we can to get things done,” and the Supervisor tried to test the AED weekly. The Supervisor only checked the crash cart. Interview on 03/11/2026 at 1530 with Nursing Leader #3 revealed the House Supervisors were responsible for the logs on each unit (glucometer, medication fridge, and emergency crash cart). Interview revealed there was no current plan of communication to report if the logs were not being completed, but it should be communicated to the Nursing and Quality leaders. The Nursing Leader revealed the AEDs should be checked and tested daily. Interview revealed there were concerns with the crash carts not being checked, and the Nurses needing to use the crash carts. 2. Review of facility policy, “Glucometer/Blood Sampling-Capillary (Finger Stick),” effective date 01/2026, revealed, “ ... Procedure ... 5. When in use, the blood glucose meter will be monitored nightly for control solution range accuracy. Control logs (waived testing) are maintained for two (2) years ...” Observation on 03/10/2026 at 1054 of Unit A revealed incomplete logs for February and March 2026 of the glucometer (blood glucose monitor) control log. Observation on 03/10/2026 at 1146 of Unit B revealed incomplete logs for February and March 2026 of the glucometer control log. Observation on 03/10/2026 at 1157 of Unit C revealed incomplete logs for February and March 2026 of the glucometer control log. Review on 03/10/2026 of Unit A’s glucometer control log for March 1-10, 2026 revealed no control test for 5 of 10 days. Review of February’s glucometer control log revealed control tests were not performed for 8 of 28 days. Interview on 03/11/2026 at 1450 with Supervisor #4 revealed the medication nurse for each unit checked the glucometer, and the Supervisor only checked the crash cart and medication fridge. Interview on 03/11/2026 at 1530 with Nursing Leader #3 revealed the House Supervisors were responsible for the logs on each unit (glucometer, medication fridge, and emergency crash cart). Interview revealed there was no current plan of communication to report if the logs were not being completed, but it should be communicated to the Nursing and Quality leaders. The Nursing Leader revealed the AEDs should be checked and tested daily. Interview revealed there were concerns with the crash carts not being checked, and the Nurses needing to use the crash carts. 3. Review of facility policy, “Medication & Lab Specimen Refrigerator Temperatures,” effective date 01/2026, revealed, “ ... Procedures. 1. All medication refrigerators will be monitored two (2) times per day by assigned licensed staff. Temperature readings will be recorded on the ‘Temperature Log’ specific to each individual device and include the date/time and initials of the person recording the temperature ... 7. Completed temperature logs are to be maintained in the Nursing Department for 3 years unless state/local jurisdictions require a longer period.” Observation on 03/10/2026 at 1054 of Unit A revealed incomplete logs for February and March 2026 of medication refrigerator temperature control log. Observation on 03/10/2026 at 1146 of Unit B revealed incomplete logs for February and March 2026 of medication refrigerator temperature control log. Observation on 03/10/2026 at 1157 of Unit C revealed incomplete logs for February and March 2026 of medication refrigerator temperature control logs. Review on 03/10/2026 of Unit A’s medication refrigerator temperature log for March 1-10, 2026 revealed the temperatures were not recorded twice daily per policy for 6 of 10 days, and 3 of 10 days had no recorded temperatures. Review failed to reveal a temperature log for February 1-15, 2026 (15 of 28 days). Further review revealed for February 16-28, 2 of 13 days had no recorded temperatures, and only 2 of 13 days had twice daily recorded temperatures. Review on 03/10/2026 of Unit B’s medication refrigerator temperature log for March 1-10, 2026 revealed the temperatures were not recorded twice daily per policy for 7 of 10 days, and 2 of 10 days had no recorded temperatures. Review of February’s temperature log revealed only 3 of 28 days had twice daily recorded temperatures, and 11 of 28 days had no recorded temperatures. Review on 03/10/2026 of Unit C’s medication refrigerator temperature log for March 1-10, 2026 revealed the temperatures were not recorded twice daily per policy for 8 of 10 days, and 5 of 10 days had no recorded temperatures. Review of February’s temperature log revealed only 5 of 28 days had twice daily recorded temperatures, and 14 of 28 days had no recorded temperatures. Interview on 03/10/2026 at 1420 with Director #1 revealed the Director was unable to locate the medication refrigerator temperature log from Unit A for February 1-15, 2026. Interview on 03/11/2026 at 1450 with Supervisor #4 revealed the House Supervisors were responsible for checking the medication fridge temperature. The Supervisor revealed that they “do the best we can to get things done”. The Supervisor revealed the medication nurse for each unit checked the glucometer, and the Supervisor only checked the crash cart and medication fridge. Interview on 03/11/2026 at 1530 with Nursing Leader #3 revealed the House Supervisors were responsible for the logs on each unit (glucometer, medication fridge, and emergency crash cart). Interview revealed there was no current plan of communication to report if the logs were not being completed, but it should be communicated to the Nursing and Quality leaders. The Nursing Leader revealed the AEDs should be checked and tested daily. Interview revealed there were concerns with the crash carts not being checked, and the Nurses needing to use the crash carts.”

“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: 34065 Based on observations, review of policies, personnel files and staff interviews, the hospital’s infection control program failed to ensure annual screening for Tuberculosis of established employees working current assigned shifts in 2 of 13 employeess of personnel files reviewed. The findings included: Observation on 03/11/2026 at 1210 of the dietary department revealed Dietary Aide #10 working at the sandwich area assembling sandwiches for the patients. Review of policy titled “Employee Health Program” with effective date of October 2025 revealed “Purpose: To establish a Health Program that promotes health and safety for healthcare personnel and reduces risk of transmission of communicable or infectious illness. Scope of Policy: All employees, all Licensed Independent Practitioners, and all unpaid personnel. Policy: The Facility will perform health evaluations of all hospital/outpatient employees and TB (Tuberculosis--a contagious often severe infection primarily affecting the lungs. It is curable with antibiotics but requires long term antibiotics) screening for ICs and Unpaid Personnel, to ensure a safe environment for all. A health record including a health screen, urine and drug screen, tuberculosis screen, immunizations, and respirator fit-testing as required by their position will be maintained by the Employee Health Nurse. Tuberculosis (TB) Screening: 1. All hospital/outpatient employees and IC (Independent Contractors--such as Physicians, Physician assistants) will submit to TB screening Test and complete a TB Symptom Questionnaire prior to working at the facility....3. All HCP (Health care Personnel) will complete a TB Symptom Questionnaire annually thereafter, unless additional testing is indicated. 1. Review on 03/13/2026 of personnel file for Dietary Aide #10 with a hire date of 12/4/2023 revealed no TB screen documented during December 2025 screening review. Review of current staffing schedule revealed Dietary Aide #10 had worked eighteen (18) shifts since February 16, 2026. 2. Review on 03/13/2026 of personnel file for Therapist #11 with a hire date of 10/29/2022 revealed no TB screen documented during December 2025 screening review. Review of current staffing schedule revealed Therapist #11 had worked 20 shifts during the entire month of February 2026. Interview on 03/13/2026 with HR Director #12 revealed all employees should have a TB screening documented in the personnel file. Interview revealed the policy was not followed. NC00227985; NC00236066; NC00234203; NC00231418; NC00230589; NC00226687; NC236177; and NC00232762”