Sunrise Vista Health and Wellness

“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: 35765 Based on record review, interview and policy review, the facility failed to ensure hot water was an appropriate temperature to prevent second-degree burns. This affected two patients (Patients #14 and #18 ) of 20 patient records reviewed. The facility census was 65. Findings include: 1. Review of the medical record revealed the Patient #14 was admitted to the facility from the hospital on 12/24/25 and was discharged on 12/31/25. Admitting diagnoses included schizoaffective disorder bipolar type, auditory hallucinations, anxiety, suicidal ideation, hypertension, seizures, and hypothyroidism. Patient #14 was admitted to the emergency room after making statements of wanting to hurt herself. She was going to take a knife and stab herself. She indicated she had been awake for days with racing thoughts and she had not been eating. She had poor hygiene, was agitated, had feelings of sadness and hopelessness. Review of the Doctor’s Note dated 12/25/25 at 5:25 P.M. revealed Patient #14 had a scald injury to the left buttock, superficial, less than one percent. Local skin care. Review of the concern log dated 12/25/25 revealed Patient #14 had been in the shower sometime between 12/24/25 to 12/25/25 and stated she was burned. It was uncertain what time this happened or how long she was in the shower. Due to the potential temperature, she had burns on her buttocks that started as first degree burn and has sloughed off on one side and had a large, reddened area on the other. The medical team was consulted when nursing was notified, and they saw her the same day. This was listed as a ruptured blister and was a relatively small area. On 12/28/25 a call was received where the charge nurse reported that the burn had worsened and that medical was seeing her again. They documented this as a large hyperpigmented vesicle without drainage. Patient #14 was ordered Silvadene twice daily for wound care. Review of the Doctor’s Note dated 12/28/25 at 3:43 P.M. revealed Physician Staff Z was asked to see Patient #14 for burns to her buttocks from hot water in the shower which occurred four to five days ago. The assessment determined she had second degree burns to her buttocks. New order for Silvadene cream twice daily. Review of the concern log dated 12/29/25 at 6:50 P.M. revealed at 4:50 P.M. the nurse spoke with Nurse Practitioner (NP) Staff Y regarding the wound. NP Staff Y had seen the wound on the first day that it was recognized and encouraged her to view the uploaded pictures. She stated it appeared to be a lot more advanced than when she had seen it last. She advised consulting with medical and explaining the extent if the wound to see if they would like her to be sent out for additional evaluation. At 5:30 P.M., medical recommended she be sent to the hospital non-emergent to be evaluated, intake was called, and transport was arranged for 6:35 P.M. Patient #14 requested her responsible party be notified. She left with emergency medical service at 6:55 P.M. Review of the Plumbing Company Service report dated 12/30/25 revealed the water temperature in the shower was 140 degrees Fahrenheit (F). They replaced the mixing valve and had to repair the piping. The temperature was set on new mixing valve. Review of the Plumbing Company Service report dated 12/31/25 revealed the water temperature in the shower was 140 degrees F. The temperature was checked in multiple rooms, and they found a ball valve needed installed on one of the hot water circulating lines. They would be back the next day to add the valve. Review of the Plumbing Company Service report dated 01/02/26 revealed the water temperature in the shower was 140 degrees F. They added a new ball valve on the hot water circulating line, checked temperatures on mixing valve, and everything was working properly now. Review of the Incident Summary and Review, undated, revealed on 12/24/25 Patient #14 refused her initial skin assessment. Patient #14 experienced a fall prior to being transferred to another unit however, there was no documentation indicating a full skin assessment was completed following the fall. On 12/25/25 at approximately 5:00 A.M. a reaction/burn was initially noted. Patient #14 was observed running in the hallway without clothing and redness was noted to the buttocks by NP Staff Y. Patient #14 reportedly placed herself on the dayroom floor and made statements referencing her buttocks, Patient #14 was on one-on-one observations on 12/25/25 from 3:27 P.M. until 12/26/25 at 12:00 P.M. Four injections of Haldol were administered on this date, which may have contributed to the worsening of the skin condition. From 12/26/25 through 12/29/25, shift assessments for 7:00 P.M. to 7:00 A.M. were signed off by a Licensed Practical Nurse (LPN), which was against policy. Daily assessment and skin assessments must be completed by the Registered Nurse. Nurses denied patient reported any pain during this time period. On 12/28/25 the physician evaluated the patient and documented that the wound had progressed to a second-degree burn, described as a large hyperpigmented vesicle without drainage. On 12/30/25 Patient #14 reported pain for the first time, rating it an eight on a one to ten scale. Nursing staff observed the wound to be worse than previously documented, wound was dressed, nursing staff consulted with the Emergency Room physician at hospital, patient was transferred to hospital for further evaluation, Silvadene cream used was identified as excessive, treatment frequency was reduced, and patient was placed on oral antibiotics. From 12/30/25 through 12/31/25 Patient #14 was evaluated daily, wound care adjusted to leave the area more open to air and nurses educated to rotate the patient for back to side, new tissue formation noted, no signs of infection observed, progressive wound photographs initialed and documented daily in progress notes. Medical review revealed the burns assessed as first degree and later progressed to second degree. It was very unlikely that Midazolam and Benadryl caused the burn, injections of Haldol were administered in the arm per documentation not in the affected area, multiple falls had occurred with no documentation post fall skin assessments, one might have been done by an LPN not an RN which was against hospital policy. It was noted in a progress note that the burns may have resulted from shower water exposure, and the facility identified an issue with shower temperature regulation and pump functionality. Documentation and process concerns were identified as followed: failure to document skin findings on 12/25/25, incident report was not completed until 12/29/25 when Nursing Manager Staff A assessed the patient, delay in notification of leadership and medical team, RN daily assessments and skin assessments were improperly completed by an LPN, Patient refusal of skin checks did not consistently trigger enhanced monitoring protocols which was one-on-one, and the patient’s medical records were released to the family prior to consultation with legal counsel. During an interview on 02/10/25 at 10:24 A.M., Nurse Manager Staff A revealed there was no documentation indicating Patient #14 had refused her initial skin assessment as documented in the facility investigation. She verified there was no documentation of a treatment being provide to the burns to Patient #14 buttocks from 12/25/25 to 12/28/25, a LPN performed the skin assessments on Patient #14 even though facility policy indicated all assessments were to be completed by a Registered Nurse. The LPN never notified the Registered Nurse that Patient #14 had a wound that needed assessed and there was no incident report completed until 12/29/25 after she was notified of the incident. Nurse Manger Staff A stated she was not made aware of the incident until 12/29/25 due to being off for Christmas. She stated the responsible party of Patient #14 came to the facility on 12/29/25 very upset about her burns and the lack of medical care provided and demanded she be sent to the hospital. She stated she took pictures on the wound and they sent her out to the hospital, but she came back to the facility the same day. During an interview on 02/10/26 at 4:30 P.M., Director of Plant Operations Staff L revealed after he was notified that Patient #14 had gotten burned he had a plumber come out to the facility to see what was wrong. He stated the reason the water was so hot was because the mixing valve had gone bad causing the water to not regulate properly. He stated it was never installed properly. He stated he was then informed that another patient got burned in the shower, so he had the plumber come out again and they found another issue that had to be fixed. He stated everything was fixed now concerning the water temperature however they still had to replace the pipes. He stated he completed weekly water checks in random rooms, and he had not had any concern with the water being too hot and they mixing valve was set at 108 degrees F. 2. Review of the medical record revealed Patient #18 was involuntarily admitted to the facility on 12/27/25 with an admitting diagnosis of physical harm to herself and not providing for her own basic needs. She was discharged on 01/05/26 to home. Review of the Nursing Progress note dated 12/31/25 at 11:03 A.M. revealed Patient #18 was laying in the shower and refused to get up. Her left arm was reddened from her upper left arm to her hand. Medical was notified and would evaluate. Review of the Nursing Progress note dated 12/31/25 at 5:36 P.M. revealed the RN was called at 10:40 A.M. for a patient that was burned in the shower. Patient #18 had a large area of redness of her left arm that wrapped around to a small portion of her back and shoulder. There were no blisters or open areas noted. Patient #18 was not speaking at this time so her pain level could not be assessed. Review of the Incident Report dated 12/31/25 at 10:45 A.M. revealed Patient #18 was in her shower, and the Mental Health Technician was doing rounds and saw water running from the patient’s room, went into the room, and found Patient 318 lying on the floor. Patient #18 had allowed the water to run over her body for an extended period of time. The patient was observed with erythema, resulting in a scald to the left arm and left backside area. Medical did an examination , prescribed ibuprofen for pain and Silvadene cream and the patient was placed on one-on-one for a short period of time. Patient #18 stated she did not realize the water was that hot and it felt good running over her body, she was calm and communicating with staff. She rated the pain a ten on a one to ten scale and requested Tylenol. The plumbing company came to the building to make sure the water temperatures were adjusted correctly. Review of the Nursing Progress note dated 01/01/26 at 5:41 P.M. revealed the registered nurse assessed the burn of Patient #18 and there were blisters to her skin. The patient had several very large blisters that were raised and had visible pressure to them. On 02/09/26 at 10:00 A.M. an interview with Director of Quality Staff C revealed the water temperature was normally set at 110 degrees Fahrenheit. The facility had no policy for water temperatures.”

“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: 42015 Based on record review, interview and policy review, the facility failed to ensure an allegation of sexual abuse was investigated. This affected one (Patient #2) of five patients reviewed for abuse. The facility census was 65. Findings include: Review of the medical record for Patient #2 revealed and admission date of 09/08/25 and a discharge date of 09/15/25. Diagnoses included schizophrenia, psychosis, schizoaffective, posttraumatic stress disorder, and tooth infection. The patient was noted to have a history of endocarditis, lupus, and homelessness. The record indicated that the patient was pink slipped from another hospital for psychosis and “THC gummy induced psychosis”. On 9/12/25 at 9:30 A.M. the patient went to Local Hospital A due to chest pain. She returned the same day at 5:00 P.M. with no new orders and no definitive diagnoses. Review of the Patient#2’s the Psychiatric Progress Note dated 09/12/25 at 9:21 P.M. by Nurse Practitioner (NP)Staff K revealed the patient was in the hospital and could not be a assessed. While in the hospital, Patient #2 reported that she was sexually assaulted by another patient while at the facility. Per nursing and incident report, the patient was grabbed by the arm by another patient, but staff intervened. Local Hospital A reported that when the SANE nurse arrived, Patient #2 refused to talk. Patient #2 would change units upon return. Review of the incident report dated 09/11/25 at 8:29 P.M. revealed Patient #2 was sitting in the television room watching television with several patients. Patient #11 came over and grabbed the Patient #2’s arm. Patient #2 felt uncomfortable and Patient #11 was told by the Mental Health Technicians (MHT) to keep his hands to himself. Patient #11 became agitated, and Patient #2 ended up tearful in her room. Patient #2 took as needed Atarax and was calm and cooperative. Patient #2 went to her room to sleep after the incident with no further issues. Review of the documents revealed no evidence the faciliy investigated Patient #2’s allegation of sexual assault. Review of the Patient #2’s Hospital A discharge paper work revealed, upon further discussion with the patient, she does express concerns with returning back to the psychiatric hospital. She stated she feels that she is not being cared for there and taking seriously, she feels that she is being held there against her well by mistake, she does not believe that she has any mental health disease. Additionally, she is expressing that she has been assaulted by other patients there as well and feels unsafe. SANE services have been contacted at this time to evaluate the patient with ultimate deposition pending. Review off the nursing progress note date 09/15/25 at 5:20 P.M. revealed Patient #2 was sent to Hospital B’s emergency department for seizure activity. During an interview on 02/10/26 at 1:19 P.M., NP Staff K stated she spoke with Patient #2 the day after she returned from the hospital. Patient #2 was very psychotic with disorganized thinking. Patient #2 did not appear to recall the allegation at the time of her interview. During an interview on 02/09/26 at 4:15 P.M., Milieu Manager Staff J reported while at Hospital B a staff member reported to him that the Patient #2 was alleging that she was sexually assaulted. Milieu Manager Staff J stated he reached out to intake department and Nurse Manager Staff A reporting on the allegation. During an interview on 02/09/26 at 4:30 P.M., Nurse Manager Staff A revealed Patient #2 went to the ER on 09/12/25 due to chest pain and hypertension. Initially why she was there she had requested to speak with a SANE nurse and then refused to speak with her stating she just wanted a social worker. She reported she was assaulted by another patient in this hospital. They did a camera review and did see where a male patient grabbed her arm, and the facility staff weren’t sure due to the the way she was presenting if she was mistaking that as an allegation of sexual assault. Nurse Manager Staff A reported she completed a camera review and to be on the safe side they moved her to a different unit. Hospital B called after she was transported there on 09/15/25 and reported she alleged sexual assault happened while she was admitted at the facility. Hospital B gave a date range of 09/11/25 or 09/12/25. Nurse Manager Staff A was unsure if they had completed a SANE exam. Nurse Manager Staff A reported she was unsure if administration notified the police, took witness statements or interviewed staff members related to the allegation she made to both Hospital A and Hospital B regarding her time at their facility. During an interview on 02/10/26 at 12:20 P.M., Director of Quality Staff C verified they were aware of the allegations the Patient #2 made while at Hospital A and Hospital B. Due to her refusal of a SANE examination at Hospital A, her only alleging that the incident occurred while she was at the facility, and not wanting to come back to the facility, they did not feel it was creditable. Camera review was done and a patient was observed grabbing her arm. Due to her condition, she may have confused the interaction as an assault. He verified a full investigation into the allegation was not done. Review of the facility policy titled, “Incident Reporting and Investigation,” dated 01/23 revealed the purpose was to provide guidelines for reporting and investigation of all internal and external adverse events related to patients, staff or visitors to the facility. It was the policy of the facility to support an open incident reporting process and provided an effective mechanism for reporting, investigation, and/or prevention of all incident and injuries to patient, staff, or visitors of the facility, including identification of the type of incident such as critical and sentinel events.”

“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: 35765 Based on record review, interview and policy review, the facility failed to ensure a second-degree burn was properly assessed and treated. This affected one (Patient #14) of 20 patient records reviewed. The facility census was 65. Findings include: Review of the medical record revealed the Patient #14 was admitted to the facility on 12/24/25 after being hospitalized. She was discharged on 12/31/25. The admitting diagnoses included schizoaffective disorder bipolar type, auditory hallucinations, anxiety, suicidal ideation, hypertension, seizures, and hypothyroidism. Patient #14 was admitted to the emergency room after making statements of wanting to hurt herself. She was going to take a knife and stab herself. She indicated she had been awake for days with racing thoughts and she had not been eating. She was observed to have poor hygiene, was agitated, had feelings of sadness and hopelessness. Review of the Medication Administration Record (MAR) revealed on 12/24/25 Patient #14 received Benadryl 50 milligrams (mg) intramuscularly (IM), Versed two mg IM at 6:57 P.M. due to agitation and Desyrel 50 mg orally for insomnia. Review of the MAR revealed on 12/25/25 Patient #14 received Ativan 0.5 mg orally at 5:40 A.M., Haldol five mg IM at 6:03 A.M., 2:32 P.M. and 11:33 P.M. and Benadryl 50 mg IM at 6:27 P.M. and 11:33 P.M. for agitation. Review of the Nursing Progress Note dated 12/25/25 at 5:08 A.M. revealed at approximately 4:00 A.M. Patient #14 came out of her room and put herself on the ground in the day room. This was witnessed by the nurse and the mental health technician. The nurse helped Patient #14 to her room and the patient stated, “touch my butt and pray over it”. Patient #14 denied pain at this time and stated she was going to go to sleep. She was resting in bed with regular respirations. Nurse Practitioner (NP) Staff Y was notified. Review of the Narrative Note dated 12/25/25 at 1:42 P.M. revealed Patient #14 was alert but delusional and religiously preoccupied. She stated she was God and had messed Heaven up for everyone, she was screaming at the unseen, she was praying intently asking for a 100 million trillion Advil. Review of the Nursing Progress note dated 12/25/25 at 2:26 P.M. revealed Patient #14 had been running the halls that afternoon and she ate soap twice. NP Staff Y was notified and ordered Haldol five mg intramuscularly (IM) now and Patient #14 had asked for Seroquel because she said she had not slept for days. NP Staff Y order Remeron 15 mg at bedtime. Review of the medical record revealed no documentation of the incident or of a skin assessment of Patient #14’s buttocks on 12/25/25. Review of the Doctor’s Note dated 12/25/25 at 5:25 P.M. revealed Patient #14 had a scald injury to the left buttock, superficial, less than one percent. Local skin care. Review of the Nursing Progress note dated 12/25/25 at 11:40 P.M. revealed Patient #14 was in active psychosis, having grand delusions indicating she was God, pacing the hallways, refusing medication despite several attempts. The last attempt she threw them into the nursing station. Patient #14 was yelling in the hallway and was not diversional. NP Staff X was contacted and ordered Haldol and Benadryl IM. Patient #14 allowed the injections. Review of the concern log dated 12/25/25 revealed Patient #14 had been in the shower sometime between 12/24/25 to 12/25/25 and stated she was burned. It was uncertain what time this happened or how long she was in the shower. Due to the potential temperature, she had burns on her buttocks that started as first degree burn and has sloughed off on one side and has a large, reddened area on the other. The medical team was consulted when nursing was notified, and they saw her the same day. This was listed as a ruptured blister and was a relatively small area. On 12/28/25 a call was received where the charge nurse reported that the burn had worsened and that medical was seeing her again. They documented this as a large hyperpigmented vesicle without drainage. She was ordered Silvadene twice daily for wound care. Review of the Doctor’s Note dated 12/28/25 at 3:43 P.M. revealed Physician Staff Z was asked to see Patient #14 for burns to her buttocks from hot water in the shower which occurred four to five days ago. Assessment determined she had second degree burns to her buttocks. New order for Silvadene cream twice daily. Review of the concern log dated 12/29/25 at 6:50 P.M. revealed at 4:50 P.M. the nurse spoke with NP Staff Y regarding the wound. NP Staff Y had seen the wound on the first day that it was recognized and encouraged her to view the uploaded pictures. She stated it appeared to be a lot more advanced than when she had seen it last. She advised consulting with medical and explaining the extent if the wound to see if they would like her to be sent out for additional evaluation. At 5:30 P.M. Medical recommended she be sent to the hospital non-emergent to be evaluated, intake was called, and transport was arranged for 6:35 P.M. Patient #14 requested her responsible party be notified. She left with emergency medical service at 6:55 P.M. Review of the Plumbing Company Service report dated 12/30/25 revealed the water temperature in the shower was 140 degrees Fahrenheit (F). They replaced the mixing valve and had to repair the piping. The temperature was set on new mixing valve. Review of the Plumbing Company Service report dated 12/31/25 revealed the water temperature in the shower was still 140 degrees F. The temperature was checked in multiple rooms, and they found a ball valve needed installed on one of the hot water circulating line. They would be back the next day to add the valve. Review of the Plumbing Company Service report dated 01/02/26 revealed the water temperature in the shower remained 140 degrees F. They added a new ball valve on the hot water circulating line, checked temperatures on mixing valve, and everything was working properly now. Review of the Incident Summary and Review revealed on 12/24/25 Patient #14 refused her initial skin assessment. )(There was no documentation in the medical record to confirm this.) Patient #14 experienced a fall prior to being transferred to another unit however, there was no documentation indicating a full skin assessment was completed following the fall. On 12/25/25 at approximately 5:00 A.M. a reaction/burn was initially noted, Patient #14 was observed running in the hallway without clothing and redness was noted to the buttocks by NP Staff Y. Patient #14 reportedly placed herself on the dayroom floor and made statements referencing her buttocks, Patient #14 was on one-on-one observations from 12/25/25 at 3:27 P.M. to 12/26/25 at 12:00 P.M. Four injections of Haldol were administered on this date, which may have contributed to the worsening of the skin condition. From 12/26/25 through 12/29/25 shift assessments for 7:00 P.M. to 7:00 A.M. were signed off by a Licensed Practical Nurse (LPN) which was against policy. Daily assessment and skin assessments must be completed by the Registered Nurse (RN). The nurses denied Patient #14 reported any pain during this time period. On 12/28/25 the physician evaluated the patient and documented that the wound had progressed to a second-degree burn, described as a large hyperpigmented vesicle without drainage. On 12/30/25 Patient #14 reported pain for the first time, rating it an eight on a one to ten scale. Nursing staff observed the wound to be worse than previously documented, wound was dressed, nursing staff consulted with the Emergency Room physician at hospital, patient was transferred to hospital for further evaluation. Silvadene cream use was identified as excessive, treatment frequency was reduced, and patient was placed on oral antibiotics. From 12/30/25 through 12/31/25 Patient #14 was evaluated daily, wound care adjusted to leave the area more open to air and nurses educated to rotate the patient from back to side, new tissue formation noted, no signs of infection observed. Progressive wound photographs initialed and documented daily in progress notes. Medical review revealed the burns assessed as first degree and later progressed to second degree. Per medical review it was very unlikely that Midazolam and Benadryl caused the burn. Injections of Haldol were administered in the arm per documentation not in the affected area. Multiple falls had occurred with no documentation of post fall skin assessments. One might have been done by an LPN not an RN which was against hospital policy. It was noted in a progress note that the burns may have resulted from shower water exposure, and the facility identified an issues with shower temperature regulation and pump functionality. Documentation and process concerns were identified as followed: failure to document skin findings on 12/25/25, incident report was not completed until 12/29/25 when Nursing Manager Staff A assessed the patient, delay in notification of leadership and medical team, RN daily assessments and skin assessments were improperly completed by an LPN. Patient refusal of skin checks did not consistently trigger enhanced monitoring protocols which was one-on-one. During an interview on 02/09/26 at 10:00 A.M., Director of Quality Staff C revealed the water temperature was set at 110 degrees F. During an interview on 02/09/26 at 11:30 A.M. an interview with Nurse Manager Staff A stated all the rooms have their own shower and the patient can shower unsupervised whenever they want. During an interview on 02/10/25 at 10:24 A.M., Nurse Manager Staff A stated there was no documentation indicating Patient #14 had refused her initial skin assessment as documented in the facility investigation. She verified there was no documentation of a treatment being provide to the burns to Patient #14 buttocks from 12/25/25 to 12/28/25. A LPN performed the skin assessments on Patient #14 even though facility policy indicated all assessments were to be completed by a RN. The LPN never notified the RN that Patient #14 had a wound that needed assessed and there was no incident report completed until 12/29/25 after she was notified of the incident. Nurse Manger Staff A stated she was not made aware of the incident until 12/29/25 due to being off for Christmas. She stated the responsible party of Patient #14 came to the facility on 12/29/25 very upset about her burns and the lack of medical care provided and demanded she be sent to the hospital. She stated she took pictures on the wound and they sent her out to the hospital, but she came back to the facility the same day. Review of the facility policy titled, “Incident Reporting and Investigation,” dated January 2023, revealed the purpose was to provide guidelines for reporting and investigation of all internal and external adverse events related to patients, staff or visitors to the facility. It was the policy of the facility to support an open incident reporting process and provided an effective mechanism for reporting, investigation, and/or prevention of all incident and injuries to patient, staff, or visitors of the facility, including identification of the type of incident such as critical and sentinel events. Review of the facility policy titled, “Wound Assessment and Wound Care,” dated March 2023, revealed the purpose was to conduct a full skin assessment at the time of admission and follow-up on all areas of impaired skin integrity in a structured and clinically appropriate manner. The policy was to ensure consistent individualized high-quality care in wound management for all patients. To ensure wound management which was delivered by staff which the appropriate knowledge and skill.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 42015 Based on record review, interview and policy review, the facility failed to document all patients who presented to the Emergency Department (ED) on the ED log. This affected one (Patient #1) of 20 patients reviewed for ED services. The facility census was 65. Findings include: Review of the medical record for Patient #1 revealed he was admitted to the facility on 11/18/25 due to negative symptoms of psychosis and delusional behavior. He had a history of paranoid schizophrenia, cocaine dependence with cocaine induced psychotic disorder with delusions, noncompliance with medication, and multiple previous psychiatric hospitalizations. The patient was discharged on 11/24/25 with instructions to follow up with outpatient behavioral health services on 11/25/25 at 8:00 A.M. Review of the local police incident report dated 11/29/25 at 2:10 A.M. a call was received from the facility. The officer arrived at 2:16 A.M. and Patient #1 was found to be suffering from a mental health incident. Review of an additional local police mental health incident report dated 11/29/25 at 2:47 A.M. revealed on 11/29/25 while on patrol, the officer was dispatched to the facility in regard to a unwanted person. The notes for the call stated Patient #1 was outside the business refusing to leave. When the officer arrived on scene he spoke with Patient #1 who advised he was having mental health trouble. Patient #1 stated he was hearing voices, seeing things, and had raccoons in his stomach. The patient requested to go to the hospital to seek mental health treatment. The patient was transported to Local Emergency Department A and turned over to hospital staff without incident. Review of the facility EMTALA Intake logs from 11/29/25 revealed no evidence of Patient #1 was logged as a patient that presented for emergency care. Review of Patient #1’s Hospital A’s Emergency Department (ED) notes revealed on 11/29/25 the patient presented to the hospital for a psychiatric evaluation. He is a known schizophrenic. He stated he needed to be in a psychiatric ward for five years where they can inject him with drugs. He denies any suicidal or homicidal ideation. The note stated he was knocking on the door of his previous hospital. They called the police and the police and they brought him here. He is very internally stimulated. He cannot give any significant history. He stated he feels like there are people trying to kill him by putting pins in his head. The notes state that because of his psychosis will require placement. The patient was transferred to another hospital for further psychiatric stabilization. Review of the electronic medical record for Patient #1 revealed the patient was never entered into their system on 11/29/25. There was no evidence of his being present at the facility on this date. During an interview on 02/10/26 at 11:18 A.M., Police Officer V stated he responded on 11/29/25 at around 2:00 A.M. to a call from someone at facility reporting that Patient #1 was not a patient and was trying to get into the facility. He responded and found Patient #1 in the first set of sliding doors by the Emergency Room bay. It was a cold night and wasn’t sure if he was looking for some warm place or needed assistance. When he talked with him, he appeared to be in a mental health crisis and said he was talking about raccoons in his belly. He asked what he wanted to do and he reported he wanted the hospital to see him. Police Officer V said he didn’t talk to anyone at the facility but took the patient to local Hospital A’s Emergency Room for evaluation. Review of the Staffing Schedules for 11/29/25 revealed three staff members were present in the intake unit. These included Intake Coordinator Staff R, Intake Coordinator Staff S, and Intake Assessor Registered Nurse (RN) Staff W. Nurse practitioner (NP) Staff X was on call. During an interview on 02/10/26 at 2:09 P.M., Intake Coordinator Staff R revealed she worked early in the morning of 11/29/25 when Patient #1 was trying to enter into the hospital through the ambulance bay. He was reporting he was cold and hungry. She stated she was unaware of his mental health needs, stating “he was just trying to get into the facility”. She stated staff members provided him with a blanket and gloves. They called the practitioner (unsure of who) and he said not to let the patient in. She confirmed he was not added to the intake log because she was told he had just been an inpatient there. She stated she called the police and told them he was trespassing. During an interview on 02/10/26 at 4:38 P.M., NP Staff X stated he does not recall ever being notified of Patient #1 reporting to the facility on 11/29/25. He said that usually if someone reported to the facility off the street they are usually admitted. He stated he was unaware of this incident. During an interview on 02/12/26 at 10:56 A.M., Intake Assessor Registered Nurse (RN) Staff W revealed she is familiar with Patient #1 stating he has been admitted to the facility a few times. In the early morning on 11/29/25 he came to the facility and walked into the vestibule. The first set of doors were unlocked but the facility has an additional set of doors that remain locked. He was banging on the second set to come in. She asked, “Do you want to come in for an assessment” and he said he was only hungry and cold. He was sitting in the vestibule at that time blocking the entrance for emergency service personnel if they showed up. She reported the way he was sitting he was taking up most of the sally port. He was there for well over 15 minutes and was “becoming an situation”. She decided to call 911 to ask to escort him off the property. She reported through the doors she asked if he was homicidal and suicidal, which he denied. At one point he was pounding on the doors aggressively but refused to consent to be assessed. She reported it is her understanding that only patients that come in for an assessment or admission would go on the intake log and this is why he was not added to the intake log. During an interview on 02/12/26 at 3:00 P.M., Intake Coordinator Staff S reported Patient #1 came to the door on 11/29/25. She asked if he was okay and he responded that he was. She then asked if he would like an assessment and he stated he did not want one. He reported he just wanted something to eat and drink. He was refusing to come in for an assessment but also was refusing to leave so the facility called the police. He left when they called the police but then came back about fifteen minutes later. She gave him a hat and gloves and, but he continued to sit in the ambulance bay. They did ask him if he was homicidal or suicidal, which he denied. The police were called again, and he left with them willingly. She reported she did not add the patient to the intake log. During an interview on 02/10/26 at 2:31 A.M., Medical Director Staff U reported that when someone arrives at the facility it is his expectation for them to be assessed by the intake personnel. If intake feels like the patient needs admitted, they should call the on-call provider. All patients who are seeking treatment should be screened and added to the intake log. Review of the facility’s rules and regulations page 19 under emergency care, revealed (a) person presenting at the facility potentially seeking treatment for an emergency medical condition shall be appropriately medically screened and treated in accordance with the Facility’s EMTALA policy, to the extent of the facility’s capabilities.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 42015 Based on record review, interview and policy review, the facility failed to document evidence of a medical screening exam (MSE) to rule out an emergency medical condition. This affected one (Patient #1) of 20 reviewed for ED services. The facility census was 65. Findings include: Review of the medical record for Patient #1 revealed he was admitted to the facility on 11/18/25 due to negative symptoms of psychosis and delusional behavior. He had a history of paranoid schizophrenia, cocaine dependence with cocaine induced psychotic disorder with delusions, noncompliance with medication, and multiple previous psychiatric hospitalizations. The patient was discharged on 11/24/25 with instructions to follow up with outpatient behavioral health services on 11/25/25 at 8:00 A.M. Review of the local police incident report dated 11/29/25 at 2:10 A.M. a call was received from the facility. The officer arrived at 2:16 A.M. Patient #1 was found to be suffering from a mental health incident. Review of an additional local police mental health incident report dated 11/29/25 at 2:47 A.M. revealed on 11/29/25 while on patrol the officer was dispatched to the facility in regard to a unwanted person. The notes for the call stated Patient #1 was outside the business refusing to leave. When the officer arrived on scene he spoke with Patient #1 who advised he was having mental health trouble. The patient stated he was hearing voices, seeing things, and had raccoons in his stomach. The patient requested to go to the hospital to seek mental health treatment. The patient was transported to Local Emergency Department A and turned over to hospital staff without incident. Review of the electronic medical record for Patient #1 revealed the patient was never entered into their system on 11/29/25. There was no evidence of his being present at the facility on this date or receiving a MSE. During an interview on 02/10/26 at 4:38 P.M., NP Staff X stated he does not recall ever being notified of Patient #1 reporting to the facility on 11/29/25. He reported that usually if someone reported to the facility off the street they usually are admitted and he was unaware of this incident. During an interview on 02/12/26 at 10:56 A.M., Intake Assessor Registered Nurse (RN) Staff W revealed she is familiar with Patient #1 stating he has been admitted to the facility a few times. In the early morning on 11/29/25 he came to the facility and walked into the sally port or vestibule. The first set of doors are unlocked but the facility has an additional set of doors that remain locked. He was banging on the second set to come in. Intake Assessor Registered Nurse (RN) Staff W reported she was the only assessor. She asked, “Do you want to come in for an assessment” and he said he was only hungry and cold. She reported the way he was sitting he was taking up most of the sally port. He was there for well over 15 minutes and was becoming an situation. She decided to call 911 to ask to escort him off the property. She reported through the doors she asked if he was homicidal and suicidal, which he denied. At one point he was pounding on the doors aggressively but refused to consent to be assessed. She verified she did an initial screening to see if he was suicidal or homicidal. She verified she did not document her assessment. During an interview on 02/10/26 at 2:31 A.M., Medical Director Staff U reported that when someone arrives at the facility it is his expectation for them to be assessed by the intake personnel. If intake feels like the patient needs admitted, they should call the on-call provider. All patients who are seeking treatment should be screened and added to the intake log. Review of the facility’s rules and regulations page 19 under emergency care, revealed (a) person presenting at the facility potentially seeking treatment for an emergency medical condition shall be appropriately medically screened and treated in accordance with the Facility’s ENTALA policy, to the extent of the facility’s capabilities. Review of the facility policy, “Emergency Medical Treatment and Active Labor Act” revised 03/2023 revealed this organization will screen and evaluate any person who presents to this facility to determine whether the person has an emergency medical condition. If so, the patient/client must be stabilized, and/or appropriately transferred.”

“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: 31597 Based on record review, interview and policy review, the facility failed to honor a patient’s guardian’s request to refuse a medication. This affected one (Patient #9) of ten medical records reviewed. The facility’s census was 55. Findings include: Patient #9 was admitted to the facility on 09/05/24 with a diagnosis of bipolar disorder and discharged on 09/16/24. The Patient #9’s Guardian consented to Wellbutrin (a psychotropic medication) to be administered on 09/06/24 at 8:10 PM. On 09/07/24 at 6:05 PM, staff documented Patient #9’s guardian declines Wellbutrin. The medical record did not contain evidence of the guardian ever reapproved the administration of Wellbutrin. Patient #9 received Bupropion (Wellbutrin) 150 milligrams (mg) on 09/07/24 and daily from 09/09/24 through 09/15/24. The findings were shared with Staff B on 10/01/24 at 12:18 PM and confirmed. The facility’s policy titled “Informed Consent for Psychotropic Medications”, dated March 2022, stated to assure that the dignity and rights of all patients are respected and protected, and that patients and/or their representatives have the information necessary to exercise their rights. The Hospital fully supports, endorses and enforces the rights of patients. The Hospital informs each patient, patient’s guardian, and/or patient’s family when appropriate, of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. Patient rights include all federal and state requirements. Patient Rights according to federal guidelines include the following at a minimum: The right to participate in the development and implementation of his or her plan of care and the right to make informed decisions regarding his or her care, including being informed of their health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right does not include the provision of treatment or services deemed medically unnecessary or inappropriate.”