Mountainview Behavioral Hospital

“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: 38289 Based on observation, medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure the protection and promotion of patient rights. Cross Reference: 482.13: Condition: Patient Rights”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38289 Based on observation, medical record review, staff interviews, and review of facility documents, it was determined the facility failed to ensure that: 1) patient’s health information is protected (A0143); 2) a safe environment free of ligature risks and environmental hazards is maintained (A0144); and 3) patients placed in restraints, physical hold, or seclusion are under the order of a provider, and a face-to-face assessment is completed by a provider (or trained designee) within one hour, in accordance with facility policy (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patients. An IJ was identified on 12/17/25 at 3:30 PM, for the facility’s failure to keep a safe environment that was free of ligature risks and environmental hazards. The IJ template was presented to the facility administration on 12/17/25 at 4:13 PM, and a removal plan was received on 12/19/25 at 12:14 PM. The facility immediately removed ligature risks and environmental hazards and provided re-education to staff on the identification of ligature risks. The State Agency (SA) verified the immediate interventions were implemented and the IJ was resolved. A second IJ was identified on 12/19/25 at 2:38 PM, for the facility’s failure to secure a physician order when a patient was placed in restraints in accordance with facility policy. The IJ template was presented to the facility on 12/19/25 at 4:05 PM, and a removal plan was received on 12/22/25 at 11:50 AM. The facility immediately provided re-education to staff on the policy and procedure when a patient is placed in restraints. The SA verified the immediate interventions were implemented and the IJ was resolved. Cross Reference: 482.13(c)(1) Patient Rights: The Patient has a Right to Privacy 482.13(c)(2) Patient Rights: Care in Safe Setting”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 38289 Based on observation, staff interview, and review of facility documents, it was determined the facility failed to ensure that a patient’s protected health information is kept private for nine of 20 patient medical records reviewed (Patient (P)2, P7, P8, P10, P11, P12, P13, P19, and P20). Findings include: On 12/17/2025 at 11:40 AM, a tour was conducted of the East Side Unit. The unit did not have any patients, and housekeeping staff was observed cleaning the floor in front of the nurse’s station. At the nurse’s station, the following was observed: A patient identification bracelet found in a drawer for P19 that included information such as date of birth, admission date, attending physician, unit and room number. A patient identification bracelet found in a second drawer for P20 that included information such as date of birth, admission date, attending physician, unit and room number. An open box under the Nurse’s Station desk that contained portions of medical records of patients such as: Transfer Form to another facility and discharge Information Form of P7; patient labels that included information such as date of birth, admission date, attending physician, unit and room number for P12 and P13; The signed “Important Message from Medicare about you Rights” form for P8; The “Order Summary Report” for P2; The “Discharge Coordinator Progress Note” for P10; The medical record of P11; and a list of the patients (full names) with weight and room number for the following dates: 4/16/25, 4/23/25, 5/21/25, 6/25, 9/10/25, and 10/15/25. At 11:50 AM, Staff (S)2 and S3 presented themselves at the East Side Nurse’s station. S3 stated that the East Side is currently closed for patients, but is used as an overflow from the West Side. S3 further stated that the East Side had been used as recently as “a couple of weeks ago” and in September and October of 2025. The above findings were shared with S2 and S3. S3 stated that the process for when a unit closes, is that a sweep should be completed on the unit to ensure items are not left behind, including patient items and documents that include protected health and patient personal information. S3 confirmed that the documents located in the box were meant to be destroyed and not left behind. S2 stated that the leaving of the documents “must have been an oversight.” When S2 and S3 were asked who was designated to completed the task of sweeping the unit, both S2 and S3 were unable to provide an answer. S3 was asked to provide the policy and or process in place for the closure of the unit to ensure personal items and patient information are not left behind. S3 was unable to provide evidence or documentation of a policy or process in place. Facility policy titled, “Closed Medical Records: Access, Release, and Retention,” stated, “... Information contained in the patient’s medical record is privileged communication and shall remain confidential between patient and clinician. The medical record shall be protected against loss, destruction, unauthorized access and disclosure ...” N.J.A.C. 8:43G-4.1(a)(21)”

“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: 47131 Based on observation, medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure 1) a safe environment free of ligature risks and environmental hazards; and 2) patients placed in restraints, physical hold, or seclusion are under the order of a provider, and a face-to-face assessment is completed by a provider (or trained designee) within one hour, in accordance with facility policy for four of four medical records reviewed of patients in restraints (Patient (P)10, P14, P15, and P20). Findings include: 1. On 12/17/25, a review of the facility’s document titled, “Safety and Risk Assessment” dated 7/9/25, stated, “ ... Compliance Rate 100% ... 1. Design, Construction, and Operation-General ... 1.2 Is all furniture designed with rounded rather than sharp edges? ... Yes ... 1.6. All areas are constructed to prevent suspension latch points, either enclosed or incapable of bearing weight. (ceiling, light fixtures, doors, sprinklers, towel bar, hardware, etc.) ... Yes ... 2. Design and Construction- Patient Rooms ...2.12.1 All areas are constructed to prevent suspension latch points, either enclosed or incapable of bearing weight. (ceiling, light fixtures, doors, sprinklers, towel bar, hardware, etc.) ...Yes ... 2.13. Are all beds constructed and maintained to prevent it or its components from being a hazard. ...Yes ...” On 12/17/25 at 11:14 AM, a tour of Mountainview [MV]-West Unit was conducted in the presence of Staff (S)3. It was confirmed that MV-West was a 24-bed-unit with a current patient census of 16. Upon interview, S7 stated that EOC (Environment of Care) Rounds are conducted twice per day, once at 2:00 PM and once at 9:00 PM. S7 stated that the EOC rounds were conducted by IAs (Institutional Aides) and any concerns discovered are reported to the charge nurse. S7 confirmed that there was no environmental concerns reported that day. During the tour of the West Unit, the following safety/ligature risks were identified: Twenty-four of 24 beds with ten metal loops attached to the frame (three metal loops on the left side, three metal loops on the right side, two metal loops at the foot of the bed and two metal loops at the head of the bed). Upon interview, S3 stated that patients are permitted to sleep in the room with the door closed. At the time of discovery, S3 confirmed that patients could use the metal loops on the beds as ligature points. Twenty-four of 24 bed frames with four adjustable legs located on the bottom of the bed frame. Upon interview, S3 confirmed that patients could use the legs on the bed as a ligature point. Twenty-four of 24 patient bed mattresses with exposed zippers creating a self-harm risk. Patient Room CW-76, was unoccupied and unlocked, contained linens and towels that were accessible to patients. S7 confirmed that all unoccupied patient rooms were to be locked. At 11:22 AM, S7 confirmed there were no patients assigned to Room CW-76, and further stated that once a patient is discharged, the housekeeper will be notified, who will sanitize the room, and make the bed with linens so it is ready to be used for the next patient. S7 confirmed that linens and towels are not permitted to be in unoccupied patient rooms to avoid patients being able to stockpile linens and towels. At 11:35 AM, S8 was observed entering Room CW-76 which had linens and towels on the bed. Once S8 exited the room, he/she confirmed it was clean and ready for the next patient. S8 walked away from the room and left the door open and unlocked with the linens and towels in the room. Two patient restrooms located in Room CW-60 and CW-74, had an over-the-sink light fixture, mounted with a metal frame which posed a ligature risk. Patient Room CW-60 had a metal conduit over the door frame with a gap that posed a ligature risk. The communal Shower Room contained one shower chair. The community female bathroom contained one shower chair. Both shower chairs had anchor points which posed a ligature risk. At 11:37 AM, during an interview, S9 confirmed that patients are not supervised while using the community shower/bathrooms. S9 further stated that the shower/bathrooms are locked during the weekdays and staff would let the patients in unsupervised. S9 stated on the weekends and holidays, they are kept unlocked for patients to use whenever they want, unsupervised. The bathroom in the Seclusion Room contained a mounted metal paper towel holder with a metal frame with a gap that created a ligature point. At the time of discovery, S3 confirmed patients could use the metal frame as a ligature point. The bathroom in the Seclusion Room had a trash can with a plastic bag, which created a self-harm/ligature risk. At 2:31 PM, upon interview, S16 stated that the bathroom was only used by patients who are in seclusion and further stated that female patients were allowed to close the door while using the bathroom. S16 indicated housekeeping was responsible for putting the plastic bags in the trash can. S3 confirmed plastic bags were not allowed in patient areas. The above findings were confirmed with S3 on 12/17/25 at 4:13 PM. On 12/18/25, a tour was conducted of the MV-East Unit. Not all rooms were able to be observed due to being locked. The following safety/ligature risks were identified in the rooms observed: Fourteen of 14 beds in Room E020, E021, E027, E028, E029, E030, and E038 had 10 metal loops attached to the frame (three metal loops on the left side, three metal loops on the right side, two metal loops at the foot of the bed and two metal loops at the head of the bed). Fourteen of 14 bed frames in Room E020, E021, E027, E028, E029, E030, and E038 had four adjustable legs located on the bottom of the bed frame. Five of five patient bed mattresses in Room E020, E029, and E038 had exposed zippers which posed a risk for self-harm. Twelve of 14 light fixtures in Room E020, E021, E027, E028, E029, E030, and E038 had light fixtures with metal brackets which posed a risk for self-harm. One patient restroom located in Room E027 had a cracked light fixture which posed a risk for self-harm. One wooden bed frame located in Room E029 was cracked posing a risk for self-harm. Three patient restrooms located in Rooms E027, E028, and E029 had light fixtures that were not slanted which posed as a ligature risk. Two heater control panel doors in Room E021 and E029 were unlocked which posed a risk for self-harm. Room E035 had one picture frame secured to the wall by screws, one corner was not secured to the wall which created a gap and posed as a ligature risk. On 12/18/2025 at 11:14 AM, upon interview, S3 explained the facility is capping at 24 patients, which is the capacity for the MV-West unit. S3 stated, we do not plan to take admissions for the MV-East unit, we plan to remodel the unit, once it’s remodeled, we plan to admit patients, then remodel the MV-West unit. N.J.A.C. 8:43G-26.2(a)(2) 2. Facility policy titled, “Restraint/Seclusion For Behavioral Management: Special Treatment Procedures” revised 5/25, stated, “Definition: ... Physical Hold: Holding a patient in a manner that restricts the patient’s movement against the patient’s will is considered a restraint. Physical holds should not exceed 10 minutes ... Physical Hold: Use of Physical Hold Physical hold may only be used in an emergency situation and is considered a restraint. ... The nurse will document the need for physical hold on the Restraint/Seclusion Physician’s Order (Form 213.014B). ... Ordering Restraints/Physical Hold or Seclusion Registered Nurse ... A Registered Nurse will notify the Licensed Independent Practitioner of emergency restraint/physical hold or seclusion as soon as possible following initial intervention. ... Physician/LIP [licensed independent practitioner] or trained RN/PA [Registered Nurse/Physician Assistant] The Physician/LIP or RN/PA will respond to the bedside within one hour to complete a face-to-face assessment of the patient. The face-to-face assessment will include, but is not limited to, the situation, the patient’s reaction to the restraint/physical hold or seclusion, the patient’s condition, and the need to continue or discontinue the restraint/seclusion. If the face-to-face assessment is performed by a trained designee, they must consult the ordering Physician/LIP or attending LIP as soon as possible with within two hours of the evaluation. ... Each restraint/physical hold or seclusion event requires a one-hour face-to-face assessment and a LIP order and documentation. ... A restraint/physical hold or seclusion order must include: a. Documentation on the Mountainview Restraint/Seclusion Physician’s Order (Form 213.014B); b. Date and time; ... e. Identification of type of restraint/seclusion required ...” On 12/19/25 at 12:35 PM, during an interview, S13 confirmed that staff were expected to complete a Restraint/Seclusion Physician’s Order Form any time a patient is placed in a physical hold, restraints, or seclusion. A review of the “Restraint On 12/18/25, a review of the “Restraint Log 2025” indicated that on 10/23/25, P10 was placed on Seclusion for a total of 155 minutes. Upon review of P10’s medical record, the “Restraint/Seclusion Physician’s Order Form” dated 10/23/25 at 7:50 PM, stated, “ ...Type of Restraints/Seclusion: ... Seclusion [check-marked] ...Ordering Physician: [printed name] Date 10/23/25 & Time 8:10 PM LIP was contacted [check-marked] Verbal/Telephone order ...Signature: [blank] Date: [blank] Time: [blank] (If not onsite during the episode the ordering Physician/LIP must sign the order as soon as possible) ...” P10’s medical record lacked documented evidence of a provider signature for a seclusion order, and a face-to-face assessment within one-hour on 10/23/25. A review of the “Restraint Log 2025” indicated that on 09/30/25, P14 was placed on a physical hold for three minutes. On 12/19/25, upon request of the Restraint/Seclusion Physician’s Form with LIP orders for P14 to be placed in a physical hold on 09/30/25. S13 confirmed there was no form completed for the physical hold in accordance with the facility’s Restraints policy. P15 was placed in restraints on 10/29/25 at 4:25 PM. Upon medical record review, the “Restraint/Seclusion Physician’s Order Form” completed by S7 stated, “Ordering Physician: [name]; Date: 10/29/25; Time: 4:25 PM ...Verbal/Telephone order ... [LIP] Signature: [blank] Date: [blank]; Time: [blank] (If not onsite during the episode the ordering Physician/LIP must sign the order as soon as possible) ...RN Initials [Initials]; RN Signature [signature]; Date: 10/29/25; Time: 4:25 PM ...” S13 confirmed the restraints order was not signed in accordance with the facility’s Restraints policy. On 12/18/25, a review of the “’Restraint Log 2025” indicated that on 11/19/25, P18 was placed on a “Hold” for a total of 5 minutes. Upon review of P18’s medical record, the Nursing Progress Note dated 11/19/25 at 7:07 PM stated, “ ...7:pm [sic], At this time, patient started to verbally attacking staff, loud speaking, shouting at staff, calling staff names. Behavior remain delusional, irritable, anxious, agitated and angry. Patient refused PO [by mouth] medications. Patient was physically assisted by staff to [his/her] room. IM [intramuscular] Zyprexa 10mg [milligrams] given at this time with physical hold lasting for 5 minutes. ...” P18’s medical record lacked documented evidence of a provider order for physical hold, and lacked a face-to-face assessment within one hour on 11/19/25. On 12/19/25 at 11:22 AM, an interview was conducted with S6, who confirmed a face-to-face assessment should be completed by a provider within one hour of a patient being placed in restraints or seclusion. S6 indicated he/she did not think a physical hold required an order from a Physician/LIP. S6 stated, “if a physical hold is over ten minutes, then it’s a restraint.” On 12/19/25 at 1:00 PM, upon interview, S13 indicated restraints and seclusion require an order from a Physician/LIP. S13 stated that they were unsure if a face-to-face assessment was required within one hour for patients in seclusion. S13 confirmed a face-to-face assessment is required for patients in restraints or physical hold. On 12/19/25 at 4:05 PM, the above findings were confirmed with S3, S4, S17, and S18. N.J.A.C. 8:43G-26.2(b) 48414”

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 48913 Based on observation, medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure that a process is in place concerning the handling of patient specific medications for patients who are discharged from the facility. policies and procedures that address returning of patient specific medications to the pharmacy or destroying them after patient is discharged, are developed and implemented. Findings include: On 12/17/25 at 10:55 AM, a facility tour was conducted of the Mountainview East Unit in the presence of Staff (S)1. The Medication Room located on the Mountainview East Unit was inspected. The following medications specific to Patient (P)2 were found stored in the medication refrigerator: One bag labeled for P2 containing 10 ml (milliliter) solution of Lantus injection (an insulin to lower blood sugar) dated 10/12/25 and one bag labeled for P2 containing 3 ml of Lantus Solostar Pen (a prefilled injector) dated 11/16/25. Review of medical record for P2 indicated that P2 was discharged from the facility on 12/12/25. On 12/17/25 at 1:00 PM, the policies and procedures addressing returning patient specific medications to the pharmacy once patient is discharged, was requested from S1. On 12/19/25 at 10:00 AM, S3 provided a policy titled, “Returned medications to the Pharmacy and Credits.” Upon review, the policy failed to include the process of returning medication to the pharmacy once a patient has been discharged from the facility. On 12/18/25 at 1:45 PM, upon interview, S1 confirmed the above findings and stated that the medications should have been returned to the pharmacy and not available for use in the medication room once a patient has been discharged from the facility. S1 stated that Mountainview East unit was currently not patient-ready on the day of the survey. S1 further stated that there were patients on the East Unit in November, however he/she was not sure of the exact dates. N.J.A.C. 8:43G-23.6(d)”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 48913 Based on observation, staff interview, review of manufacturer’s instruction for use (MIFU), and review of facility documents, it was determined the facility failed to ensure that expired items are removed from the active inventory in accordance with facility policy. Findings include: Facility policy titled, “Storage of Medications and Use of Multidose Vials,” dated 01/25, stated, “ ... G. Drugs shall not be kept on hand after the expiration date on the label, and no contaminated or deteriorated drugs shall be available ...” On 12/17/2025 at 10:50 AM, a facility tour was conducted in the presence of Staff (S)1. The Medication Room located on the Mountainview East Unit was inspected and the following expired items were found stored and available for patient use: An opened vial of Aplisol (Tuberculin Purified Protein Derivative) was found labeled with open date of 11/13/2025. At 11:00 AM, upon interview, S1 confirmed this finding and stated that the Aplisol vial should have been discarded 30 days after it was opened. The MIFU for Aplisol (Tuberculin Purified Protein Derivative) vial stated, “ ... Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency ...” Two boxes of EvenCare Glucose Control Solutions with an expiration date of 11/02/2025. One box of Novofine Pen needles with an expiration date of 11/30/2025. On 12/17/2025 at 11:05 AM, S1 confirmed the above finding and stated that the staff should check consistently for outdated drugs and supplies before administering them to patients. S1 further stated that Mountainview East unit was currently not patient-ready on day of the survey, and the facility will remove all expired medications and supplies before admission of patients to this unit. N.J.A.C. 8:43G-23.6(i)”

“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: 39724 Based on observation, staff interview, and facility document review, it was determined the facility failed to ensure that emergency equipment, such as an Automated External Defibrillator (AED) is available and maintained in accordance with facility policy. Findings include: Facility policy titled, “AED/Defibrillator/Monitor - Testing and Maintenance” last revised 07/25, stated, “... To ensure full capability of equipment, in power pack and battery pack mode during a medical emergency and to test the functioning ability of the equipment ... Daily, the assigned licensed nurse will complete a visual inspection, and check that the battery is charging from the power pack, then record findings on the ‘AED/Defibrillator/Monitor: Testing & [and] Maintenance Checklist Form’ ... The AED/Defibrillator/Monitor: Testing & Maintenance Checklist must be turned in on the first day of every month to the ADON [Assistant Director of Nursing] ...” On 12/17/25 at 11:05 AM, in the East Unit Treatment Room with Staff (S)1 and S3, a blue metal cart was observed which contained various airway supplies. Upon interview, S1 confirmed that the cart was not a code cart. S3 confirmed that the East unit lacked a code cart or AED and stated that the unit was not patient ready on the day of survey. At this time, S1 and S3 confirmed that the East Unit was used by patients in November, however they did not have the exact dates. The AED daily inspection logs for the East Unit were requested at this time as they were not present in the Treatment Room. On 12/22/25 at 11:14 AM, S3 confirmed that the East Unit was occupied by patients from 11/12/2025 to 11/19/2025. The AED daily inspection logs for the East Unit were requested again at this time. S3 stated that the AED that was on the East Unit may have been moved upstairs to be used when the East Unit closed, but S3 was unsure. On 12/22/25 at 12:30 PM, S3 confirmed that the facility did not have the inspection logs for the AED from the East Unit, as required by facility policy. It could not be determined if the facility had an AED on the East Unit for use in emergencies when patients were present. N.J.A.C. 8:43G-18.2(a)”

“Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This Standard is not met as evidenced by: 33557 Based on observation and staff interview, it was determined that the facility failed to ensure all exit discharges lead to the public way. Findings include: On 12/17/25 at 11:30 AM, in the presence of Staff (S)5, the Exit Discharge from the West Unit Activity/Dining Room did not lead to the public way. The path of egress was identified with a lit Exit Sign which directs occupants out the glass door and onto a patio. A locked metal gate is located at the end of the patio. An approximate twenty-four inch vertical drop is located on the non-egress side of the metal gate. No steps exist to allow occupants to egress down to the paved driveway below from the patio. During an interview, S5 stated, “Its an exit, just not a fire exit.””