Laurel Ridge Treatment Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 21863 Based on observations, review of facility’s policies and procedures, record reviews and interviews, it was determined the facility failed to ensure specific patient rights were protected and promoted in accordance with the facility’s policies and procedures; and in accordance with State law for 7 of 7 patients reviewed (#22, #23, #24, #32, #33, #34, and #35) with observed patient rights violations. Specifically, the facility failed to ensure: 1.) patient’s rights that allowed a patient or his or her representative [as allowed under Texas State law, Texas Administrative Code, Title 26, Chapter 320, Rule 320.7(7)] to be notified and involved in care planning and treatment to make informed decisions for Patient’s #32, #33, #34, and #35; 2.) Anesthesia Services obtained informed consent before administering general anesthesia for Patient’s #23 and #24; and 3.) patients received care in a safe setting by ensuring facility staff conducted the contraband safety searches and ordered observation monitoring checks in accordance with the facility’s policy, procedures, and training for Patient #22, that was at risk and found the morning of 10/12/25 by a Mental Health Worker (MHW) unresponsive and subsequently pronounced deceased. These deficient practices affected patient’s rights receiving treatment in the facility and placing them at risk for injury, harm, delay of care, and unmet clinical needs that could potentially result in death. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Patient Rights. Refer to deficiencies; A0131 and A0144 for evidence of specific findings.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 21863 Based on observation, review of patient records, policies, and interviews, it was determined the facility failed to have an effective medical record service that ensured medical records were accurately written, promptly completed, and maintained in a secured and protected environment. Specifically, 1.) Patient #22’s clinical inpatient record was not accurate when on, 10/12/25 at 09:04 AM, she was found unresponsive and determined deceased at 09:34 AM after resuscitation ended. Patient #22’s electronic documented observation checks for 10/12/25 by the Registered Nurse (RN) and Mental Health Worker (MHW) from 09:05 AM through 10:26 AM documented patient “appears sleeping - stomach” even after Patient #22 was pronounced deceased; 2.) the Memorandum of Transfer (MOT) for 7 of 7 patients (Patient #25, #26, #27, #28, #29, #30, and #31) reviewed who were transferred into the hospital from another facility were not completed with the required information; and in accordance with the facility’s policy; and 3.) Patients Clinical Medical Records were not maintained in a secure and protected environment that ensured confidentiality, security, and fire/life safety protection. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Medical Record Services Refer to deficiencies; A0438 and A0441 for evidence of specific findings.”

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition is not met as evidenced by: 26870 Based on observation, interview, and record review, the facility failed to ensure that pharmaceutical services were organized and administered in accordance with accepted professional principles and; that pharmacy operations were guided by policies and procedures to maintain patient safety and regulatory compliance. Specifically, the facility failed to: 1.) ensure medications, including controlled substances, were delivered/transported to all units including the specialized unit across the street using secured medication boxes. The coolers used were not designated for pharmaceutical transport, were not locked during delivery, and were not cleaned between deliveries. This practice involved all medications, not just non-controlled substances, creating a potential risk for contamination, diversion, and loss of drug integrity. Refer to deficiency A-0500 and A-503 for specific evidence, 2.) ensure scheduled IV-controlled medication, Modafinil, was secured with documentation of accountability, controlled use, and disposition. A bottle of Modafinil was observed in the controlled drug storage area with the patient’s name scratched off and no documentation or tracking information available. The pharmacist manager confirmed there was no log, record, or explanation for the medication’s presence. Refer to deficiency A-0505 for specific evidence, 3.) ensure policies and procedures were followed, developed, and/or available for the management of outdated and unusable medications to ensure these medications were not available for patient use, compromised, and kept secured. In the unlocked pharmacy manager’s office, there was a large bin with outdated/expired medications. There were individual pill packs, including ones with expiration dates of 2026, 2027, and 2028 (not outdated), that the pharmacy manager placed back into common stock for reuse. Refer to deficiency A-0505 for specific evidence. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Pharmaceutical Services.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 40989 Based on observations, interviews, and document review, the facility failed to maintain a clean and sanitary environment to mitigate the transmission of infectious and communicable diseases in 11 (Guadalupe, San Jacinto, Navasota, Brazos, Medina, Missions, Electroconvulsive Therapy (ECT) Unit, Comal, Pharmacy, the Kitchen, and the Linen storage area) of 11 areas observed. Refer to deficiency A0750 for evidence of specific findings. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Infection Control and Prevention.”

“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: 36827 Based on observations, review of records, review of policies, and interview, the facility failed to meet the standard of patient’s rights that allowed a patient or his or her representative [as allowed under Texas State law, Texas Administrative Code, Title 26, Chapter 320, Rule 320.7(7)] to be involved in care planning and treatment and; make informed decisions by providing informed consent for Anesthesia Services provided. Specifically, the facility failed to ensure: 1.) patients and patients’ parent, guardian, conservator, or other person were allowed to participate actively in the periodic review update process for the individualized treatment plan for 3 of 3 patients (Patient #32, #33, and #34) whose treatment plan was updated during interdisciplinary treatment team meeting, 2.) the patient’s parent, guardian, conservator, or other person was notified of the date, time, and location of each meeting so that he or she could actively participate in treatment planning as allowed by Texas Administrative Code, Title 26, Chapter 320, Rule 320.7(7) for 4 patients (Patient #32, #33, #34, and #35) of 4 charts reviewed for treatment planning and; 3.) Anesthesia Services obtained informed consent before administering general anesthesia for 2 of 2 patient records reviewed (Patient #23 and #24). Anesthesia Services failed to follow the facility’s policy titled “Informed Consent” Policy Number RI-12, with an effective date of November 2010, and ensure informed consent was obtained for the anesthesia services provided. Findings were as follows: 1.) On 10-20-2025 at approximately 11:00 AM, an interview was conducted with Staff #6 in the hospital intake area. Staff #6 provided a copy of the admission paperwork that included the patient rights paperwork given to patients. Review of the form #HV-108 Patient Bill of Rights 08.01.2019 showed it contained Item #26 under the Care and Treatment section as follows: “You have the right to a treatment plan for your stay in the hospital that is just for you. You have the right to take part in developing that plan, as well as the treatment plan for your care after you leave the hospital. This right extends to your parent or conservator if you are a minor, or your legal guardian when applicable. You have the right to request that your parent/conservator or legal guardian take part in the development of the treatment plan. You have the right to request that any other person of your choosing, e.g., spouse, friend, relative, etc., take part in the development of the treatment plan. You have a right to expect that your request be reasonably considered and that you will be informed of the reasons for any denial of such a request. Staff must document in your medical record that the parent/guardian, conservator, or other person of your choice was contacted to participate.” A review was made of Policy Title: Treatment Planning-Interdisciplinary Patient/Resident Centered Care Planning; Policy Number PC - 61; Last Review Date of May 2025. The following was found under Procedure: Developing the Treatment Plan, Item #7. “The patient/resident and family/representative are to sign the treatment plan to indicate their agreement with and participation in development of the plan. The therapist is responsible for discussing the treatment plan with the patient/resident and family/representative if they are not present at the treatment team meeting. If the patient/resident refuses to sign or is unwilling to sign, that will be documented. If necessary to do the review with the family member/representative remotely, that will also be noted on the form.” The following was found under Procedure: Interdisciplinary Treatment Plan Update, Item #1: “Treatment Plan Review The treatment team, including the patient/resident and their family/representative, will complete a review of the treatment plan as clinically indicated, or at a minimum every (7) seven days for acute ...” On the afternoon of 10-21-25, Staff #7 was interviewed about scheduling observations of the treatment team. Staff #7 advised that treatment teams took place daily at 8:00 AM. When questioned about the early timing of treatment team since patients were just getting up, conducting personal hygiene, eating breakfast, and getting ready for the day. Staff #7 explained that the 8:00 AM time facilitated discharges for the day and fit better into staff scheduling. Staff #7 explained that patients did not attend treatment teams, so it did not add to their busy morning routine. When asked how patients participated, Staff #7 explained that the therapists discussed the treatment plan with the patient after treatment team and got the patient’s signature. The therapist gathered any input the patient may have on their treatment plan, and it was considered during the treatment team meeting. This was not consistent with the patient’s right to be an active participant in the interdisciplinary treatment team making decisions about the treatment plan. Review of Texas Administrative Code Title 26 Chapter 568, Standards of Care and Treatment in Psychiatric Hospitals, 568.3 was found to define an interdisciplinary treatment team as follows: “(14) Interdisciplinary treatment team (IDT)--A group of individuals who possess the knowledge, skills and expertise to develop and implement a patient’s treatment plan and includes: (A) the patient’s treating physician; (B) the patient and the patient’s legally authorized representative (LAR), if any; (C) the staff members identified in the treatment plan as responsible for providing or ensuring the provision of each treatment in accordance with §568.61(c)(1)(E)(iii) of this chapter (relating to Inpatient Mental Health Treatment and Treatment Planning); (D) any individual identified by the patient or the patient’s LAR, unless clinically contraindicated; and (E) other staff members as clinically appropriate.” Review of the Master Treatment - Interdisciplinary form was made. The form did not include the patient as a Treatment Team member. It contained a section with the heading “Team Member” that was pre-populated with the titles: Psychiatrist, Nurse, Therapist and Other as treatment team members. The patient was not listed as a treatment team member under this heading. At 8:07 AM on 10-22-25 on the Brazos Unit (adolescents), observations of treatment team were made. The interdisciplinary team consisted of the physician (Staff #7), therapy staff, case management staff, discharge planner, nursing staff, and nurse practitioners. Three (3) patient admissions (Patient #32, #33, and #34) were presented for treatment plan review update. All patients on the unit were discussed for discharge planning updates. The patients, their parents, guardians, conservators, or other persons were not there to actively participate in the treatment planning process. Review of Texas Administrative Code, Title 26, Chapter 320, Rule 320.7(7) was as follows: “Persons receiving mental health services from department facilities, community centers, and psychiatric hospitals have the following rights. -(7) The right to participate actively in the development and periodic review of an individualized treatment plan (extending to a parent or conservator of a minor, and the legal guardian of the person, when applicable); and the right to a timely consideration of any request for the participation of any other person in this process, with the right to be informed of the reasons for any denial of such a request. Staff must document in the medical record that the parent, guardian, conservator, or other person was notified of the date, time, and location of each meeting so that he or she could participate.” Patient #32 Patient #32 was admitted on 10-20-25. An initial treatment plan was developed on 10-20-25. This plan was valid for 72 hours until the interdisciplinary treatment team could meet and develop a Master Treatment Plan. Review of Patient #32 ’ s Master Treatment Plan showed the treatment team met on 10-22-25 at 8:00 AM. The psychiatrist, Nurse, Therapist and Other were listed as treatment team members. The patient was not listed as a treatment team member. The section listed as “Patient Participation” indicated the patient: “Contributed to plan goals/plans” and was “Aware of plan content”. The patient signed a statement “This treatment plan update has been presented and reviewed with me in a language that I understand. I had the opportunity to ask questions.” It was dated 10-21-25 at 10:30 AM. This was the date prior to the treatment team meeting to fully develop the Master Treatment Plan. This meant that the plan could not have been presented and reviewed at that time since it had not been developed yet. Patient #33 Patient #33 was admitted on 10-20-25. An initial treatment plan was developed on 10-20-25. This plan was valid for 72 hours until the interdisciplinary treatment team could meet and develop a Master Treatment Plan. Review of Patient #33 ’ s Master Treatment Plan showed the treatment team met on 10-22-25 at 8:00 AM. The psychiatrist, Nurse, Therapist and Other were listed as treatment team members. The patient was not listed as a treatment team member. The section listed as “Patient Participation” indicated the patient: “Contributed to plan goals/plans” and was “Aware of plan content”. The patient signed a statement “This treatment plan update has been presented and reviewed with me in a language that I understand. I had the opportunity to ask questions.” It was dated 10-21-25 without a time documented. This was the date prior to the treatment team meeting to fully develop the Master Treatment Plan. This meant that the plan could not have been presented and reviewed at that time since it had not been developed yet. Patient #34 Patient #34 was admitted on 10-20-25. An initial treatment plan was developed on 10-20-25. However, the patient signature on the initial treatment plan dated 10-20-25 at 2:40 AM was not the signature of patient #34. The initial treatment plan was valid for 72 hours until the interdisciplinary treatment team could meet and develop a Master Treatment Plan. Review of Patient #34 ’ s Master Treatment Plan showed the treatment team met on 10-22-25 at 8:00 AM. The psychiatrist, Nurse, Therapist and Other were listed as treatment team members. The patient was not listed as a treatment team member. The section listed as “Patient Participation” indicated the patient: “Contributed to plan goals/plans” and was “Aware of plan content”. The patient signed a statement “This treatment plan update has been presented and reviewed with me in a language that I understand. I had the opportunity to ask questions.” It was dated 10-21-25 and was not timed. This was the date prior to the treatment team meeting to fully develop the Master Treatment Plan. This meant that the plan could not have been presented and reviewed at that time since it had not been developed yet. The patient signature on the treatment plan review update was not the signature of patient #34. Review of medical records for 4 patients (Patient #32, #33, #34, and #35) showed that there was no documentation that the parent, guardian, conservator, or other person was notified of the date, time, and location of each meeting so that he or she could participate. Interview was conducted on 10-22-25 at 9:30am with Staff #30 after the treatment team concluded. Staff #30 confirmed that the parent, guardian, conservator, or other persons were not invited to attend the treatment team. Staff #30 confirmed that there was not a process for that and that it would not be documented in the patient medical record. 08686 Interview on 10/22/2025 at 10:30 AM with facility program director for child/adolescent outpatient services, Staff #50, revealed that patients’ treatment team meetings consisted of the facility psychiatrist, the program director (himself), the patient’s social worker and/or therapist, the facility registered nurse, and the facility care manager who interacts with patient insurance companies. Staff #50 confirmed the patient was not part of the treatment team meetings that are normally conducted at 8:00 AM. He further stated that after the above listed treatment team members formulate the treatment plan, the plan is presented to the patient and the patient’s parents/guardian during individual/family therapy sessions for signatures. 40989 Findings: (3.) Patient #23 A review of Patient #23’s medical record was conducted on 10/22/2025 with Registered Nurse (RN) Staff #13. A review of the Electroconvulsive Therapy Consent (ECT, a treatment in which seizures are electrically induced in anesthetized patients) dated 10/20/2025 revealed a signature by Patient #23, a witness (illegible signature), and Physician #26. There was no time documented when the patient, witness, or physician signed the informed consent. A review of the Pre-Anesthesia Evaluation and Record and the ECT informed consent dated 10/20/2025 did not reveal that the anesthesiologist had discussed the type of anesthesia to be administered or the risks and benefits of the planned anesthesia with Patient #23 before the administration of the anesthesia. Patient #24 A review of Patient #24’s medical record was conducted on 10/22/2025 with Registered Nurse (RN) Staff #13. A review of the Electroconvulsive Therapy Consent (ECT) dated 10/22/2025 revealed a signature by Patient #24, a witness (illegible signature), and Physician #26. There was no time documented when the patient, witness, or physician signed the informed consent. A review of the Pre-Anesthesia Evaluation and Record and the ECT informed consent dated 10/22/2025 did not reveal that the anesthesiologist had discussed the type of anesthesia to be administered or the risks and benefits of the planned anesthesia with Patient #24 before the administration of the anesthesia. A review of Page 2 of the informed consent documents for Patients #23 and #24 was as follows: “ ...Anesthesia and muscle relaxants will be used during these treatments to prevent accidental injury. I understand that anesthesia involves risks and hazards, but I request the use of anesthesia for the relief and protection from pain and accidental injury during the procedure. I realize that anesthesia may possibly have to be changed without explanation to me. I understand that certain complications may result from the use of anesthesia, including respiratory problems, drug reactions, paralysis, brain damage, or even death. Other risks and hazards which may result from the use of general anesthesia range from minor discomfort to injury to vocal cords, teeth, or eyes. Oxygen will be administered to minimize the small risk of heart, lung, or brain malfunction, or death, as a result of the anesthesia or treatment procedures ...” An interview was conducted with Physician #26 on 10/22/2025 after 9:00 AM. Physician #26 was asked if she discussed the type of anesthesia and the risks and benefits of the planned anesthesia with the patient before the informed consent was signed. Physician #26 confirmed that she did not discuss the specifics regarding anesthesia with the patient and that the anesthesiologist discussed the risks and benefits of general anesthesia with the patient before the procedure started. Further review of the medical record did not reveal any documentation by the anesthesiologist that the type of anesthesia, risks, and benefits had been discussed with 2 (Patient #23 and #24) of 2 patient records reviewed. A review of the policy titled “Informed Consent” Policy Number RI-12, with an effective date of November 2010, was as follows: Policy: Individuals served receive adequate information about all aspects of treatment, care, and service, in accordance with Laurel Ridge Hospital policy. All patients age 16 and over shall be required to give written informed consent to be admitted and treated at Laurel Ridge Hospital. Procedures: 1. Specific written and patient signed informed consents for all patients 16 years of age and older shall be required for any of the following activities: a. Treatment with psychoactive medication. b. Participation in research programs. c. Surgical or other invasive procedures. d. Behavior therapy using aversive stimuli. e. Hazardous assessment procedures. f. Recording by audiovisual equipment. g. Other procedures where consent is required by law, according to the Texas State list A and B of the Texas Administrative Code ...” A review of 25 Texas Administrative Code (TAC) Rule 602.1 requires informed consent with full disclosure of specific risks and hazards-List A. “Rule 602.1 Anesthesia Treatments and Procedures “ ...(b) General. (1) Permanent organ damage. (2) Memory dysfunction/memory loss. (3) Injury to vocal cords, teeth, lips, and eyes. (4) Awareness during the procedure. (5) Brain damage...” During an interview with RN Staff #13 on 10/22/2025, after 9:00 AM was asked who administered the anesthesia for the ECTs. She confirmed that the anesthesiologist administered all anesthesia. RN Staff #13 stated that the facility used a contracted service for anesthesia, and the providers could vary from week to week. RN Staff #13 confirmed that the anesthesia provider did not sign the informed consent before each treatment. RN Staff #13 confirmed there was no documentation of who the anesthesia provider was, the type of anesthesia to be administered, or who discussed the risks and benefits of the planned anesthesia in 2 (Patient #23 and #24) of 2 patient records reviewed.”

“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: 21863 29242 Based on observations, record reviews and interviews, the facility staff failed to follow policy and procedures to ensure patients received care in a safe setting for 1 of 1 patient reviewed (Patient #22), that was at risk and pronounced deceased on 10/12/25. The facility failed to: 1.) Ensure the Charge Registered Nurse (RN) performed nursing observation rounds twice per shift on patients, in accordance with the facility’s policy. Patient #22’s Observation checks from 10/11/25 at 12:10 AM through 10/12/25 at 09:04 AM when patient was found unresponsive, only had one documented RN Observation check on 10/11/25 at 03:34 AM. The overnight shift, 10/11/12 into 10/12/25 (7pm-7am), RN #24 failed to perform observation rounds to check on Patient #22’s condition. Patient #22 was found the morning of 10/12/25 by a Mental Health Worker (MHW) unresponsive and subsequently pronounced deceased. 2.) Ensure all direct care staff (Nurses, MHW’s, etc.) conducted the ordered observation rounding, 15-minute checks, for Patient #22 in accordance with the facility’s policy, procedures, and training. 3.) Ensure the RN notified the physician of Patient #22’s elevated Blood pressure (B/P) as per physician’s orders. On 10/11/25 at 7:21 pm, Pt #22’s blood pressure was recorded as 171/100, with no evidence that nursing staff notified the Physician or Physician Assistant (PA). 4.) Ensure staff followed the contraband safety search policy for Patient #22 admitted to the facility on 10/10/25 at 8:30 pm, when Patient #22 was found by a MHW in possession of a vape pen that contained “marijuana” and sharing it with other patients in the unit during smoke break. These deficient practices have the potential to cause injury and/or harm to all patients receiving treatment in the facility, leading up to and including the possibility of death. Findings included: Record review of the facility clinical records for Patient #22 revealed that she was a 26-year-old female admitted involuntary on 10/10/2025 at 2:15 pm for Suicidal Ideation (SI) and Homicidal Ideation (HI). Further review of the record revealed that she had a history of obesity (weight at admission was 460 Lbs.) Fibromyalgia, Danos Syndrome, Obstructive Sleep Apnea (OSA) and bipolar disorder without psychotic features. Record review of the CODE BLUE FORM, dated 10/12/25 for Patient #22 revealed the following: -“09:04 AM, Patient found lying face down on her bed in her room, unresponsive, no detectable pulse. Pt presents breathless. Charge RN (Staff #19) was unaware of Pt medical history. RN Called rapid response instead of Code Blue, Vital Signs were not attempted on patient prior to code. When code was called, staff arrived in a timely manner. Vital Signs, B/P, Pulse, Respiration all documented as none detected at 09:04, 09:07, and 09:21. Blood Sugar at 09:21 was 228 (normal range 80-120). CPR compressions began at 09:04, transferred CPR and care to EMS at 09:12 and Resuscitation ended at 09:34 AM with Patient determined deceased.” Record review of the Emergency Detention Orders dated 10/10/2025 at 12:21 pm revealed that Patient #22 was transported to facility by local law enforcement for the following: - “Consumer stated she’s been having a hard time and has been having issues with her family. Consumer states she has been having suicidal and homicidal ideations. Consumer has several cuts on her thighs and forearm and stated she did it to herself with scissors to feel something. Consumer stated her plan is to overdose.” Record review of the Physician’s pre-admission and medical clearance screening form, dated 10/10/2025 at 2:14 pm, for Patient #22 revealed the following information: -Patient has a history of stress induced seizures, fibromyalgia, Post Traumatic Stress Disorder (PTSD), Depression, Generalized Anxiety Disorder (GAD) and Bipolar. Patient is non-compliant with medication. -Suicide risk level: Moderate Risk -Based on available information, there is evidence of: Risk of SI, HI. -Observation: Q 15-minute checks. Record review of Patient #22’s Nursing Admission Assessment dated 10/10/25 at 6:56 PM by RN #32 documented on page 4 for Reproductive History: “Currently Miscarrying.” Record review of the Incident Reporting Log dated 10/10/25 at 8:30 PM revealed: -“MHW reported to that after fresh air break/smoke break she witnessed Patient #22 passing an object to another patient. The other patient quickly placed the object in his pocket. MHW asked for the object and the patients handed it over. MHW brought the marijuana pen/vape inside to show me. The supervisor was notified immediately and came down to the unit. Patient #22 was understanding, cooperative and accountable for her actions. Patient #22 was educated on how her item is contraband and not allowed on the unit, or at our facility period. Patient #22 is redirectable and trying to get her point across. Patient #22’s doctor was notified, supervisor notified and charge nurse. Patient #22’s eyes were glossy, red and low. No injuries suffered and Vital Signs within normal limits.” Psychiatric Evaluation 10/11/25 at 09:30 AM indicated Patient #22 was a 26-year-old female presented involuntarily. Patient with Suicidal Ideation with a plan to overdose on Heroin. Patient homeless and reported spending 4 days in jail. Patient reports having sleep apnea and insomnia. Start Suboxone 8mg trial now and continue home medications. Record review of the Medical History and Physical for Patient #22, dated 10/11/2025 at 8:00 am, revealed the following information: -Elevated Blood Pressure (B/P)- No chest pain. PRN (As Needed) Hydralazine (blood pressure medication) follow up if uncontrolled. ER (Emergency Room) for acute concerns. Patient reports recent miscarriage. No acute signs/symptoms. Monitor Vital Signs/labs. Record review of the Vital Signs for Patient #22, dated 10/11/2025 at 7:21 pm, revealed that the patient’s blood pressure was recorded as 171/100. Record review of the Physician’s orders for Patient #22, dated 10/10/2025, revealed the following: Hydralazine 10 mg tab by mouth 4 times daily as needed for Systolic B/P >160 and Diastolic B/P > 100. Record review of the Final Physician’s Medication Orders revealed that Hydralazine 10 mg was discontinued on 10/11/2025 at 1:01 pm by the Physician’s Assistant (PA). Record review of the Daily Nurses Progress notes for Patient# 22, dated 10/11/2025 and 10/12/2025 for the time period 7:00 am-7:00pm and 7:00 pm- 7:00 am, revealed no evidence that nursing staff notified the physician of Pt #22’s elevated B/P. Further review of the Nurses progress notes revealed the following: -10/10/25 @ 8:30 pm: “MHW reported and brought to the charge nurse that a marijuana pen/vape was confiscated during fresh air/ smoke break. MHW states witnessing the patient passing an object to her peer. MHW intervened and asked patients to hand over the object seen in passing. To MHW’s eyes and understanding, it was indeed a marijuana pen/vape in other words a “dab pen?”. Patient was redirected and educated that the item is considered contraband and not allowed on the unit or facility. Patient is understanding and cooperative during redirection and correction. MHW reported to the nursing supervisor and the charge nurse alerted the physician. The patient reported SI (Suicidal Ideations) x 4 with no plan or intent stating “It’s seasonal affective disorder and this happens in the fall.” That was also reported to the patient’s doctor. BYR (sic, unknown acronym) implemented for both patient and peer. Patient is cooperative, slightly agitated yet bright prior to incident. Patient states that “admissions” didn’t search her properly due to the marijuana pen/vape being in her jacket pocket through the whole process and even while on the unit. The patient is extremely apologetic and took full accountability for her actions. Will continue to monitor Q15 mins for safety.” -10/11/2025 7:00 pm- 7:00 am: “Pt came to the nursing station requesting her suboxone meds (used for narcotic withdrawal), states I didn’t get it yet. I [RN#24] told pt it’s past due time by pt states I need it because I am craving, my body is shaky and not letting her sleep. I encouraged Pt to lay down, Pt was talking with peers in the dayroom, maybe she will be able to sleep. Pt states she needs it because of her craving. Pt waited in the dayroom until med (suboxone) was administered to her at 1:08 am and apologized for not taking her meds at schedule time.” -10/12/2025 @ 9:04 am: “Nurse (RN#19) went into pts room at 0715-0730 to wake pts up for vital signs and breakfast. Pt was lying on stomach with face to the left side. Pt did appear to be breathing. Mental Health Worker (MHW) (#18) did not take vital signs in the a.m., on this pt, pt needed to be awake and up in dayroom to get vitals. Pt had been up during the night talking with other pts and went to bed late in the a.m. MHW came to RN and told RN that pt did not seem to be breathing, RN went into room and noticed pt was unresponsive. RN called rapid response.” -10/12/2025 @ 10:01 am: “As I (MHW #18) walked into unit at 7:00 am, I noticed the LVN was here waiting to be released, and the other tech didn’t show up. She was also assisting me with rounds. I had to go to the cafeteria to bring the trays back, so I asked her to keep an eye out on the rounds so. When I came back, I started rounding and getting everyone ready to get up. I did check on Pt #22 multiple times until I noticed she was cold. I turned her head around and noticed her lips were blue and that’s when I called the RN (#19) into the room, he helped me flip her over. We examined her and tried to wake her up then called a rapid response.” Record review of the Physician’s Progress Note for Patient #22, dated 10/12/2025 at 8:50 am, revealed the following: -“This provider (NP #25) attempted to evaluate the patient however the patient was observed to be asleep in her room. This provider proceeded to the nurses’ station and spoke with the assigned nurse who reported that he had recently spoken with the patient. The patient stated to him that she was experiencing difficulty sleeping and preferred to rest at that time. This provider advised the nurse that I would return later to allow the patient additional time to rest. A short time thereafter, this provider called the nurse to inquire if the patient was awake in order to proceed with rounding. The nurse informed this provider that a code was about to be called without specifying that it involved this patient. Approximately twelve minutes later, the same nurse contacted this provider to report that the patient was currently undergoing cardiopulmonary resuscitation. This provider immediately returned to the unit and was informed of the ongoing resuscitation efforts. Attending physician, (Staff #57) and covering provider (Staff #58) were notified. The patient was subsequently pronounced deceased. No further follow-up was completed for this patient.” Review of the facility’s policy and procedures titled, Patient Observation Levels, last revised June 2025 indicated the following: ObservSMART: The ObservSMART system is an electronic compliance monitoring process using a tablet [iPAD] to observe and record patient safety check observations (behaviors and locations) for each patient. Procedures: Routine Observation - -On admission, patients are informed that staff will be checking in with them at least every 15 minutes to ensure their safety. -Unit staff are responsible for pairing and placing the ObservSMART band on the patient’s wrist or ankle during the admission process. -Staff will make direct visual contact with each patient every 15 minutes, and confirm they are not in danger or distress, respirations are normal. -Staff will round the hallways during sleeping hours (11 pm to 7 am) every 15 minutes. When making direct 15-minute observation, staff will observe the patient at a minimum of arm’s length distance to confirm the patient’s identity and confirm the rise and fall of the patient’s chest for 3 cycles of respirations to ensure respiration is adequate. -During sleeping hours, staff will identify, confirm movement, and indicate the patients’ position while sleeping while rounding with the ObservSMART system. -Visualize patients in bedrooms/bathrooms, during activities, including fresh air breaks and off unit groups, and/or while sleeping. -Notify charge nurse when patient exhibits high-risk behaviors(s): isolating self, increased agitation, self-harming, etc. -During rounding, staff should never involve the patient (i.e. ask to raise arm, approach directly to invade space, or wake up patient). Charge Nurse a. The unit nurse is responsible for ensuring all assigned staff meet the hospital’s compliance goals. This is best accomplished by completing his/her assigned rounding while monitoring the feedback bar of their assigned staff throughout the shift. Oversight of the ObservSMART rounds and giving constructive feedback ensures that every employee is working to improve patient safety outcomes as stated in the PI Plan. d. Completes walking rounds with off-going RN. f. The Charge Nurse will log into a SMART tablet and conduct a set of observation rounds on every patient present on the unit at that time, at a minimum of twice per shift. The Charge Nurse oversight of patient observation rounds is evident per review of the ObservSMART transaction log report MHW a. At the onset of a shift, the oncoming MHW will sign out a tablet from the nurse and log in. The off-going MHW and the oncoming MHW must complete a dual round of all the patients to ensure their wellbeing. The nurse must be informed about all abnormalities. The oncoming MHW is actively completing rounds while the outgoing is shadowing. After completion, the off-going MHW logs out and signs his/her tablet back into the nurse Hand Off from shift to shift: Charge Nurse: Off going and oncoming staff will walk/monitor the unit jointly, identifying and correlating the patients with the Nursing Shift Report to ensure continuity of care. Both staff will sign the Nursing Shift Report at change of shift to indicate the completion of the handoff procedure. Mental Health Worker: At the onset of a shift, the incoming MHW will sign out a tablet from the nurse and log in. The off-going MHW and the incoming MHW must complete a dual round of all the patients to ensure their wellbeing. The nurse must be informed about all abnormalities. The incoming MHW is actively completing rounds while the outgoing is shadowing. After completion, the off-going MHW logs out and signs his/her tablet back into the nurse. Record review of Patient #22’s documented Observation checks (q-15 minutes) from 10/11/25 at 12:10 AM through 10/12/25 at 09:04 AM, when patient was found unresponsive, only had one documented Charge Nurse/RN observation check, which was on 10/11/25 at 03:34 AM. The overnight shift, 10/11/12 into 10/12/25 (7pm-7am), Charge Nurse/RN #24 failed to perform observation rounds to check on Patient #22’s condition. Further review of the documented observation 15- minute checks for Patient #22, dated 10/12/2025 revealed the following documentation, in part: At 1:05 AM Patient was in the dayroom. Calm. MHW #20 Beacon Signal obtained during observation check. At 1:19 AM Patient was in her bedroom. Calm. No Beacon. MHW #20 At 1:32 AM Patient was in her bedroom, Appears Sleeping - Stomach. No Beacon. MHW #20 At 1:44 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. MHW #20 At 2:28 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Signal. MHW #44 At 2:42 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Signal. MHW #44 At 3:27 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. MHW #20 At 3:42 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. MHW #20 AT 3:56 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. MHW #20 At 4:25 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Signal. MHW #44 At 5:10 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. MHW #20 At 5:27 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. MHW #20 At 5:42 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. MHW #20 At 5:56 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. MHW #20 At 7:09 AM Patient was in her bedroom, Appears Sleeping -Stomach. No signal. MHW #18 (7 AM-7PM staff). At 7:44 AM Patient was in her bedroom, Appears Sleeping -Stomach. No signal. MHW #18 At 7:56 AM Patient was in her bedroom, Appears Sleeping -Stomach. No signal. MHW #18 At 8:17 AM (21 minutes from last documented check at 7:56 AM) Patient was in her bedroom, Appears Sleeping -Stomach. Signal obtained. MHW #18 At 8:28 AM Patient was in her bedroom, Appears Sleeping -Stomach. Signal obtained. MHW #18 At 8:38 AM Patient was in her bedroom, Appears Sleeping -Stomach. Signal obtained. MHW #18 At 8:44 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. MHW #18 (Note: Code blue called at 09:04 AM, due to pt was found unresponsive, no detectable pulse, and breathless. CPR began at 09:04 AM, with EMS taking over at 09:12 AM, and resuscitation ending at 09:34 AM with patient determined deceased.) At 9:05 AM Patient was in her bedroom, Appears Sleeping -Stomach. RN #19. (Active CPR according to Code Blue Form) AT 9:11 AM Patient was in her bedroom, Appears Sleeping -Stomach. RN #19. (Active CPR according to Code Blue Form). AT 9:18 AM Patient was in her bedroom, Appears Sleeping -Stomach. RN #19. (Active CPR by EMS according to Code Blue Form). At 9:32 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Signal. RN #19. (Active CPR according to Code Blue Form). AT 9:37 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. RN #19. (Patient determined deceased after resuscitation ended at 09:34 AM according to Code Blue form). At 9:49 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. No Signal. MHW #59 (Patient deceased). At 9:50 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. MHW #59 (Patient deceased) At 10:05 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. No Signal. MHW #59 (Patient deceased) 10:26 AM (last documented check for this patient) Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. No Signal. RN #19. (Patient deceased). Observations conducted on 10/21/25 at 5:15 PM of Unit L’s cameras from 10/12/25 beginning at 12:15 AM until 9:30 AM revealed the following: Patient #22 is seen sitting at a table in the dayroom from 11:00 pm to 1:00 am, accompanied by 2 other patients. At approx. 1:15 am, Patient #22 is seen obtaining medications from RN #24, then she walks down the hall to her bedroom. MHW #21 is observed at approx. 2:14 am standing just inside the doorway frame (Shoes can be seen in video) of Patient #22’s bedroom while holding the ObservSMART iPad. MHW #20 is observed at approx. 3:42 am standing just inside the doorway frame (Shoes can be seen in video) of Patient #22’s bedroom while holding the ObservSMART iPad. MHW #18 is observed at approx. 7:44 am and 7:56 am standing at the doorway entrance (Shoes can be seen in video) of Patient #22’s bedroom while holding the ObservSMART iPad. (Observation 15- minute checks for 7:44 am and 7:56 am indicated, “no signal.”) Continued review of the facility surveillance video revealed no evidence that RN #24 went into Patient# 22’s bedroom to perform a check on her at any time during the shift. NP is observed at 8:45 am going into Patient #22’s, stays there approx. 17 seconds then walks out, exiting the unit. MHW #18 is observed at approx. 8:52 am entering Patient #22’s bedroom. She is then seen leaning out of Pt #22’s bedroom door at approx. 8:53 am. At approx. 8:56 am, Patient #22’s room mate is seen running down the hall to the nurse’s station, speaking with RN #19. RN #19 walks down the hall and enters Patient #22’s bedroom at approx. 8:58 am. At 9:04 am, other facility nursing staff are observed entering Pt’s bedroom (According to documentation, code blue was called at this time.) Interview on 10/21/25 at 6:00 PM with the facility’s Director of Risk Management when asked about Patient #22’s documented checks and video observation not in accordance with the facility’s policy, she responded the facility was actively completing their investigation and “Root Cause Analysis;” they had 30 days to complete, and from there would implement any necessary action plans once the concerns were determined. In an interview conducted on 10/21/25 at 6:12 pm with MHW #18 revealed that she was on duty the morning of 10/12/25 and she “found” Patient #22 unresponsive in her room that morning. During further interview, MHW #18 stated she had to go to the cafeteria to bring the trays back, so she asked the LVN on duty to keep an eye out on the rounds. When she came back, she started rounding and getting everyone ready to get up. MHW #18 stated that she checked on Pt #22 multiple times, but she didn’t respond or move when called. She was sleeping “on her belly with her arms above her head and couldn’t see rise and fall.” MHW #18 indicated she thought she was asleep, but felt something wasn’t right. After the 3rd time, MHW #18 stated that she touched the Patient’s arm and noticed she was cold. MHW #18 stated she then turned her head around and noticed her lips were blue and that’s when she called the RN (Staff #19) into the room to check her out; they flipped her over and noticed she wasn’t breathing, and a rapid response was called and then a code blue. Further interview with MHW #18 indicated that Patient #22’s roommate stated that she normally snores loudly at night when sleeping, but she didn’t hear her snoring that night. MHW #18 also stated she felt something “may have happened overnight.” MHW #18 was asked about the documented 15 minute checks that indicated, “no beacon” and what that meant. She explained that if you are not close enough to the patient, you will not “catch the beacon.” She also said when patient’s are sleeping, many times they are lying on the beacon and you cannot get a reading, however, she said she was getting a reading from Patient #22’s beacon because the iPAD was “lighting up green.” If it’s red, you have to get closer to the patient. If the iPAD says, “no signal,” then you are not getting the wi-fi transmission for the data and you have to “force the round.” In an interview conducted on 10/21/25 at 7:05 pm, PA # 48 revealed that he conducted Patient #22’s initial medical examination on 10/11/25. PA stated that Pt #22 was admitted with diagnosis of bipolar disorder and suicidal ideations. He revealed that Patient #22 was “a very poor historian” when trying to obtain medical information from her, and at the time of the assessment, Patient #22 was stating she was currently pregnant and having a miscarriage. He further stated that the she exhibited no signs or symptoms of pregnancy/ miscarriage and that her blood pressure was noted to be elevated with Patient denying chest pain. PA #48 revealed that he prescribed hydralazine for her elevated BP and ordered a serum pregnancy test. When asked by the surveyor why he discontinued the afore mentioned Hydralazine on 10/11/25 at 1:01 pm, PA #48 stated, he received a “warning signal” from the Electronic record for the PRN order, it had been 24 hours and it was a “judgment call; because the patient kept saying she was pregnant, I discontinued it due to potential concerns about the fetus.” PA #48 confirmed there had not been any labs available to confirm if Patient #22 was, or was not pregnant. During further interview, surveyor asked PA #48 if nursing staff reported that Patient #22’s blood pressure was severely elevated (171/100) on 10/11/25 at 7:21 pm. He stated, “No, they didn’t tell me, I had no idea. She was about to go on COWS [Clinical Opiate Withdrawal Scale] protocol, which could include Clonidine.” In an interview conducted on 10/23/25 at 12:15 pm, RN #19 revealed that on the morning of 10/12/25 (day of the incident involving Patient #22) he was on duty at 7am, and received report from the night shift RN (#24) he stated that the unit was short staffed that morning as one of the MHW had called-in to work. The off-going night shift RN reported that Patient #22 had been up late the night before (10/11/25) and didn’t go to bed until about 1 am. After the report, MHW staff started their 15-minute checks. At that time (Approx. 7:15 am- 7:20 am) MHW #18 went into Patient #22’s room to wake her up. MHW#18 reported to him that the pt was lying on her stomach with her face turned to the left. MHW #18 further stated that she had tried to wake her up several times, but she wouldn’t wake up. Then at 8:30 am, MHW #18 yelled for him in Patient #22’s room. When he arrived, she reported to him that Patient #22 was not responding. At that time, he stated that he touched her arm gently, and she didn’t seem to be stirring, and he could not see her breathing, and he could not feel any pulse. At that time, he called code blue in an attempt to resuscitate Patient #22. When asked by the surveyor if he was aware of any distance requirements in order for the Pt identification band to be picked up by the iPad using the ObservSMART system, RN #19 stated that he did not know. In an interview conducted on 10/23/25 at 1:30 PM, MHW #20 revealed that she has been with the facility since 2016. She further revealed that on the night of 10/11/25 to 10/12/25 she was on duty and worked from 7pm- 7am. MHW #20 stated that night was uneventful at first, with Patient #22 waiting for her medication by the nursing station with 2 other patients. After receiving her medication, she went to bed quite late. She further stated that it was herself and one other MHW on duty that night to perform 15-minute checks on patients. MHW #20 further stated that during the night, Patient #22 was sleeping on her stomach the whole night (no movement), and as she was a larger patient, it gave her an “alarming feeling.” She stated that Patient #22 started having very short and shallow breaths at some point during the night and reported that to the RN in charge (RN #24). When asked by the surveyor if the RN went down to check on Patient #22 after her report, MHW #20 stated that she never saw her go down the hall to check. During further interview, MHW #20 stated that she was familiar with the ObservSMART system that the facility uses for 15-minute checks. She revealed that “the software is a bit tricky and the distance the iPad can pick-up the arm band signal varies between iPads.” She further stated that if a staff cannot pick up the beacon from the Patient arm band, you can select the option “No Beacon.” In an interview conducted on 10/23/25 at 2:05 pm, RN #24 revealed that she was the nurse in charge of the “side” of the unit Patient #22 resided on the night of 10/11/25- 10/12/25 (7pm-7am shift). She further stated that Patient #22 did not complain all night about any pain or discomfort, only that she wanted her medication. RN #24 stated that at about 1 am that night, she administered Patient #22’s Suboxone medication and then she (Patient #22) went to bed. When asked by the surveyor if RN #24 went to check on Patient #22 after she left the nurses station, RN #24 stated “I checked on her about 15- 20 minutes after she went to bed and she (Patient #22) said she was fine.” When asked by the surveyor what position Patient #22 was in when she went to see her, RN #24 stated that “She (Patient #22) was lying on her chest, with her left arm down by her side, and her right arm up above her head.” When asked if RN #24 checked on Patient #22 later in the shift (after her initial check) RN #24 stated “I can’t remember if I checked on her again that night, but I don’t think so. But I told the MHW to do their rounding’s and make sure everything is ok.” During continued interview, RN #24 revealed that while using the ObservSMART system, MHW’s are supposed to be walking close enough up to the patient to see if their chest is rising and falling (checking breathing). Observations conducted on 10/23/25 at 11:08 AM in Unit H of the iPAD, ObservSMART documented observation checks electronic system and process, revealed the following: LVN #45 was completing patient observation checks using the iPAD for those patients that were highlighted red, which meant the 15-minute observation checks were due, and/or past due. During the observations, LVN #45 would be required to get close enough to the patient’s beacon; within arm’s length, or at times within 4-8 inches of the beacon for the iPAD to make the Bluetooth Beacon connection on the patient’s wrist. Once LVN #45 obtained connection with a signal, the iPAD would light up green, with a pop menu where LVN #45 would choose the observation details for “Location” (i.e. Bed Room, Dayroom, Group Room, Cafeteria, etc.), and “Behavior” (i.e., calm, cooperative, eating, appears sleeping- Left, appears sleeping, Right, appears sleeping, back, appears sleeping, stomach), then click “submit.” Further observation revealed if LVN was not getting a Bluetooth connection with the Beacon or a failed signal, it required the staff to “force the round” according to the LVN, which meant another pop up that indicated, “No Signal. Continue observing patient while out of range?” This required LVN #45 to choose one of the two options; No Beacon, or No Signal, and then Yes, Continue, or No, Cancel. Observation of the iPAD where LVN #45 was logged into had the following statistics: “Obs [Observations]:” 138, “Forced:” 43%, “Comp [Compliance]:” 78%, and “MaxT [Maximum Time Interval]:” 26 Interview on 10/23/25 at 11:20 AM with Unit H’s Charge RN #47 indicated he had no way of reviewing the patient’s history of observation checks within the patient’s records or on the iPAD itself. He could only view the observation documentation in “live time.” Charge RN #47 stated the MHW’s were to conduct documented observations at least every 15 minutes and Charge RN’s were to complete documented checks, “once an hour.” Interview on 10/23/25 at 11:30 AM with MHW #46 stated that every staff had an iPAD on the unit that staff were logged into. He stated when conducting patient observation checks; if you did not get a connection or signal that it could be the patient did not have a beacon, in which the iPAD has it documented on another screen of patients that have a “Paired Beacon,” and those that do not have a Beacon, “Unpaired (No Beacon).” Those without a Beacon would be documented as such, “No Beacon.” Those with a Beacon, but no signal, you would choose “No Signal.’ No signal would mean you did not get a Bluetooth connection with the Beacon or a failed signal. MHW #46 indicated that on the overnight shift, it was a higher probability of getting failed connections because either staff were not getting close enough to the patient to obtain the connection, or the patient’s “sleep on them [Beacons],” and you do not get a signal when they sleep on them. In this situation, you will have to “force the round,” which makes your “forced percentages, go up; which are not supposed to exceed 40% of that person logged in,” or you will be getting a phone call because it is monitored. MHW #46 stated you are not supposed to indicate “No Beacon” if the patient had a Beacon on. The tablet will tell you if there is a Beacon paired and there is a Bluetooth icon that will be green if you are in close enough proximity and a red Bluetooth icon if you are not in close enough proximity to get a signal. MHW #46 further indicated some iPAD’s were difficult in obtaining a good connection when close in proximity and others would obtain them when you were multiple feet away. Observations on 10/23/25 at 11:35 AM, MHW #46 displayed these findings when he demonstrated to this surveyor the iPAD he was using did not obtain good connections within 5-8 inches of the patient’s beacon. MHW #46 would almost have to tap the patient’s Beacon on their wrist to obtain a connection. MHW #46 then obtained another iPAD that would show connections with patients when he would get within 5 to 10 feet away from the patient. MHW #46 further demonstrated he was able to obtain a connection on a patient who was on the other side of a wall, and not visible. The iPAD shows “grayed out” for patients until you get within proximity to obtain a connection. It will also tell you how many feet you are away from the patients. As you get closer, the number of feet decreases, and then once close enough in proximity the patient will no longer be greyed out, which allows you to document an observation round on the patient. Review of MHW #18’s Re-Training dated 7/21/25 for, “Patient Observation Rounds Expectations Acknowledgment” indicated the following, in part; -Visualize and account for each patient assigned to me within the required timeframe (q15). -Update and document the patient’s location and activity on the Patient Observation Rounds Sheet/ObservSMART app each time I observe the patient. Visualize each sleeping patient to ensure they are safe and breathing adequately by: - Looking for the rise and fall of the chest, -Counting at least three respirations, and -Spend sufficient time (10 seconds per patient) in the room to identify patient and ensure the patient is not in distress. Review of MHW #18’s “Patient Observation Rounds Post-Test” indicated the following, in part; 3. The Charge Nurse/Unit Supervisor is required to oversee staff completion of Patient Observation Rounds no less than twice per shift and this must be documented at a minimum of six (6) times evenly distributed over a 24 hour period. True. 4. Checking on patients at night or on bed rest requires no additional activities. False. -According to the ObservSMART website at: https://www.observsmart.com indicated the following information, in part: With ObservSMART, staff complete required safety rounds using tablets that sync with tamper-resistant patient wearables; Bluetooth enabled “beacons.” The beacon is a small, Bluetooth-enabled wireless device worn by a patient, typically in a wristband or ankle band. The observation is assured through customizable staff-to-patient proximity settings. Checks cannot be completed unless the staff member is within the prescribed distance of the patient. This ensures observation compliance and mitigates the severe risks and costs associated with missed and falsified observations. Reporting and Analytics- ObservSMART provides real-time reporting - staff performance feedback bar. Unit and staff compliance reports, Advanced reporting with proactive alerts, filters, and comparative views, that help support the clinical, business risk and quality teams. Review of Policy and Procedure titled “Searches”, last revised June 2025 revealed the following, in part: 3. Full body searches and process for skin assessment: Full body searches require removal of clothes with a full visual inspection of the patient’s body, including the inspection of clothing and property carried by the patient. Full body searches are conducted on all patient admissions during the initial nursing assessment that takes place on the unit. Will be conducted by two staff members; one being a Registered Nurse. Full body searches occur only in the examination room. Any patient requiring a full body search is in full observation of staff prior to this search, to prevent the patient from removing hidden items and storing them in the facility.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 21863 Based on review of records, policy, and interview, the facility failed to ensure medical records were accurately written and promptly completed. Specifically, 1.) Patient #22’s clinical inpatient record was not accurate when on, 10/12/25 at 09:04 AM, she was found unresponsive and determined deceased at 09:34 AM after resuscitation ended. Patient #22’s electronic documented observation checks for 10/12/25 by the Registered Nurse (RN) and Mental Health Worker (MHW) from 09:05 AM through 10:26 AM documented patient “appears sleeping - stomach” even after Patient #22 was pronounced deceased; and 2.) the Memorandum of Transfer (MOT) for 7 of 7 patients (Patient #25, #26, #27, #28, #29, #30, and #31) reviewed who were transferred into the hospital from another facility were not completed with the required information; and in accordance with the facility’s policy. Findings included: 1.) Review of the facility’s policy and procedures titled, Patient Observation Levels, last revised June 2025 indicated the following: ObservSMART: The ObservSMART system is an electronic compliance monitoring process using a tablet [iPAD] to observe and record patient safety check observations (behaviors and locations) for each patient. Procedures: Routine Observation - -On admission, patients are informed that staff will be checking in with them at least every 15 minutes to ensure their safety. -Staff will make direct visual contact with each patient every 15 minutes, and confirm they are not in danger or distress, respirations are normal. -Staff will round the hallways during sleeping hours (11 pm to 7 am) every 15 minutes. When making direct 15-minute observation, staff will observe the patient at a minimum of arm’s length distance to confirm the patient’s identity and confirm the rise and fall of the patient’s chest for 3 cycles of respirations to ensure respiration is adequate. -During sleeping hours, staff will identify, confirm movement, and indicate the patients’ position while sleeping while rounding with the ObservSMART system. -Visualize patients in bedrooms/bathrooms, during activities, including fresh air breaks and off unit groups, and/or while sleeping. Review of the documented observation 15- minute checks for Pt #22, dated 10/12/2025 revealed the following documentation, in part: At 7:56 AM Patient was in her bedroom, Appears Sleeping -Stomach. No signal. MHW #18 At 8:17 AM (21 minutes from last documented check at 7:56 AM) Patient was in her bedroom, Appears Sleeping -Stomach. Signal obtained. MHW #18. At 8:28 AM Patient was in her bedroom, Appears Sleeping -Stomach. Signal obtained. MHW #18 At 8:38 AM Patient was in her bedroom, Appears Sleeping -Stomach. Signal obtained. MHW #18 At 8:44 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. MHW #18 Record review of the CODE BLUE FORM, dated 10/12/25 for Patient (Pt) #22 revealed at 09:04 AM, Patient found lying face down on her bed in her room, unresponsive, no detectable pulse. Pt presents breathless. CPR compressions began at 09:04, transferred CPR and care to EMS at 09:12 and Resuscitation ended at 09:34 AM with Patient determined deceased. Further review of Patient #22’s documented observation checks for 10/12/25 revealed: At 9:05 AM Patient was in her bedroom, Appears Sleeping -Stomach. RN #19. (Active CPR according to Code Blue Form) AT 9:11 AM Patient was in her bedroom, Appears Sleeping -Stomach. RN #19. (Active CPR according to Code Blue Form). AT 9:18 AM Patient was in her bedroom, Appears Sleeping -Stomach. RN #19. (Active CPR by EMS according to Code Blue Form). At 9:32 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Signal. RN #19. (Active CPR according to Code Blue Form). AT 9:37 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. RN #19. (Patient determined deceased after resuscitation ended at 09:34 AM according to Code Blue form). At 9:49 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. No Signal. MHW #59 (Patient deceased). At 9:50 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. MHW #59 (Patient deceased) At 10:05 AM Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. No Signal. MHW #59 (Patient deceased) 10:26 AM (last documented check for this patient) Patient was in her bedroom, Appears Sleeping -Stomach. No Beacon. No Signal. RN #19. (Patient deceased). Interview on 10/21/25 at 6:00 PM with the facility’s Director of Risk Management when asked about Patient #22’s documented checks, she responded the facility was actively completing their investigation and “Root Cause Analysis;” they had 30 days to complete, and from there would implement any necessary action plans once the concerns were determined. 2.) Review of the MOTs for Patients #25, #26, #27, #28, #29, #30, and #31 were reviewed. All were found to be missing the following required information: (xi) the time and date on which the receiving physician assumed responsibility for the patient (xii) the time and date on which the patient arrived at the receiving facility (xiii) signature and date of receiving administration. Interview was conducted with Staff #6 on the morning of 10-20-25 in the hospital intake area. All patients arriving at the hospital were processed through this area. Staff #6 explained that the intake department was also responsible for the transfer center. The transfer center was responsible for coordinating all patients being transferred into the facility and out of the facility. Interview was conducted with Staff #27 on 10-20-25 at 11:28 AM. Staff #27 confirmed that as part of the Transfer Center duties, she completed the MOT for patients who were transferring out of the facility but did not ensure the receiving portion of the MOT (Acknowledgement of Memorandum of Transfer - To be completed by Accepting Hospital) was completed. Staff #27 explained that the MOT remained with the patient medical record when the patient was admitted to their assigned unit. Review was made of policy Title: Memorandum of Transfer; Policy Number: PC-60-A; Last Review Date: May 2025. Under the Policy section, “The Memorandum of Transfer form will be completed for each patient who is being transferred from Laurel Ridge Treatment Center to another hospital.” This policy did not address the obligations of the hospital as the receiving facility to complete the MOT provided by the transferring hospital. Review was made of policy Title: Patient Transfer; Policy Number: PC-60-B; Last Review Date: May 2025. Under the Policy section, “Laurel Ridge shall provide appropriate medical screening examinations and if the individual is determined to have an emergency medical condition (EMC), any necessary stabilizing treatment or an appropriate transfer for the individual as required by the Emergency Medical Treatment and Active Labor Act (EMTALA) and Title 26, RULE 510.43 of the Texas Administrative Code.” On Page 6 of 6, Memorandum of Transfer: “1. The Memorandum of Transfer form will be completed for each patient who is being transferred from Laurel Ridge Treatment Center to another hospital. Refer to PC-60-A.” 2. A copy of the memorandum of transfer shall be retained by the transferring and receiving facilities. The memorandum shall be filed separately from the patient’s medical record and in a manner which will facilitate its inspection by the Department of State Health Services. All memorandum of transfer forms filed separately shall be retained for five years.” This policy did not address the process or responsibilities as the receiving facility to complete the MOT provided by the transferring hospital.”

“PROTECTING PATIENT RECORDS CFR(s): 482.24(b)(3) The hospital must have a procedure for ensuring the confidentiality of patient records. Information from or copies of records may be released only to authorized individuals, and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records. Original medical records must be released by the hospital only in accordance with Federal or State laws, court orders, or subpoenas. This Standard is not met as evidenced by: 46435 Based on observation, interview, and record review, the facility failed to maintain its patient medical records in a manner that ensured confidentiality, security, and fire/life safety protection. The failure to control access to patient medical records and to provide fire protection, placed all medical records and adjacent occupied areas at risk of unauthorized access, tampering, loss, and/or fire hazards. Findings included: During multiple tours of the Health Information Management (HIM) department located within the “School Building,” on 10/21/2025 between 9:30 a.m. and 12:30 p.m, the following was observed: -The surveyor observed the medical records file room door propped open. -Inside, the medical records room were six months of active and discharged confidential patient’s medical records that were stored on open shelving and movable racks. -While standing near the HIM main entrance area, the surveyor observed at least four separate staff members and one staff member accompanied by two patients enter through the HIM main door and exit out the side door leading to other areas of the building. Staff #28 confirmed all staff have keycard access and that the room is routinely used as a passageway. These practices placed all patient medical records at risk of unauthorized use or disclosure of patient confidential information. Examples of confidential patient information accessible from the patient’s charts were: patient’s mental health diagnoses, medical history, and treatment(s), along with demographic information (name, date of birth, address, phone number, social security number), and emergency contact information. -There was no signage that restricted access, and no staff intervention occurred during these observations. -Further observation confirmed that the file room also contained food storage, a microwave, and break items for the staff. -The Filling room had no fire suppression system or fire-rated separation from other areas of the building. These same conditions were confirmed upon a return visit later that same morning on 10/21/25, with the file room door still open and unmonitored. Interview with Staff #28 during these observations acknowledged that there was no work order for a fire suppression system and that a previous discussion with administration had been dismissed. During a review of the facility’s Incident Reports revealed a Fire occurred within the School Building, staff bathroom on 9/11/25 at 05:00 AM. The Medical Records, HIM is also located within this same building. It was determined the fire in the bathroom was started by an exhaust fan that overheated in the ceiling of the bathroom. This caused the fan to catch fire and ignited the toilet directly below. Staff present in building quickly became aware of the fire via smell of smoke, and smoke coming from bathroom direction. Staff present immediately pulled fire alarm. The local fire department arrived within 10 minutes and successfully extinguished a fire to ensure safety.”

“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: 26870 Based on observations, record review and interview the facility failed to ensure medications, including controlled substances, were delivered/transported to all units including the specialized unit across the street using secured medication boxes. The coolers used were not designated for pharmaceutical transport, were not locked during delivery, and were not cleaned between deliveries. This practice involved all medications, not just non-controlled substances, creating a potential risk for contamination, diversion, and loss of drug integrity. Findings included: Observations on 10/22/25 at 11:00AM during the tour of the facility pharmacy revealed soft black totes with a silver colored lining inside, that were kept in the cabinet. Interview on 10/22/25 11:00AM with facility Staff #15 at the time of the observation revealed those totes were used to transport medication to various units across the campus and at the special facility across the street. When asked if the medications were locked during the transport, Staff #15 revealed the tote bags were not locked and revealed the tote bags were not cleaned and disinfected between use. Record review of the facility policy titled, CONTROLLED MEDICATION AND DIVERSION PREVENTION, revised 1/2025 states in part... Storage of Controlled Substance Drugs 4.4.1 Controlled substance drugs are stored in a locked, secure place within pharmacy. The pharmacist has keys to the controlled substance cabinet. Interview on 10/23/2025 at 2:00PM with facility Staff #7 revealed they do not have a policy on transportation of medications through out the facility and transporting medications across the street. 45179”

“CONTROLLED DRUGS KEPT LOCKED CFR(s): 482.25(b)(2)(ii) Drugs listed in Schedules II, III, IV, and V of the Comprehensive Drug Abuse Prevention and Control Act of 1970 must be kept locked within a secure area. This Standard is not met as evidenced by: 26870 Based on observations, record review and interview the facility failed to ensure medications, including controlled substances, were delivered/transported to all units including the specialized unit across the street using secured medication boxes. The coolers used were not designated for pharmaceutical transport, were not locked during delivery, and were not cleaned between deliveries. This practice involved all medications, not just non-controlled substances, creating a potential risk for contamination, diversion, and loss of drug integrity. Findings included: Observations on 10/22/25 at 11:00AM during the tour of the facility pharmacy revealed soft black totes with a silver colored lining inside, that were kept in the cabinet. Interview on 10/22/25 at 11:00AM with facility Staff #15 at the time of the observation revealed those totes were used to transport medication to various units across the campus and at the special facility across the street. When asked if the medications were locked during the transport, Staff #15 revealed the tote bags were not locked and revealed the tote bags were not cleaned and disinfected between use. Record review of the facility policy titled, CONTROLLED MEDICATION AND DIVERSION PREVENTION, revised 1/2025 states in part... Storage of Controlled Substance Drugs 4.4.1 Controlled substance drugs are stored in a locked, secure place within pharmacy. The pharmacist has keys to the controlled substance cabinet. Interview on 10/23/2025 at 2:00PM with facility Staff #7 revealed they do not have a policy on transportation of medications through out the facility and transporting medications across the street. 45179”

“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: 26870 Based on observation, interview, and record review, the facility failed to ensure policies and procedures were followed, developed, and/or available for the management of outdated and unusable medications to ensure these medications were not available for patient use, compromised, and kept secured. Specifically, 1.) the pharmacy manager’s office was unlocked with a large bin that contained outdated/expired medications. There were individual pill packs, including ones with expiration dates of 2026, 2027, and 2028 (not outdated), that the pharmacy manager placed back into common stock for reuse; and, 2.) a scheduled IV-controlled medication, Modafinil, was not secured with documentation of accountability, controlled use, and disposition. The pill bottle that contained Modafinil was observed in the controlled drug storage area with a patient’s name scratched off and no documentation or tracking information available. Findings included: 1.) Observations on 10/22/2025 at 11:20 AM during the tour of the pharmacy revealed a grey trash bin. Inside the grey trash bin was medications in pill packs. When the Staff #15 showed the medications to the surveyors, the medications were not expired. Sertraline 100mg expiration date 2/29/28 Olanzapine 5mg expiration date 12/2027 Thorazine 50 mg expiration date 9/16/2026 Interview on 10/22/2025 at the time of the observations with Staff #15 revealed that the grey trash bin is where they keep their expired medications and medications they do not want to return to stock. When asked why non expired medications were in that bin, Staff #15 explained it “too labor intensive to restock” after a patient was discharged. When asked if she was following the facility policy, she stated “she was just doing her own thing”. Observation at the time of the interview, Staff #15 took the non- expired medications from the surveyor’s hand and placed the non expired medications back to the current stock. Record review of the pharmaceutical policies and procedures revealed the facility did not have a policy or procedure that addressed outdated, mislabeled, or otherwise unusable drugs. 45179 2.) During a tour of the pharmacy on 10/22/2025 @11:00 am the following observations were found: In the locked narcotics cabinet above the pharmacist counter a plastic pill bottle with medication name scratched out in black marker leaving the medication name and initials of staff illegible. The contents of bottle unknown and no count identified on label. Upon visual inspection several white tablets were cut in half. Readable was 100mg TAB Indication: Hx: ADHD; daytime sleep, send 7, Stop: 7/30/2024 23:59 Exp Date 7/2/26. In an interview with Staff #15 during the time of the observations, stated that the pill bottle that was scratched out and not readable was Modafinil, used for seizures, and it is “not a fast mover” in the pharmacy. Review of Policy and Procedure PHR-128 RE: Controlled Medication and Diversion Prevention Medication Management states in part, Page 3 of 6; 4.7 Labeling of Controlled Substance Containers, 4.7.1 The labeling of controlled substance containers shall be limited to the pharmacist and shall contain: 4.7.1.1 Name of Medication 4.7.2.1 Number of Tablets 4.7.2.3 Initials of Pharmacist”

“ADEQUACY OF LABORATORY SERVICES CFR(s): 482.27(a) The hospital must have laboratory services available, either directly or through a contractual agreement with a certified laboratory that meets the requirements of part 493 of this chapter. This Standard is not met as evidenced by: 21863 Based on observation, interviews, and record review, it was determined the facility’s waived laboratory testing used for patients drug urine screenings were not following the manufacturer’s instructions in regards to the documentation of the patient’s results in their medical record, and in accordance with CLIA regulatory requirements; 493.15(e) Laboratories performing waived tests, must - (1) Follow manufacturers’ instructions for performing the test. Findings included: Review of the facility’s Policy titled, CLIA-Waived Testing last reviewed April 2025, indicated the following, in part; Policy: Laboratory testing is performed in accordance with the Clinical Laboratory Improvement Amendments of 1988 (CLIA). CLIA-waived testing performed at the facility provides a consistent approach of waived test results that may be used for diagnosis and treatment when follow up testing is provided. Procedures: Urine Drug Screening (UDS): Preliminary Qualitative, Confirmatory testing must be performed using outside lab. Reagent Use- Manufacturer’s Instructions. Results Reporting - Results are reported to the Licensed Independent Practitioner (LIP) may obtain validation of results as needed. 3. In addition to detailed information in table above, specific manufacturer’s instructions will be used as policy or procedures for each waived test and or waived testing instrument. Observation of the CLIA waived Multi-Panel Drug Test Cup [urine collection cup] manufactured by DrugSure revealed there were 10 separate dip sticks within the plastic urine collection cup. The testing strips were observed as follows and in accordance with the manufacturer’s instructions provided by the staff: COC150 - Orange [Cocaine] THC - Blue [Tetrahydrocannabinol, Cannabinoids, Marijuana] MOP - Purple [Morphine, not on manufacturer’s instructions provided by staff, dated 12/17/2024] AMP500 - Teal [Amphetamine] MET500 - Green [Methamphetamine] BZO - pale Brown [Oxazepam, Benzodiazepines] MTD - Orange [Methadone] OXY - Pink [Oxycodone] MDMA - light Green [Methylenedioxymethamphetamine] BUP - Brown [Buprenorphine] Email with the manufacturer representative indicated MOP, is also referred to as an Opiate Panel - OPI300 which uses the Morphine as the calibrator but with the concentration cut off level of 300 (ng/ml) for this Opiate panel and would not include all opiates. Review of the CLIA Waived Multi-Drug Urine Screening Cup, Manufacturer’s “Instructions for Use,” revision date 12/17/2024, indicated the following, in part; INTERPRETATION OF RESULTS: Negative: This negative result indicates there is no drug in the specimen, or the drug is present but below the cutoff concentration of the test. Preliminary Positive: This preliminary positive result indicates the specimen “may contain the drug” at a concentration above the cutoff level of the test. “IMPORTANT: A positive result on a drug screen is called preliminary for a reason. A more specific alternative chemical method must be used to obtain a confirmed positive result.” A preliminary positive test result does not always indicate that the donor took illegal drugs, and a negative test result does not always indicate the donor did not take illegal drugs. LIMITATIONS: 1.) The DrugSure Multi-Drug Urine Screening cup provides only a qualitative, preliminary analytical result. A more specific alternative chemical method must be used to obtain a confirmed preliminary positive result. Gas Chromatography-Mass Spectrometry (GC-MS), Liquid Chromatography-Mass Spectrometry (LC-MS), and their tandem mass-spectrometer versions are the preferred confirmatory methods. Observation of the facility’s Health Care Systems (HCS) electronic Medical Record (eMR) documentation for UDS on 10/23/25 at 2:15 PM indicated the following listed drugs to document either negative or positive only: Amphetamines Benzodiazepines Buprenorphine Cocaine Ecstasy (This is a street name of the drug MDMA, and not a clinical term) Marijuana (Did not include the clinical term Tetrahydrocannabinol (THC) Methadone Methamphetamine MOP Opiates Oxycodone Review of Patient #36’s, Medical Record documentation for the UDS documented on 10/23/23 at 13:30 by LVN #31 indicated the following: Amphetamines - Negative Benzodiazepines - Positive Buprenorphine - Negative Cocaine - Negative Ecstasy - Negative Marijuana - Positive Methadone - Negative Methamphetamine - Negative MOP Opiates - Negative Oxycodone - Negative Name of MD notified of result - Yes (No name provided.) Further review revealed there was no indication in the patient’s record that the UDS positive testing was “preliminary positive,” or a confirmed preliminary positive obtained by a more specific alternative chemical method. Review of Patient # 37’s eMR physician orders indicated in part; Urine Drug Screen In House Nurse Perform. Every shift until complete. If positive results order drug screen #770701 and send to labcorp for confirmation. Interview on 10/23/25 at 2:15 PM with LVN #31 stated the patient’s medical record program, HCS eMR, only allowed entry for “negative or positive values” when entering the UDS results into the patient’s online eMR. LVN #31 stated that if there was a positive result, then she would notify the physician. LVN #31 stated that the UDS are not automatically sent off to the facility’s contracted lab for confirmation or separate testing unless the physician specifically orders it, (referencing Patient #37), and then a lab request is printed out and the urine sample sent.”

“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: 40989 Based on observation, interview, and record review, the facility failed to ensure the facilities, supplies, and equipment was maintained to ensure an acceptable level of safety and quality. Findings included: A tour of the Electroconvulsive Therapy (ECT) Unit was conducted on 10/20/2025 at 2:30 PM with Registered Nurse (RN) Staff #12 and RN Staff #13. While observing in the ECT Treatment Room, there was a defibrillator (a medical device that delivers an electric shock to the heart to restore a normal rhythm during a cardiac arrest or life-threatening arrhythmia) stored on top of a red emergency cart. The equipment did not have a current preventive maintenance (PM) sticker. Preventive maintenance is a process of inspecting, servicing, and repairing equipment to prevent failures before they occur. RN Staff #13 was asked if there was something wrong with the defibrillator. RN Staff #13 stated that when the maintenance person came to perform the PM, he did not place a sticker on the equipment and told us that it needed to be replaced. The surveyor asked RN Staff #13 to print a strip from the defibrillator. The printed strip will show the date, time, and the cardiac rhythm. The printed strip was not readable. There was little to no ink in the machine. A review of the Safety Check Inventory document revealed the last time the Defibrillator was checked was 8/2025. The equipment was marked as “Failed. Unit needs maintenance, printer not working”. RN Staff #13 was asked if an alternate defibrillator was available for use. RN Staff #13 confirmed there was no other defibrillator available for use. RN Staff #13 confirmed the equipment failed the PM check in 8/2025, but remained in the treatment room for patient use for greater than 2 months after being instructed to remove it from service. 26870 Observations on 10/20/2025 at 10:18AM of the Emergency Treatment Room on the Brazos Unit revealed the following: -The crash cart’s, Automated External Defibrillator (AED, used to treat sudden cardiac arrest) was set up with Pediatric Pads. There were no pediatric patients on the Brazos unit. Interview at the time of the observations with Staff #7 revealed the AED would not have been set up with pediatric pads as the youngest patient in the unit was 12 years old, and confirmed knowledge that pediatric AED pads were only used for pediatric patients 8 years old, and younger. Record review of the facility policy revealed there was no policy on the facility’s AED. Staff #7 confirmed there was no policy when asked. -The Electrocardiogram (ECG or EKG) machine that measures and records a person’s heart electrical activity, in the corner of the treatment room. Surveyor asked Staff #4 the last time the EKG was checked. Interview with Staff #4 at the time of the observation stated it should have been checked monthly. Surveyor requested documentation for the monthly checks and Staff #4 stated there were not any EKG check sheets found. -The Eye Wash station did not have enough water pressure to cleanse the eyes of any harsh chemicals that may have gotten in patients or facility staff eyes. Interview with Staff #40 during these observations confirmed the water pressure was not strong in the Brazos Unit, stating, “that would not wash the eyes”. Observations on 10/20/2025 at 2:30 PM of the Guadalupe Unit revealed the Eye Wash station had too strong of water pressure which potentially can cause injury to the eyes. When surveyor turned on Eye Washing station, the water shot up to the ceiling, with water dripping on the floor. Interview with Staff #7 during these observations confirmed the water pressure was too strong to use the Eye Wash station in the Guadalupe Unit. Observations conducted on 10/20/2025 at 11:10 am in the Guadalupe unit with Staff #7 present revealed the washer and dryer room was left unlocked with chemicals stored on the floor next to the equipment. This room was accessible to the all patient’s in the common area of the unit. Interview with Staff #7 during these observations stated that the washer and dryer room should be locked at all times, but the latch above the door was not in its proper position. 32143 Findings: A tour was taken of the Missions unit 100, 200, and 300 on 10/21/25 at 12:13 pm. The general courtyard grounds had multiple large rocks on the ground. Rocks were loose and able to be used as a possible weapons. Emergency Treatment Room The Otoscope and Ophthalmoscope hanging on the wall had an inspection sticker dated 5/25 but the scopes were not working and were unable to be turned on. General Bathroom The bathroom on hall 100 had a plastic bag in the trash can. A patient could use the bag for suffocation. The Seclusion Room The seclusion room had picture tiles on the walls. 41048 During the facility tour on 10/20/2025 at 11:15 AM the following was found in the facility grounds: The facility has a pool that is currently closed as per the administrative team. The main gates leading to the pool area are locked and require a staff member with a key to open. The surveyor found direct pool access around the corner where two orange cones with a sign that reads “no patients allowed” allows access to the pool area. The pool area is under construction. Several tools and machinery were found unattended and easily reachable. Two saw blades were left on a picnic table. Interview with Staff #56 during these observations on 10/20/25 at 11:20 AM confirmed that these tools should not be unattended. The pool area did not have a fence around the pool as the maintenance team is repairing the fence. The pool is currently filled with water. Further Observations, upon walking around the pool, double doors were found. This door led to the facility’s maintenance area, as explained by staff #56. Staff #56 stated that the doors are controlled by access and are always locked. Observations- the doors were found unlocked and easily opened when the surveyor pulled on the door handle. The double doors upon closer inspection were in disrepair, missing hinges were noted. The doors did not lock properly, and it took several pulls to engage the locking mechanism. The surveyors were able to freely enter the workshop and maintenance area plus office space. The area was vacant at the time and the surveyor was able to access the offices, the workshop area where multiple tools were found as well as chemical materials. The shop opened an unsecure staff parking lot. Staff members were seen in this area. This is a patient safety concern and presented elopement prevention issues as these doors were found to be nonfunctional, potential for unauthorized egress or access to restricted areas. Interview with Staff #56 on 10/20/2025 at 11:35 AM stated that this door must be pulled hard to close and that it would be fixed. 21863 Observation of the ECT Unit on 10/20/2025 at 3:15 PM with Registered Nurse (RN) Staff #10 revealed the entrance door to the pre and post operative area had a built in ledge above. On top of this ledge was metal conduit routed throughout and there was an unsecured bundle of thin red wire lying on top where patient’s had access to. Interview with RN #10 during these observations indicated she did not know why that wire had been left there and she would notify Staff #56 who is over the environment. 45179”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 40989 Based on observations, interviews, and document review, the facility failed to maintain a clean and sanitary environment to mitigate the transmission of infectious and communicable diseases in 11 (Guadalupe, San Jacinto, Navasota, Brazos, Medina, Missions, Electroconvulsive Therapy {ECT} Unit, Comal, Pharmacy, the Kitchen, and the Linen storage area) of 11 areas observed. Findings included: Observation tours were conducted on 10/20/2025-10/22/2025 with Registered Nurse (RN) Staff #12, RN Staff #10, and Staff #23. The following infection control deficiencies were observed: Guadalupe Unit In the patient medication room an accumulation of dirt, dust, and trash was noted on the inside of the blue and green storage bins used to store single-use patient medication cups, sterile syringes with needles, and Fixodent for a patient. The patient’s medication refrigerator was soiled with dirt, dust, and trash. The Patient Nutrition Room had a coffee maker sitting on top of a metal cookie sheet that appeared to have heavily burned grease buildup in the corners. This would make the pan difficult to clean and sanitize. The coffee maker had a dried white substance on the side, and dust was noted around the bottom of the coffee maker. An opened carton of 9-oz Maxwell House coffee was not dated with the open date or beyond-use date. Inside the patient nutrition refrigerator, the bottom shelf was noted to have a dried white substance on the surface next to the milk cartons, and inside the door on the bottom rack, dirt and dust were seen. The shower in room 812 was missing paint around the showerhead, leaving the metal surface unable to be properly sanitized. Navasota Unit In the Patient Nutrition Room in front of the double sink, the front of the cabinet was missing a board, and was exposing the porous surface that cannot be cleaned or sanitized. That piece of wood was seen lying on the metal rack next to the sink. Under the double sink, the cabinet was broken and had exposed screws where the doors had been screwed shut at one point. When the cabinet was opened, there were two towels and a plastic container stored under the sink. The towels were heavily soiled with dirt and dust. The white towels had turned brown on the edges and were dry after what appeared to be a water leak. The bottom of the cabinet was heavily soiled with dirt, dust, and debris. The inside of the cabinet door was soiled with a dried brown liquid that had run from the top of the door to the bottom of the door. The fan on top of the microwave was powered on when the surveyor entered the room and was noted to be heavily soiled with dirt and dust. The inside of the microwave was soiled with dirt and dust, a yellow-colored dried liquid, and cooked popcorn kernels that had fallen out of a bag. The floor was covered with dust and trash. A two-tiered cart that was used to transport meals from the cafeteria to the unit for patients who were on unit restrictions had a buildup of dirt and dust on both levels of the cart. Inside the patient medication room was an Omnicell (an automated medication dispenser). The empty trays at the bottom of the Omnicell were soiled with dirt and dust. San Jacinto A hand-washing sink for patient and staff use was available in the dayroom area. The caulk around the sink was brown and peeling away from the metal sink. On the surface of the sink were multiple areas of a dried white residue. In the patient nutrition room, a lower cabinet was noted to have a full 3-gallon bottle of water. It was placed on the shelf, causing it to collapse. The shelf was soiled with dirt, dust, and debris. On the outside of the cabinet, closest to the floor, there were visible cobwebs. The cabinets above the microwave were used to store snacks for patients. Next to the packages of microwavable popcorn, multiple live ants were seen. A two-tiered cart used to transport meals from the cafeteria to the unit for patients who were on unit restrictions had a buildup of dirt and dust on both levels of the cart. Inside the patient nutrition refrigerator, RN Staff #12 confirmed that the staff had stored their personal food on the bottom shelf in the door. All shelves were soiled with dirt and dust. An open bottle of Gatorade was stored inside the refrigerator without an open or expiration date, or a patient’s name. The half door that allows you to enter the nurses’ station was missing a large piece of wood, exposing the porous surface. That surface could not be cleaned or sanitized to prevent the spread of infectious disease. Inside the equipment storage room was a mobile vital sign machine that was labeled as clean. The bottom of the equipment was heavily soiled with dirt and dust. Next to the sink, on the countertop, was a large dried brown liquid. Inside the sink were bits of trash and white and brown colored stains. The wall behind the sink was missing paint and exposing the porous surface. The floors were heavily soiled with dirt and trash. Under the sink, cleaning supplies, crayons, and office supplies were being stored. Inside the patient exam room was an electronic portable language line used for patients who did not speak English. The bottom of the equipment was so soiled that the surveyor could draw a line in the dust. The outside of the emergency cart, on the top and bottom, was heavily soiled with dirt, dust, and debris. Electroconvulsive Therapy (ECT) Unit Inside the procedure room where ECTs were performed, there was a cart that was used to store anesthesia supplies. The top and bottom of the cart was heavily soiled with dirt and dust. In the bottom drawer was a cardboard box with webbed edges. Webbed edges can harbor small insects. Inside that box was a smaller bin that was storing approximately 20-25, 3(milliliters) ml syringes with a blunt tip needle attached to the syringe. The syringes and needles were outside of the original sterile package. Two rolls of tape were noted to have lint, dust, and debris stuck to the outer edges along the adhesive. The red emergency cart was soiled with a dried brown liquid, dirt, and dust around the bottom and on the inside of the bottom drawer. The door that entered the procedure room had old gauze sponges covered by tape over the locking mechanism to hold the door shut during procedures. A storage closet across the hall from the pre-operative area stored clean supplies. There were 3 shelves storing used Ambu bags with disposable face masks (a bag and mask used to provide positive pressure ventilation to a patient who is not breathing). The Ambu-bags had the patients’ first name and last initial on the bag. There was no other identification for the patient, and no documentation of when the face mask needed to be replaced. An interview was conducted with RN Staff #13 on 10/20/2025 after 11:40 AM. RN Staff #13 stated that the nurses cleaned the Ambu-bags and disposable face masks with a Sani-wipe (a pre-moistened disposable cloth containing a chemical solution) and put them back in the bag and used them the next time the patient came in. RN Staff #13 was asked how often the Ambu bags and face masks were replaced. She confirmed that the same mask and Ambu bag were used for the entirety of the patient’s treatment unless they needed to be replaced before then. Staff #13 confirmed the masks were reused to help lower the cost because some of the patients were coming 3 times a week. RN Staff #12 and #13 confirmed the facility did not have a written process to clean the disposable Ambu bags and face masks. A review of the Instructions for Use of the Ambu Disposable Face Mask was as follows: “ ...CAUTIONS 1. Never store the Ambu Disposable Face Mask in a deformed state; otherwise, permanent distortion of the mask could occur, which may reduce the ventilation efficiency. 2 ... 3. Do not clean the Ambu Disposable Face Mask any other way than described in this IFU. Other procedures may cause deformation or damage to the device ... 3. Product use 1... 2... 3. If deemed necessary, the surface of the product can be manually cleaned for the same patient use with water and a mild detergent. Rinse thoroughly with clean water. Allow to dry, and check that the Ambu Disposable Face mask is fully operational before reuse on the same patient. If not fully operational, the Ambu Disposable Face Mask shall be discarded ...” Comal The ice machine in the patient nutrition room was noted with a dried white stain in the tray beneath the dispenser. The top of the ice machine was heavily covered with dirt and dust that was wiped away with a napkin. The sink cabinet was missing the laminate, exposing the porous surface and making it unable to be cleaned or sanitized. The tile on the floor in the patient medication room was split and cracked, holding dirt and trash in the creases. The clear bottom drawers in the Omnicell (an automated dispensing medication system) were visibly soiled with dirt and dust. The seclusion room was missing paint in the corner of the room, and the sheet rock was exposed and falling on the floor. The floor was not a solid surface, cracks were not sealed, and dirt, dust, and debris were noted inside the cracks. This surface could not be sanitized and posed a danger to any patient placed in seclusion. An interview was conducted with Staff #42 on 10/20/2025 at 11:40 AM. Staff #20 was asked what areas of the unit she was responsible for cleaning. Staff #20 replied that she swept every day and took out the trash. Staff #20 was asked if she cleaned the patient rooms. She confirmed the patient rooms were swept every day. An interview was conducted with Staff #42 on 10/21/2025 at 10:30 AM. RN Staff #43 was available and translated for the conversation. Staff #42 was asked what areas of the unit she cleaned. Through the translator, Staff #42 stated that she swept the floor every day and wiped down the countertops and the tables. Staff #42 was asked if she cleaned the medication room, patient nutrition room, patient exam room, or clean equipment room. Staff #43 confirmed she did not have access to the locked areas and that someone would have to let her in to do that, and they were not always available. Staff #42 was asked if she cleaned patient equipment. She confirmed she did not touch any patient equipment because she was not trained on the equipment. A review of the approved Infection Control Plan for 2025 was conducted with RN Staff #12. The Infection Control Plan had a 2025 Surveillance Plan for Environmental Rounding/Cleaning. The Planned actions were: “*Ensure regular rounding is completed by both EVS and IP. *Continue current environmental cleanliness processes including possible use of disposable curtains *Ensure facility staff is aware of and competent to perform their cleaning responsibilities. Include non EVS staff with cleaning responsibilities *Implement tagging/bagging and storage process; ensure cleaning/disinfecting of VS machines prior to storing. *Utilize UHS training resources as audit tools and ongoing training for Ips ...” An interview was conducted with RN Staff #12 on 10/20/2025 after 11:30 AM. RN Staff #12 was asked how long she had been working as the Infection Control Preventionist. RN Staff #12 replied, “Since the end of September”. RN Staff #12 was asked if she routinely made infection control surveillance rounds. RN Staff #12 confirmed that surveillance rounds were made weekly, and none of the infection control deficiencies stated above were identified and documented on her surveillance round document. RN Staff #12 asked who was responsible for cleaning the patient equipment. It was confirmed that the nurses and the mental health workers were responsible for making sure that the patient equipment was cleaned between each patient’s use. 32143 Brazos Medication Room A tour was conducted on 10/20/25 at 11:20 am on the Brazos unit with staff # 7. The unit medication room was found to have no sink. The nurse cannot wash their hands in the medication room. Staff #38 LVN(Licensed Vocational Nurse) stated that she could gel her hands, but to wash, she had to go to the staff bathroom because there was no sink in the medication room or at the nurses’ station. The surveyor went to the staff bathroom to see if there was a working sink, but the bathroom was occupied for over 10 minutes. There was no place for staff to wash their hands before medication preparation or administration. The medication cabinet (Pyxis) was found to be soiled on the outside with dust, dirt, and dried spilled liquids. The inside of the cabinet was soiled with dust, dirt, and hair. There was no cleaning schedule for when the cabinet was cleaned or who was responsible for the cleaning. There was no policy available. The small medication refrigerator was sitting on the floor with no barrier to prevent dust and dirt from being swept into the refrigerator each time it was opened and closed. The inside of the refrigerator was soiled with dust and hair. An interview was conducted with staff #15 Pharmacist, on 10/21/25. Staff #15 confirmed that there was no cleaning schedule for the Pyxis or who was responsible for the cleaning. Emergency Treatment Room- Brazos The room contained a patient exam table. The table had drawers on the side to place supplies. The three drawers were soiled on the inside with hair and dust. The table was dusty and soiled with dried liquids on the sides. The floors were heavily soiled with dust, debris, dirt, and hair. The cloth curtains behind the exam table were heavily soiled with dust and unidentifiable stains. The room contained three Dinamaps (A Dinamap vital signs machine is a portable medical device used to measure and monitor a patient’s key physiological signs, including blood pressure, pulse rate, oxygen saturation, and temperature. The name “Dinamap” is an acronym for Device for Indirect Non-invasive Mean Arterial Pressure, referring to its original function of automatically measuring blood pressure without invasive methods.) These devices are on wheels and have open containers to hold thermometers and supplies. Two of the Dinamaps were not working and had signs “out of order.” They were soiled with dust and hair. The one working Dinamap was also soiled with dust and hair. The supplies were sitting in soiled containers. The EKG machine was also soiled with heavy dust and hair. A large red emergency cart holding supplies for an emergency was heavily soiled on the outside with dust and hair. Two patient scales were sitting on top of each other on the soiled floor. Both scales were soiled with dust, debris, hair, and dried liquids. Missions Unit Emergency Treatment Room The large standing patient scale and free-standing exam light were soiled with dust, dirt, and hair. The refrigerator for lab samples was sitting on the floor. The inside was soiled with dust and hair. Patient Belongings Closet The floor of the patient belongings room on M100 was soiled with dust, dirt, trash, and hair. There were patient belongings sitting on the soiled floor. Exercise and Weight Room The floor was heavily soiled with dust, dirt, and hair. The workout mats on the floor were heavily soiled. The mat was orange but black in some areas due to dirt and debris exposure. The workout equipment was soiled with dust and dirt. There were some Sani wipes in the room to wipe down the equipment, but there was no written documentation that the equipment was monitored or wiped down after use. The Director of Nurses (DON) over the mission unit stated the patients are supposed to wipe down the equipment after use, but was unable to say if that was always done and who was responsible for monitoring it. Missions 100 Unit Expired fruit was found in the cabinets above the patient snack area, and was accessible to patients. A plastic container was found with dates in it. The box stated, “Expires in 2027.” The dates were spoiled and were leaking into the container. A room was found with a sign that said, “equipment room.” Inside the room was a barber chair and 2 stands with a cabinet for barber supplies. The room also contained 2 rolling dry erase boards, old chairs, wheel chairs, patient supplies, copy paper and old brooms. The supplies in the room were covered with dust and hair. Court Yard Outside in the courtyard, a barbecue grill was found sitting by the fence. When opened, it had ashes, tools, and pans sitting inside. The contents were molded and rusted. The DON was asked if the grill was ever used for the patients. The DON stated she was unsure. Central Supply Room 4 Oxygen Concentrators were stored in the clean supply room. There was no identification that the concentrators were clean or dirty. Three shower chairs and 2 bedside commode chairs were found with no identification that the equipment was dirty or clean. The shower chairs were soiled with dust. 2 wheelchairs were found sitting next to the bedside commodes and crutches. The wheelchairs were soiled with dust, dirt, and spilled dried liquids. Dinamaps were found dirty sitting next to clean supplies. The Dinamaps were dusty, dirty and had note pads, pens, and debris in the holding cups. A refrigerator was found. The refrigerator was not plugged in and was broken. The inside was dirty and smelled. The central supply manager stated it was broken and needed to be put in the trash. 45179 A tour was conducted of Brazos unit on 10/20/25 at 11:15 am with staff # 7 and staff #8 Findings include: Room where patient belongings housed a dusty metal storage rack to store clean yoga mats. There were seven mats with white and grey debris. Staff #7 confirmed that the mats were to be stored clean and were not. A tour was conducted of Guadulupe unit on 10/20/25 at 11:35 am with staff #7 and staff #8 Findings include: Room where patient belongings housed a dusty metal storage rack to store clean yoga mats. There were seven mats with white and grey debris. Staff #7 confirmed that the mats were to be stored clean and were not. The room where patient’s trays and snacks and their personal food had debris and hair on the bottom of clear storage containers. In those containers there was fresh fruit. The wall where the fresh fruit containers were stored against had a black and red dotted substance splattered against it. Staff #7 confirmed these findings and stated that the kitchen was scheduled to be remodeled. A tour was conducted of the pharmacy on 10/22/2025 at 11:00 am with staff # 15 Findings include: Several black zipper bags lined in silver thermal reflective linings stacked in a corner on the pharmacy floor which are used to delivery medications to all units. Staff #15 stated that they are not wiped down inside or out between deliveries. Staff #15 stated wiping down these bags is not a process that they do. A tour was conducted of the facility kitchen on 10/22/2025 at 2:15 pm with staff # 52 Findings include: Chemical room floor had small white and black debris, paper and a sticky substance. Personal Protective Equipment sign outside of the chemical room hung a pair of clear goggles. The entire lens of the goggles was covered with black dust like debris. The floor where the pans are stored had a black substance between the cracks of six tiles that were visible. The translucent panel was discolored and blackish brown buildup around the edges and did not properly seal around the metal housing. There was dust and grease like substance in the light fixture. Adjacent to this fixture is a HVAC vent which is discolored and bent with blackish brown substance. In the refrigerator was five large storage containers of macaroni and cheese, two which had the lids not sealed on the containers. Staff #52 agreed with the findings and quickly resealed the containers. 26870 Linen Storage During the facility tour on October 22, 2025, at 11:22 am, the surveyor observed surplus clean linen stored in an area exposed to the outside environment. The storage location was not enclosed or protected, allowing potential contamination by dust, moisture, or pests. The storage building had 2 sets of double doors that could not be closed and were left open. One set of doors remained ajar held partially closed with a rock. The door hardware was missing on both sets of doors. Several bags of clean linen were noted on exposed shelves. These items were not maintained in a manner that ensured cleanliness and infection control. Interview on October 22, 2025, at 11:24 with the director of EVS (staff #55) stated that these items were surplus linen and that all the linen items were bagged. The director of EVS (staff #55) stated that she would have these items removed and not use the space as surplus storage until repaired.”

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 26870 45179 Based on review of the emergency preparedness policy and interview, it was determined that the facility failed to ensure pharmacy contracted staff were trained and evaluated for the effectiveness of the facility’s emergency disaster plan related to the Pharmacy department. Findings included: During an interview with staff #15 (pharmacist) on 10/22/2025 at 11:30 am surveyor asked, “What would you do if there was a fire?” Staff #15 stated that during a fire she “would run.” Surveyor asked, “What would you do in case of a hurricane and you had to evacuate?” Staff #15 stated she would not evacuate as the facility had several generators. Surveyor asked, “Do you have a PAR level [minimum amount of stock on hand] for each medication stored in the pharmacy or for what is needed in an emergency?” Staff #15 stated, “No. I am not familiar with the Emergency Disaster Plan.” A review of the facility’s Emergency Preparedness policy revealed the steps described by Staff #15 were not consistent with the facility policy or approved Emergency Preparedness Plan. Review of the Contracted Pharmaceutical Consultants Policy and Procedure titled “Disaster Plan” for this facility, Policy number- PHR-194, last reviewed 01/2025 indicated the following in part; 1.0 STATEMENT OF PURPOSE: To ensure the security of the Pharmacy department and its contents in the event of a disaster. To ensure all patients have adequate supplies of medications. 2.0 STATE OF POLICY: Pharmacy department building experiences a disaster that affects the security of the department and its contents, the Director of Pharmacy and Administrator-on-Call will be contacted for instructions. Depending on the disaster and its effects, all measures will be taken to ensure the security of the Pharmacy department and all its contents. 4.4. Pharmacy shall assure that there are adequate amounts of emergency medications for all patients. 4.5. Pharmacy shall dispense, as needed, 7-day supply of medications to all patients in the event clients will be transferred to another site. 5.0 PROCEDURE IN THE EVENT OF FIRE EMERGENCY 5.2. Pharmacy department will make every effort during the dry season (February through June) to have a 3 to 5 day supply of medications for each resident on hand to dispense in the event of an emergency evacuation due to fires. Record review of the Emergency Preparedness Plan revealed there was a list of medications needed for 96 hours in preparation of emergency. The list was last reviewed Jan 20, 2025.”

“A life safety code (LSC) full survey was conducted on site on 11/03/2025 for 17720 Corporate Woods Drive facility and on 11/04/2025 for the 17903 Corporate Drive facilities in San Antonio. An entrance conference was held for the hospital’s Chief Operating Officer and the Director of Plant Operations on the morning of 10/03/2025 to discuss the purpose of the LSC survey, and the survey process was explained. Instructions were provided on writing plans of correction. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital’s compliance. An LSC exit conference was conducted on 10/04/2025 in the hospital. In attendance were the hospital’s Chief Operating Officer and the Director of Plant Operations. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“Building Rehabilitation CFR(s): NFPA 101 Building Rehabilitation Repair, Renovation, Modification, or Reconstruction Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following: * Requirements of Chapter 18 and 19 * Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6 18.1.1.4.3, 19.1.1.4.3, 43.1.2.1 Change of Use or Change of Occupancy Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2 18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7) Additions Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8. 18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8) This Standard is not met as evidenced by: 36250 The inspector, accompanied by the Director of Plant Operations, observed renovation projects taking place without the required state notification for project approval. Currently, half of buildings 4, 6, 8, and 9 are under renovation. Any renovation, modification, or reconstruction project to a building shall be submitted to the state for approval before commencing construction. Present and future projects shall be submitted to the state for approval.”

“Multiple Occupancies - Construction Type CFR(s): NFPA 101 Multiple Occupancies - Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows: * The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1 * The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters. 18.1.3.5, 19.1.3.5, 8.2.1.3 This Standard is not met as evidenced by: 36250 The inspector, accompanied by the Director of Plant Operations, observed that hospital records are currently stored in a portion of Building 7. Based on the Life Safety Plans provided, it is difficult to determine whether this area falls under the I-2 license or what its designated use is. A significant portion of the space is dedicated to storing medical records, and the building lacks a sprinkler system, increasing the risk of a fire. The Facility shall verify that building 7 is not included within the licensed hospital infrastructure. Because Building 7 is located on the campus, it should still be subject to heightened fire safety practices during daily storage operations. The building currently houses approximately six occupants. Although building code does not require separation between these two occupancy types, NFPA 101-2012 mandates a two-hour separation, which is currently not provided. It should also be noted that only a portion of the medical suite can be stored off-site; a medical records suite shall be maintained within the I-2 setting.”

“Means of Egress Requirements - Other CFR(s): NFPA 101 Means of Egress Requirements - Other List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. 18.2, 19.2 This Standard is not met as evidenced by: 36250 The inspector, accompanied by the Director of Plant Operations, observed that during document review facility failed to provide an annual report of the fire-rated door assemblies in the means of egress.”

“Interior Wall and Ceiling Finish CFR(s): NFPA 101 Interior Wall and Ceiling Finish 2012 EXISTING Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. 10.2, 19.3.3.1, 19.3.3.2 Indicate flame spread rating(s). _____________________ This Standard is not met as evidenced by: 36250 The inspector, accompanied by the Director of Plant Operations, observed that verification of interior finishes being installed meets the required flame spread and smoke ratings. Any renovation, modification, or reconstruction project to a building shall be submitted to the state for approval before commencing construction.”

“Building Services - Other CFR(s): NFPA 101 Building Services - Other List in the REMARKS section any LSC Section 18.5 and 19.5 Building Services requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 36250 K500 The inspector, accompanied by the Director of Plant Operations, observed that sprinkler heads in the cooler/freezer in the kitchen were not protected. 6.2.8? Guards. Sprinklers subject to mechanical injury shall be protected with listed guards. NFPA 13 2012”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 36250 The inspector, accompanied by the Director of Plant Operations, observed during document review that the facility was unable to provide documents demonstrating the testing of the critical receptacles for grounding and retention force.”

“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: 21863 Based on observation, record review, and interview, the facility’s Governing Body failed to carry out responsibilities, monitoring, and oversight to ensure facility policies and procedures were followed; and that the Hospital’s Conditions of Participation were met for Patient Rights, QAPI (Quality Assessment and Performance Improvement), Nursing Services, and Special Staff Requirements For Psychiatric Hospitals. Findings included: The facility’s Governing Body failed to ensure: 1.) patients were provided an environmentally safe setting that protected the patient’s physical safety, securing or removing objects that are hazardous; as well as an environment that protected the patient’s emotional health and safety, including respect, dignity and comfort. Specifically, on 8/18/25, actual patient harm was witnessed by surveyor(s) when Patient #1 used a razor blade she brought into the facility to cut (self-harm) herself. This was a second incident in a week. On 8/11/25 she was found with a razor blade after cutting herself. The facility previously was provided an Immediate Jeopardy (citation) April 18th, 2025, for not appropriately screening patients for contraband according to policy. The facility submitted a plan of abatement, that was abated 5/13/25. Then in May 2025, the Governing Body (GB) minutes reflected that the admission times were too long and had been selected as a goal for the hospital to reduce. The plan of abatement was amended in May (5/23/25) by the facility’s GB to revert back to searching patients on the units. Review of the facility’s contraband Incidents had started to decline in May from 17 incidents in April, to 12 incidents in May. Furthermore, in June, contraband incidents increased from 12 incidents in May to 22 incidents in June (almost doubled). July had another increase in contraband incidents from 22 in June to 28 incidents in July without further interventions; which jeopardized patient safety, for decreased admission times. An interview was conducted with Staff #1 on 8-21-25 at 10:35 AM. Staff #1 explained that the cycle time in April and the beginning of May was taking anywhere from 4 to 6 hours to get a patient to their unit because the hospital did not have RN coverage in the admission area. They had trained 4 nurses in the admission role, but they didn’t stay in that role. That was what prompted the facility to go back to previous practice rather than continue to train and staff the RN position in admissions. These deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety, placing all patients at at significant risk of harm, serious injury, or potential death; and compromised their emotional health and safety. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Patient Rights. Refer to Tag A0144 for specific evidence of findings. 2.) ensure the hospital was measuring, analyzing, and tracking adverse patient events, developed performance improvement activities to implement preventive actions and mechanisms, and failed to ensure clear expectations were established and followed by the medical staff to ensure data is collected for measurement and assessment of processes and outcome. Refer to Tag A0286 for specific evidence of findings. 3.) ensure the Quality Assurance Performance Improvement (QAPI) program was followed according to the QAPI plan to conduct improvement projects with measurable progress and monitoring, failed to follow their own abatement plan from 4/18/25 to monitor and analyze incidents and contraband to ensure patient safety, and report the information to the Governing Board (GB) to ensure compliance. Refer to Tag A0297 for specific evidence of findings. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for QAPI. 4.) ensure that a Registered Nurse (RN) was always available and supervision was provided for patient care units A, B, C, D, E, F, G, and H. Refer to Tag A0395 for specific evidence of findings. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Nursing Services. 5.) ensure safe staffing levels were provided for patient care units A, B, C, D, E, F, G, and H. Refer to Tag A1704 for specific evidence of findings The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Special Staff Requirements. As a result of the Hospital’s failures to meet the Conditions of Participation for Patient Rights, QAPI, Nursing Services, and Special Staff Requirements For Psychiatric Hospitals; resulted in the facility’s inability to meet the Condition of Participation for Governing Body.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 21863 36827 Based on observation, interview, and records review, the facility failed to provide to all patients an environmentally safe setting that protected the patient’s physical safety, securing or removing objects that are hazardous; as well as an environment that protected the patient’s emotional health and safety, including respect, dignity and comfort. These deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety, placing all patients at at significant risk of harm, serious injury, or potential death; and compromised their emotional health and safety. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Patient Rights. Refer to Tag A0144 for specific evidence of findings.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 32143 Based on review and interviews the facility failed to. 1.ensure the hospital was measuring, analyzing, and tracking adverse patient events, developed performance improvement activities to implement preventive actions and mechanisms, and failed to ensure clear expectations were established and followed by the medical staff to ensure data is collected for measurement and assessment of processes and outcome. Refer to Tag A0286 2.ensure the Quality Assurance Performance Improvement (QAPI) program was followed according to the QAPI plan to conduct improvement projects with measurable progress and monitoring, failed to follow their own abatement plan from 4/18/25 to monitor and analyze incidents and contraband to ensure patient safety, and report the information to the Governing Board (GB) to ensure compliance. Refer to Tag A0297 21863”

“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: 21863 36827 Based on observation, interview, and records review, the facility failed to provide patients an environmentally safe setting that protected the patient’s physical safety, securing or removing objects that are hazardous; as well as an environment that protected the patient’s emotional health and safety, including respect, dignity and comfort. These deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety, placing all patients at at significant risk of harm, serious injury, or potential death; and compromised their emotional health and safety. Findings included the following: A) On April 18, 2025, the facility had received an Immediate Jeopardy (IJ) citation for not appropriately screening patients for contraband according to policy. As part of the abatement plan submitted, screening of patient and patient property was to be conducted in the admissions area before patients were brought through locked doors into patient care areas. This would have prevented contraband from ever entering secured patient care areas. This process was changed in May 2025, back to the original process of screening patients for contraband after they arrived in secured patient care areas. Incident reports were reviewed on 8-19-25. Incident reporting showed that in May, there had been a drop in incidents of contraband found in secured patient care areas. There were 17 reported incidents in the month of April. That decrease to 12 in the month of May. After changing back to previous practices that had been part of the original IJ, incidents for June increased to 22, almost double. No action was taken by the facility in response to this increase. Review of incident reporting showed in July that incidents of contraband again increased to 28. Again, no action was taken by the facility in response to this increase. Governing Body meeting minutes were reviewed on 8-20-25. Review of the meeting minutes from May 6, 2025, showed that the Governing Body had selected “cycle times” for admissions as a goal in order to reduce the amount of time it was taking to get a patient to the unit. Cycle time referred to the time starting from when a patient arrived at admission until a patient was on their assigned unit. An interview was conducted with Staff #1 on 8-21-25 at 10:35 AM. Staff #1 explained that the cycle time in April and the beginning of May was taking anywhere from 4 to 6 hours to get a patient to their unit because the hospital did not have RN coverage in the admission area. They had trained 4 nurses in the admission role, but they didn’t stay in that role. That was what prompted the facility to go back to previous practice rather than continue to train and staff the RN position in admissions. Observations on 8-18-25, at 12:45 PM actual patient harm was observed by surveyor(s). Patient #1 observed with injuries to both lower arms. Patient #1 ’ s forearms with linear, parallel lacerations (wounds) of varying lengths (approximately 2 to 3 inches) to each forearm. Patient #1 had approximately 12 to 13 wounds that demonstrated recent erythema, dried/coagulated blood present; consistent with sharp force trauma, and another approximate 12 to 13 wounds on each arm that were scabbed/healing. In addition, there was older, linear, parallel, and perpendicular scarring on both forearms. Interview with Patient #1 on 8-19-25 at 1:15 PM stated that she had brought two razor blades to the unit she was assigned by hiding them in the waistband of her clothing. She further stated last week on 8-11-25 she was found by hospital staff with a razor blade after cutting her lower arms. Staff put her into paper scrubs and took her clothing from her. Patient #1 said the staff must not have searched her clothing because when she received them back it still had the other razor blade in the waistband and then today she retrieved the second razor blade and cut her lower arms again. During an interview with RN #8 on 8-18-25 at 2:25 PM stated when contraband checks were performed on the units, the Registered Nurse must leave the unit to go to the treatment room, behind a locked door inbetween two units to assess and search the patient. RN #8 confirmed that while off the unit, there was not a Registered Nurse readily available to provide patient care in an emergency or supervise the Licensed Vocational Nurse and non-licensed staff. This presented a risk to safe patient care as an RN should always be readily available. B) A tour of the facility was conducted on 8-19-25 at 11:30 AM with Staff #7 with the following observations: 1) In an outdoor common area where patients were observed to be able to congregate, a large bin was observed with an empty plastic bag laying in the bottom of it that could be easily picked up by a patient, hidden on their person to be brought back to the unit and then used for suffocation. 2) In an outdoor common area where patients were observed to be able to congregate, a beanbag toss game board was observed with rope handles that could be untied by a patient, hidden on their person to be brought back to the unit and used as a ligature for self-harm or to harm others. 3) Throughout the common outdoor areas, the paths and sidewalks were decorated with rocks that were small enough for a patient to easily pick up and hide on their person to be brought back to the unit. They could then be slipped into a piece of clothing like a sock and used as a weapon to attack staff and other patients. 4) Throughout the common outdoor areas, broken pieces of paving tiles were observed along the edge of the sidewalks. Some pieces of tile had sharp edges that could be picked up by patients and used for self-harm or to harm others. 5) The building that housed Unit A and Unit B was toured on 8-19-25 at 11:32 AM with Staff #7. A storage closet was observed with yoga mats stored in it. The yoga mats were soiled and stained on both sides of them. Staff #7 confirmed that patients did use the yoga mats, and that staff were supposed to clean them after every use. If patients wanted to participate in yoga, they had no choice but to use soiled and stained equipment, contributing to a loss of respect and dignity. 6) The entrance door to Unit B was observed to have a window in the door. The wooden trim around the window was observed to be broken with missing pieces. The broken pieces were taped. The taped long piece on the right of the window was loose. If pulled off, the sharp pointed end could be used as a stabbing instrument for a patient to harm self or others. 7) The entrance to the nurses’ station on the Unit A was a half-door. Staff #7 confirmed all nurses’ station doors were the same type on all units. The door had a slide-type handle on the inside of the nursing station. Patients could reach over the half-door and slide the handle open to easily access the nurse’s station. The short wall to the nurse’s station was low enough for patients to be able to reach over and grab items from the countertop near the wall. The wall was low enough for patients to easily jump over. RN Staff #8 and RN Staff #13 were interviewed on 8-19-25. Both described multiple instances of patient excursions into the nurses’ station. Staff #8 stated they had just had an incident the day before of a patient running into the nurse’s station. Staff #8 and Staff #13 both reported that they don’t normally put in an incident report for that unless it involves a serious incident such as an assault/aggressive actions. Both reported that excursions into the nursing station happen often. Staff #13 stated that she is always worried about it because it’s a dangerous situation and, even though administration has been asked many times, nothing has been done to improve the security of the nurses’ station. 8) Staff #8 and Staff #13 both said there were times when nursing staff were on the unit providing patient care and the nurses’ station was unattended. During those times, patients had the ability to just walk into the nurses’ station and access to available items. Observations conducted on 8/20/25 at 3:25 PM in the nurses station of Unit A revealed the RN (#15) left the unit through the locked door into the hallway of Unit A and Unit B, leaving LVN (staff #18) alone in the unit without an RN present while she went to complete an admission in the treatment room. RN #15 returned at 3:31 PM (6 minutes later). Further observations at 3:46 PM, RN (#15) left the unit through the locked door into the hallway of Unit A and Unit B, leaving LVN (staff #18) alone in the unit without an RN present. Then at 3:49 PM, LVN #18 left the unit through the locked door into the hallway of Unit A and Unit B; leaving the unit without a licensed nurse present or an RN. Approximately 30 to 45 seconds later, RN #15 returns to the unit at 3:50 PM. Observation of the nurses’ stations showed numerous items readily available to patients. Smoking material to include lighters were kept in an unsecured drawer. Spray cans of chemicals were observed inside of a cabinet. Together, those items could be used to create a blowtorch to harm other patients and staff or start a fire. Some of the other items patients had access to included: a) hazardous cleaning chemicals and wipes, b) cell-phone charging cords that posed a ligature risk, c) telephone cords on the landlines that posed a ligature risk, d) heavy items such as hole punches and fire extinguishers that could be used to bludgeon someone, e) fire extinguishers could be used to spray someone in the face and incapacitate them, f) sharp metal items such as staples and paper clips that could be used for self-harm, g) tape dispensers with serrated metal edge to cut tape. The serrated edge could be used for self-harm. h) pens that could be used to stab someone, On 8-20-25, review of incident reports revealed that excursions into the nurses’ station were not being reported as a separate incident. The lack of tracking, trending, and analyzing of this dangerous condition created an environment where patients continued to have access to the nurses’ station and items inside it. 9) Patient snacks (fresh fruit) were observed stored in open milk crates on the dirty nurses’ station floor in Unit A. Water was stored in open pitchers under the nurses’ station counter where unknown substances could accidentally contaminate it or a patient could reach it and contaminate it. One open pitcher was observed to be sitting under the counter next to a container of patient urine. Sandwiches were observed stored in a cabinet where chemicals were also stored. These unsanitary conditions create a health risk and contribute to a loss of respect and dignity for patients who are forced to live with them. 10) The glass window in the upper part of the door leading to the bedrooms had been broken where something hit the edge, and from that spot, there were with 6 long cracks spread out across the glass in curved lines from the edge toward the middle and lower part of the glass. The backside of the cracks were sharp to the touch posing a safety hazard. 11) The smoking area of Unit A was observed on 8/18/25 at 1:20 PM with no receptacle for cigarette butts available on a wooden deck. The wood on the deck was observed to be weathered and dried. Cigarette butts were littered and discarded all throughout the area; between the boards of the deck and under the deck, presenting a fire hazard. Interview with staff #10 on 8/18/25 at 1:22 PM stated the receptacle was “took out yesterday because patients were trying to get the cigarette butts out of the container.” Further observations of this smoking area on 8/19/25, 8/20/25 and 8/21/25 revealed a cigarette receptacle had not been available to discard cigarette butts. 12) A tour of the Unit D was made on 8-19-25 at 3:15 PM with Staff #7. The unit was observed to have vulgar graffiti drawings, and graffiti that had the appearance of gang related graffiti that was allowed to remain on the walls of the day room. Graffiti such as this could create fear in some patients and contribute to a loss of respect and dignity for patients who are forced to live with them, negatively impacting their emotional well-being. 13) The drop-down ceiling was observed to be accessible to patients from the counter in the nurse’ station. This could go undetected because of the lack of visibility of the area if nursing staff were all on the other side of the unit providing patient care and the nurses’ station was left unattended. Contraband could be hidden under the ceiling tiles for later retrieval or metal framework pulled down to use as a weapon to hurt others. A ceiling tile in that area had been lifted and not set back into place. It was unknown who accessed the ceiling tile. 14) The windows to the doors leading to outside had been broken. Plywood had been placed over the broken windows. Sharp ends of screws were sticking out of the plywood that could be used by a patient for self-harm/cutting of self. 15) The seclusion room door had broken plexiglass in the window. The corner was broken and could be easily pulled off. The sharp edges could be used as a cutting instrument to harm self or others. 16) The plexiglass for the seclusion room door was installed with hex-head bolts rather than tamper-resistant hardware. Hex-head bolts provide a surface for patient to be able to work the bolts out use for self-harm. 17) Decorative bricks on the wall were missing and/or had mortar missing. This created voids in the walls where patients could hide contraband. C) A transitioning female patient was assigned to Unit A. She was assigned a room with two other females. However, she was sleeping in the living area at night. Review of Patient #2’s Psychiatric Evaluation, with a date of assessment blank, date of Admission 8/9/25 revealed Patient #2 was “a 36-year-old transgender male to female admitted” for service on Unit A. Observations of Unit A on 8/18/25 at 12:30 PM revealed the unit had been separated into two different units with males (12 patients) on one side, and females (9 patients) on the other side with the door locked in between the two areas. Review of the unit’s (A) bed assignment on 8/18/25 revealed Patient #2 was assigned a room with two other female patients but would “sleep out” in the unit living area. Interview was conducted with Patient #4 on 8/18/25 at 12:35PM. Patient #4 stated that she had concerns on behalf of Patient #2 because she assists Patient #2 into her bed (mattress) on the floor in the living area, because staff will not help her. Patient #4 said that Patient #2 sleeps on the floor in the living area, “day room”, on her mattress because she has seizures and might fall off the bed. In addition, staff will not help her to go to the bathroom when needed. Interview with Patient #1 on 8/18/25 at 12:45 PM stated she has seen Patient #2 have seizures, but the staff do not believe her, so “they just let her” seize, stating she is “obviously faking it,” and “does it for attention”. Patient #1 said that Patient #2 had a 1 to 1 staff assigned after an incident but the assigned 1 to 1 staff would not help her on the floor on to her mattress from her wheelchair, so Patient #4 helped her from her wheelchair to the bed. Patient #1 said Patient #2 sleeps in the day room so that staff can “keep an eye on her.” During an interview with Patient #2 on 8/18/25 at 1:25 PM, Patient #2 was observed with female features, however, spoke with a deep voice such as a male. Patient #2 stated she had been at the facility over 30 days and has “seizures.” Patient #2 confirmed she slept in the day room at night on a mattress on the floor because she “might roll out of bed.” Patient #2 also confirmed staff do not assist her to the bathroom and she will, “pee on myself.” Interview on 8/20/25 at 3:00 PM with RN #15 stated she thought Patient #2 “sleeps out” due to the belief of, “the way she sleeps, for safety.” RN #15 stated there should be a Physician’s Order for Patients that “sleep out.” However, after review of Patient #2’s record, including physician order’s, Staff #15 confirmed there were not any orders to “sleep out” from her assigned room, stating sometimes the patient’s “want to sleep out, they’re more comfortable.” Further interview with RN #15 stated that patients would “sleep out if sexually inappropriate; for both female and male or if they self-harm, that way we can watch them.” Observations on 8/20/25 at 3:42 PM in Unit-A revealed Patient #2 was sleeping/resting in her assigned bedroom (906) where two other patients were also resting. MHW (mental health worker) #12 was sitting outside of Patient #2’s room in the hallway. Interview with MHW #12 on 8/20/25 at 3:45 PM stated Patient #2 “likes to sleep out, feels safer; to prevent self-harm.” MHW #12 was asked if there were any concerns regarding Patient #2’s bed; having to sleep on a mattress on the floor, and she responded, that Patient #2 feels like she will “self-harm at night and knows we are watching her” when she sleeps out. Patients who require additional monitoring should be assigned staff to monitor them in their room. Patients who require additional privacy due to unique personal situations such as a patient transitioning, should be assigned a private room. Requiring patients to sleep in public areas because of unique needs contribute to a loss of respect and dignity and can negatively impact their emotional well-being. It could also impact the emotional well-being of other patients who witness what they perceive as the lack of care for patients with unique personal situations or need additional attention due to medical or mental health conditions. D) On 8-20-25, the list of incident reports for May, June, July, and August were reviewed along with the quality reporting. Quality reporting for June’s incidents was as follows: “Risk Report: The following is a summary of the Risk Report for June 2025. There was a total of 483 incidents reported for the month. The majority were physical confrontation/aggression (248) and treatment issues / AMA (against medical advice) discharges (120). There was a total of 32 boundary violations which is below the target of 38. There was a total of 207 restraint, seclusions, and emergency medications (74 restraints, 34 seclusions, & 99 emergency medications). The majority of R/S (restraints/seclusions) occurred on Sunday on first shift. DRM (director of risk management) reviewed the R/S trends by unit with (Unit B) having the most. Observation rounds at 93% in June. Action: The facility has noted several incidents of aggression which new DRM is focused on camera review and thorough analysis of each inpatient injury to include incidents of EBI (Emergency Behavioral Interventions). All level 3 & 4 incidents are discussed with CEO and DRM as well with the leadership team in daily flash meeting.” Interview was conducted with Staff #2, Staff #3, and Staff #14 on 8-20-25 at 10:00 AM. Staff #3 confirmed that the number of incidents of aggression were being tracked for total numbers such as “The majority of R/S occurred on Sunday on first shift. DRM reviewed the R/S trends by unit with (Unit B) having the most.” However, incidents were not analyzed for patterns or possible causes for possible process improvement interventions. Staff #2 confirmed that there was no process improvement teams or formal process improvement projects currently focused on tracking, trending, analyzing and developing possible solutions to reduce the number of patient aggression incidents. Other than reviewing cameras for analysis of injuries and discussion with leadership after the fact, no initiatives to prevent patient aggression incidents were developed and implemented. The lack of an effective process to develop programs aimed at preventing and/or reducing incidents places all patients and staff at risk of harm. E) Complaint TX00549972 alleged that on 07/15/2025 (date of discharge) complainant noticed bruising on the Patient #6’s arms. Complainant stated she observed bruises that looked like fingerprints. Patient #6 told complainant the nurse (name unknown) kept pushing her fingers into her and squeezing her. Complainant stated Patient #6 had gray bruises on left and right arms. The complainant sent pictures of the bruising to mental health therapist #17. The medical record of Patient #6 was reviewed with the following findings. Seclusion/Restraint/Emergency Orders revealed Patient #6 was restrained on the following dates/times: 06/29/2025 at 10:55, 06/29/2025 at 19:20, 07/04/2025 at 10:59, 07/09/2025 at 20:35, 07/11/2025 at 20:06 and 07/12/2025 at 15:59 with the skin assessments showing no bruises noted on these dates. Therapist #17 was interviewed on 08/20/2025 at 3:00PM regarding complaint TX00549972. She confirmed she was the primary therapist for Patient #6 during her admission to the facility. She confirmed that Patient #6’s guardian had contacted her by phone on 07/15/2025 stating Patient #6 came home with multiple bruising on her arm. The guardian had attached three pictures of the upper arm bruising. When asked if she related these concerns of the guardian to anyone, Therapist #17 said she had been taught during her orientation that once a patient is discharged, the facility has no responsibility towards the patient. She stated that in retrospect, it would have been appropriate to contact the patient advocate regarding the guardian’s concerns. The Reporting Abuse, Neglect and Exploitation Policy and Procedure, effective November 2010 and last revised July 2025 was reviewed with the following pertinent to this complaint: Procedure for internal reporting: When an allegation is made to a therapist or the therapist becomes aware of such, he/she notifies the Nursing Supervisor/Director of Nursing and Program Manager. Failure to report and investigate all allegations of abuse and neglect create an unsafe environment where potential abuse and neglect could continue unchecked.”

“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: 32143 Based on review and interviews the facility failed to ensure the hospital was measuring, analyzing, and tracking adverse patient events, developed performance improvement activities to implement preventive actions and mechanisms, and failed to ensure clear expectations were established and followed by the medical staff to ensure data is collected for measurement and assessment of processes and outcome. A review of the Quality Assurance Performance Improvement (QAPI) meeting minutes and monthly summary for May, June and July 2025 revealed there was only data provided. The monthly summary provided for June 2025 revealed incident reports were broken out into “Incident Categories” such as AMA, change in condition, patient injured no classification, non-suicidal self-injurious behavior, and suicide behavior. Each category had just a percentage number. The monthly summary for June 2025 revealed incidents were broken out into number of incidents for the following issues. a. Medication issues-5 b. Slips/falls-20 c. Treatment/AMA issues-120 d. Sexual Allegations-9 e. Elopement/AWOL-3 f. Aggression-248 g. Property-8 h. Security/Contraband-24 i. Boundary Violations-32 j. Miscellaneous-7 k. Complaint-6 Total of 483 incidents for June. Action: The facility has noted several incidents of aggression which new DRM is focused on camera review and thorough analysis of each inpatient injury to include incidents of EBI (Emergency Behavioral Interventions). All level 3 & 4 incidents are discussed with CEO and DRM as well with the leadership team in daily flash meeting.” (DRM-Director of Risk Management). An interview was conducted with Staff #2, Staff #3, and Staff #14 on 8-20-25 at 10:00 AM. Staff #3 confirmed that the number of incidents of aggression were being tracked for total numbers such as “The majority of R/S occurred on Sunday on first shift. DRM reviewed the R/S trends by unit with (Unit B) having the most.” However, incidents were not analyzed for patterns or possible causes for possible process improvement interventions. Staff #2 confirmed that there were no process improvement teams, or formal process improvement projects currently focused on tracking, trending, analyzing and developing possible solutions to reduce the number of patient aggression incidents. Review of the Annual Review Performance Improvement Program and the Quality Assurance &Performance Improvement (QAPI) plan revealed staff #3 signed and approved the plans and policy on 3-26-25 for Governing Board (GB) approval. Staff #3 confirmed that she was just the performance Improvement (PI) manager but did not do PI projects. Staff #3 stated that she trained to collect data. Staff #3 confirmed that she was the only QAPI person in her department, but that Risk also participated in collected data. A review of the QAPI Plan stated, “ ...12. ORGANIZATION DEPARTMENT & SERVICES All departments, services and clinical programs participate in the QAPI program. Performance metrics are established to set priorities for measurement and improvement. Objective, measurable criteria reflect expected levels of achievement against which performance can be assessed, using appropriate statistical quality control techniques and tools. Data is collected for measurement and assessment of processes and outcomes, particularly those high risk/ low volume and problem prone processes, based upon a comprehensive set of performance measures. The findings are analyzed to identify significant variances and/or opportunities to improve patient outcomes. A methodical data analysis approach is conducted that includes an evaluation of data and results over time to identify levels of performance, patterns, trends, and variation. Data are compared to external sources and benchmarks when available. Once patterns are defined, the data are evaluated at a more granular level using stratification, for example by unit, day of week, time of day etc. Reports of measurement and assessment activities are prepared and presented to the Performance Improvement Committee by the department/service director. Reports include specific actions and follow-up necessary to prevent and/or correct identified variances and improves patient care. QAPI findings are reviewed and discussed in meetings of the respective departments and clinical programs at regular meetings. Each department, service and program maintain minutes of meetings with performance management reviewed as a standing agenda item.” The director of each department, service and program is responsible for leading QAPI activities within the individual department, including effective implementation of improvement effort and process changes. Employees are empowered through training, support and delegation of authority to take appropriate actions to improve performance within their respective departments. If the problem or required action involves another department or service, the Performance Improvement Committee is notified for further action.” 21863”

“QAPI PERFORMANCE IMPROVEMENT PROJECTS CFR(s): 482.21(d) As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must be proportional to the scope and complexity of the hospital’s services and operations. (2) A hospital may, as one of its projects, develop and implement an information technology system explicitly designed to improve patient safety and quality of care. This project, in its initial stage of development, does not need to demonstrate measurable improvement in indicators related to health outcomes. (3) The hospital must document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. (4) A hospital is not required to participate in a QIO cooperative project, but its own projects are required to be of comparable effort. This Standard is not met as evidenced by: 32143 Based on review and interviews the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) program was followed according to the QAPI plan to conduct improvement projects with measurable progress and monitoring, failed to follow their own abatement plan from 4/18/25 to monitor and analyze incidents and contraband to ensure patient safety, and report the information to the Governing Board (GB) to ensure compliance. A review of the Quality Assurance Performance Improvement (QAPI) meeting minutes and monthly summary for May, June, and July 2025 revealed there was only data provided. The monthly summary provided for June 2025 revealed incident reports were broken out into “Incident Categories” such as AMA (Against Medical Advice), change in condition, patient injured no classification, non-suicidal self-injurious behavior, and suicide behavior. Each category had just a percentage number. The monthly summary for June 2025 revealed incidents were broken out into number of incidents for the following issues. a. Medication issues-5 b. Slips/falls-20 c. Treatment/AMA issues-120 d. Sexual Allegations-9 e. Elopement/AWOL-3 f. Aggression-248 g. Property-8 h. Security/Contraband-24 i. Boundary Violations-32 j. Miscellaneous-7 k. Complaint-6 Total of 483 incidents for June. “Action: The facility has noted several incidents of aggression which new DRM is focused on camera review and thorough analysis of each inpatient injury to include incidents of EBI (Emergency Behavioral Interventions). All level 3 & 4 incidents are discussed with CEO and DRM as well with the leadership team in daily flash meeting.” (DRM-Director of Risk Management) An interview was conducted with Staff #3, on 8-20-25. Staff #3 revealed that she was PI (performance improvement) and not quality. Staff #3 stated that she did not do any of the analysis or monitoring that each department should handle that. Staff #3 asked who else worked in the QAPI department and she stated she was the only PI manager, and that RISK also works on patient safety and data. Staff #3 was asked about the 438 incidents and who was analyzing and monitoring that data? Staff #3 stated they bring those issues to the “keep me safe” work group. A review of the “Annual Review of Performance Improvement Program 2024” revealed the “Keep Me Safe-LRTC work group that focuses on decreasing restrictive interventions such as restraints, seclusions, and emergency medications. This group meets to analyze data for trends, discuss trainings, and actions to reduce the use of restraints and seclusions. Nursing leadership acquired this initiative from the clinical team this year. Also in 2024, LRTC received training in Trauma Informed Care which was incorporated into the Keep Me Safe efforts.” Staff #3 confirmed that she did not keep up with that information and that nursing had some PI projects. Staff #3 confirmed that she did not have any information to share with the surveyor concerning “Keep me safe” other than what was in the annual review. Staff #3 stated that she was trained to collect data and was never trained to do the PI process with analysis, PI teams, planning, and monitoring. Staff #3 was asked about the complaint survey that resulted in an Immediate Jeopardy. The facility provided an abatement plan on 4/18/25 that stated the facility would follow the policy and procedure for contraband and searches. The facility would ensure to mitigate risk and ensure patient safety immediately, the facility conducted a unit search and safety sweep of the children and adolescent unit the contraband was detected on, Brazos unit. The facility implemented the process of the weekend RN supervisors assuming responsibility for all patient skin assessments and safety searches. The RN Educator trained the weekend RN supervisors on how to properly conduct skin assessment and safety searches as outlined in the facility’s search policy, PC-49. This process was immediately implemented. The facility will continue to review all incidents and conduct thorough and timely investigations. All investigations will be shared with the CEO for review and approval when closing the investigation. MONITORING: Monitoring will be conducted by the RN leadership at LRTC on a daily basis by auditing all new admits medical records to ensure proper completion of the skin assessment and safety searches. Nursing leaders will spot check three assessments in real time each day for the next 30 days to ensure the new process is being accurately implemented and followed. All findings are corrected immediately to include staff retraining and disciplinary action as indicated. Aggregated data is reported daily in flash leadership meeting and to the Performance Improvement Committee and Medical Executive Committee monthly and to the Governing Board quarterly.” Staff #3 confirmed that the abatement plan was changed, and the patient’s contraband and skin searches went back to the charge nurse responsibility when the patient was taken to the unit. Staff #3 confirmed that these issues are discussed in the daily flash meetings but there was no written evidence that this process was being monitored or tracked for patient safety through the PI process. An interview was conducted with Staff #5 on 8/20/25 concerning the monitoring and auditing for of the abatement plan for the three assessments in real time each day, what analysis was completed on the data and any monitoring for the abatement plan. Staff #5 stated that they discussed these issues in Flash meetings and that she was monitoring the plan. Staff #5 was asked to provide the information, and any tools, or processes put in place. Staff #5 was unable to provide any information upon multiple request. A review of the 8/14/25 Board of Trustees Meeting Minutes revealed the following. “C. CMS action Plan Compliance Review The facility received an IJ in April with 100-page state and federal action plans focusing on staffing and not investigating serious incidents. Great strides are being made to fix the staffing issue that were identified. Efforts continue to identify and address the investigation and serious incidents.,. We are expecting a return visit sometime by September.” Staff #3 and #5 was asked what are the “strides” to fix the staffing issues and how was that information utilized and analyzed in the QAPI process? Staff #3 and #5 were unable to provide the surveyor on PI process for staffing issues per request. Staff #3 stated that she did not have that information.”

“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: 32143 Based on review, observations and interviews the facility failed to ensure that a Registered Nurse (RN) was always available and supervision was provided for patient care units A, B, C, D, E, F, G, and H. A tour was conducted on 8/19/25 at 11:30am on units A with staff #7. An observation of the unit revealed the unit was locked and required the staff to use a badge for entry and exit. The unit contained a central nurse’s station that included access to the medication room. A locked door adjacent to the nurse’s station led to a hallway with four whiteboards with patient information and photographs. The hallway also provided access to a seclusion room through a second door and to an exit door, which was locked. While standing in the nurse’s station the surveyor observed a locked double door separating the day rooms. Unit A had an A and B hallways separated by locked double doors. The A and B hallways included a small day area with a hallway to patient rooms. Hallway A had 15 men and hallway B had 9 women. Staff #7 confirmed the doors were locked and the men were separated from the women due to inappropriate behaviors making it separate units. Unit A had one Registered Nurse (RN), 1 Licensed Vocational Nurse (LVN),1 Mental Health Technician (MHT), and 1 Mental Health Technician (MHT) on a 1:1. The staff were having to get to each side of the unit through the nurse’s station due to the locked doors separating the unit. If the nurse was sitting on one side of the nurse’s station, she could only view one hallway. When the RN had an issue on hallway A, she was unable to see or hear what was happening on hallway B. There was no staff assigned for both hallways of unit A. An interview with Staff # 9 LVN and Staff #8 RN was conducted on 8/19/25 in the afternoon. Staff # 8 and 9 confirmed that the unit doors were always locked to separate the patients, but they were staffed for only one unit. Staff #9 stated that this was a high acuity level unit and took violent patients. Staff #8 confirmed that the milieu was often very hectic, and patients had not only hurt other patients but the staff as well. Staff #9 reported that the staffing pattern frequently consisted of only female staff, which placed them at risk of being overpowered by physically stronger male patients. Staff #9 stated that more than often the staff consist of only women and can become overpowered by strong men. Staff #9 stated about three weeks ago she was injured by a patient. Staff #9 was thrown to the ground, and she hit her head. Staff #8 and #9 stated that when they call codes (due to violent behaviors) “sometimes only one person shows up.” Staff #8 and #9 confirmed they are short staffed, feel vulnerable and unsafe, and unable to complete all their duties within the 12-hour shift. Staff #8 and #9 stated that they have a walkie talkie at the nurse’s desk to call for help, but they do not take it with them. If they are injured or trapped “we just yell out for help.” Staff #9 passes the patient medications and requires RN supervision. Staff #8 stated that she was responsible for all patient’s, staff, patient assessments, all admissions and discharges to the unit and any other problems as they arise including monitoring patients in restraint and seclusion. Staff #8 was asked if she was able to get any help with admissions or when the unit was full. Staff #8 and #9 confirmed they were told that they could not refuse any admissions and to make it work. Staff #8 stated that she stays 3-4 hours over her shift to finish paperwork on many occasions. Staff #8 was asked about acuity and how the RN was able to determine when the staffing should be increased or decreased. Staff #8 and 9 confirmed there were no acuity levels other than a 1:1 (one staff member within arm’s length of a patient.) Staff #8 confirmed that if a patient was ordered to be on a 1:1 then they would come up with an extra MHT, but it did not increase the RN. Staff #8 confirmed “A” unit would receive very high acuity patients and many individuals with Intellectual and Developmental Disabilities (IDD) causing high risk incidents. Staff #8 and #9 was asked who covered when they went on breaks? Staff #8 and #9 stated that they were not allowed breaks. When they needed bathroom breaks, they would just have to leave the unit. Staff #8 confirmed that if she needed to go to the bathroom, she had to leave the unit unattended, leaving the LVN and MHT unsupervised and void of an RN. Staff #8 confirmed the house supervisor did not cover for breaks. Staff #8 and #9 stated they were not allowed lunch breaks. The staff have to snack or eat at the nurse’s station when they can. Staff #8 confirmed that when an admission came to the unit that had not been searched for contraband, it was RN’s responsibility to go through the locked doors behind the nurse’s station to search the patient. This action would take sometimes 15-25 minutes leaving the unit without an RN. Staff #9’s timecard was pulled and from 7/13/25 through 8/19/25 staff #9 had not clocked out for any breaks. Staff #8 and #9 were asked if they had ever been informed of the Nurse Staffing Committee and if they were invited or voted for the committee. Staff #8 and #9 stated they had never heard of that and were not involved in nurse staffing. Staff #8 and #9 stated they did not feel comfortable with calling safe harbor. Staff #9 stated that another nurse had recently “called” safe harbor and then she was fired. (In Texas, Safe Harbor is a legal process that protects nurses from employer retaliation, discipline, or termination and from Board discipline if they, in good faith, refuse to accept an assignment they believe would result in a violation of the Texas Nursing Practice Act (NPA) or Board rules, or harm a patient. The process requires the nurse to first discuss their concerns with their supervisor and, if unresolved, submit a quick request form, followed by a more detailed form to their facility’s peer review committee, which evaluates the situation and determines appropriate actions.) A tour was conducted of unit D on 8/19/25 in the afternoon hours with Staff #7. Staff #7 stated that unit C was closed but unit D was open. A tour of the units revealed unit C and D were identical to A and B. 15 adolescents were on unit D with locked doors between hallways A and B. Staff # 16 confirmed that unit D was staffed with one RN, LVN and MHT for both A&B hallways. Staff #16 was asked if she ever had to leave the locked unit unattended. Staff #16 stated that she had patients that were taken over to the closed unit (C) for programing by the therapist. She stated that the patients would stay over there all day, sometimes until bedtime but the LVN or MHT would go over leaving her unit short. However, Staff # 16 confirmed that were times she would have to go over to the other locked unit to check on the patients, leaving the unit without an RN. Staff #16 confirmed that she was not relieved for any bathroom or meal breaks. Staff #16 confirmed that she was not aware of any nurse staffing committee and has never been asked to participate. Staff #16 confirmed that she did not know who the Director of Nursing Services was and had never met her. Staff #16 confirmed that she was not aware of any acuity levels that would constitute staffing up or down. Staff #16 confirmed she did not feel comfortable calling Safe Harbor and was afraid of possible retaliation. A tour was conducted of unit B on 8/20/25 in the afternoon hours. Unit B had locked doors between hallways A and B. Staff # 13 stated that she was the only RN and was responsible for both locked units. Staff # 13 stated she could not see down both hallways at once and felt the unit was not a safe place. Staff #13 confirmed that she did not get any breaks and was told to eat on the unit without a lunch break. She confirmed that she had to leave the unit unattended to go to the bathroom or assist with a code. Staff #13 stated communication was poor and was not aware of any nurse staffing committee. According to the policy and procedure Acute Acuity, Critical Factors and Appropriate Staffing Levels stated, “Procedures: 1. The Chief Nursing Officer is responsible for developing a core staffing plan for each patient care unit based upon the population served. The staffing will include Registered Nurses (RNs), Licensed Vocational Nurses (LVNs) and Mental Health Workers (MHWs). 2. In the development of the core staffing plan the CNO shall consider the following: a. Each residential unit will have the minimum number of staff per state of Texas requirements. b. Each patient care unit will always have a minimum of one RN. If only one RN is scheduled to a unit for a shift, relief coverage for the RN will be planned and documented. c. A minimum of two staff will be assigned to all units, one of which will be an RN on each shift. d. The patient/resident specific population and special needs, the staff mix, and competencies required to provide safe, quality patient care. 3. The staffing plan for each unit establishes the minimal staffing levels for that unit (core staffing). Special needs of patients/residents related to both their medical and psychiatric care are always primary factors. Additional consideration is given to: a. General number and types of patient/resident precautions b. Medical monitoring, such as vital sign frequency, blood glucose monitoring, ECT, and detox protocols. d. Admission/discharge patterns e. Medications administration numbers (routine and/or PRN) f. Mix of more than one age group of patients, such as children and adolescents g. The physical design of the environment h. Staff competencies j. Age and emotional, behavioral, and developmental functioning of the individuals served. 4. Multiple factors influence the functioning of a patient care/residential unit, and the CNO/delegates are responsible to modify staffing as needs arise on a day-by-day and shift-by-shift basis to provide safety. Factors which affect the need to alter staffing levels include, but are not limited to: a. Overall acuity on unit based on formal scoring or nursing assessment of unit activities and patient population. b. New admissions increasing unit acuity. c. Patients/residents placed on increased levels of monitoring, to include 1 to 1 observation. d. Number of patients/residents requiring assistance with personal care e. High risk conditions such as aggressive and/or violent patients/residents toward self and/or others f. Multiple patients on detox protocols g. Patients/residents who have required multiple restraints and/or seclusions to maintain safety to self or others. h. Scheduled special procedures/tests out of facility with transport/escort required. I. Skill level of employees J. Patient/resident activity, including school and visiting hours. k. Scheduled in-services and training l. Newly hired staff completing shadow shifts. m. Environment of care issues or concerns n. Admission of patients to fulfill facility responsibilities under EMT ALA standards. 5. Determining the appropriate staffing mix is the responsibility of the CNO/delegates 6. Daily Nursing Shift Report, scheduled admissions and discharges, daily 1: 1 report, and 24-hour Administrative Reports shall be reviewed each shift by the Nursing Directors and/or Nursing Supervisor to adjust the numbers and mix of staff on each unit, with direct oversight by the Chief Nursing Officer. 7. The Daily Nursing Shift Report serves as a communication tool for nursing leadership and facilitates adequate staffing levels based on unit acuity and intensity of patient care needs. 8. The CEO and Human Resources Director conduct weekly reviews of staffing vacancies to ensure on going compliance with RN staffing requirements. 9. The CNO/delegate, RN Directors, Staffing Coordinators, and RN Supervisors meet every weekday to discuss current staffing levels in the Safety Review Huddle. 10. All staffing nonc01w2liance is discussed with leadership in daily flash meetings. 11. The CNO/delegate is authorized to increase the staffing level on any unit based on the assessment of the nursing care needs and acuity of the patients/residents and the capabilities/qualifications of the staff assigned to the unit. 12. The CNO/delegate must be kept informed of any changes in the acuity level on the units ....” An interview was conducted with Staff # 5 on 8/20/25. Staff #5 stated that she was the interim Director of Nurses for the last 4 months. Staff #5 stated that she had previous experience in staffing and had worked in leadership in the past. Staff #5 was asked why the facility was staffing two separate locked units with only one set of staff? Staff #5 stated she did not realize that the locked doors between the unit would require two sets of staff. Staff #5 confirmed that she was staffing for only one unit instead of two and was staffing to the minimum staffing grid. Staff #5 confirmed that she had no evidence to show that the RN was being covered when she/he left the unit for a bathroom break or to search a new patient admission for contraband. Staff #5 confirmed that patient units A-H were staffed all the same.”

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 32143 Based on review, observations and interviews the facility failed to ensure safe staffing levels were provided for patient care units A, B, C, D, E, F, G, and H. A tour was conducted on 8/19/25 at 11:30am on units A with staff #7. An observation of the unit revealed the unit was locked and required the staff to use a badge for entry and exit. The unit contained a central nurse’s station that included access to the medication room. A locked door adjacent to the nurse’s station led to a hallway with four whiteboards with patient information and photographs. The hallway also provided access to a seclusion room through a second door and to an exit door, which was locked. While standing in the nurse’s station the surveyor observed a locked double door separating the day rooms. Unit A had an A and B hallways separated by locked double doors. The A and B hallways included a small day area with a hallway to patient rooms. Hallway A had 15 men and hallway B had 9 women. Staff #7 confirmed the doors were locked and the men were separated from the women due to inappropriate behaviors making it separate units. Unit A had one Registered Nurse (RN), 1 Licensed Vocational Nurse (LVN),1 Mental Health Technician (MHT), and 1 Mental Health Technician (MHT) on a 1:1. The staff were having to get to each side of the unit through the nurse’s station due to the locked doors separating the unit. If the nurse was sitting on one side of the nurse’s station, she could only view one hallway. When the RN had an issue on hallway A, she was unable to see or hear what was happening on hallway B. There was no staff assigned for both hallways of unit A. An interview with Staff # 9 LVN and Staff #8 RN was conducted on 8/19/25 in the afternoon. Staff #8 and 9 confirmed that the unit doors were always locked to separate the patients, but they were staffed for only one unit. Staff #9 stated that this was a high acuity level unit and took violent patients. Staff #8 confirmed that the milieu was often very hectic, and patients had not only hurt other patients but the staff as well. Staff #9 stated that more than often the staff consist of only women and can become overpowered by strong men. Staff #9 stated about three weeks ago she was injured by a patient. Staff #9 was thrown to the ground when she hit her head. Staff #8 and #9 stated that when they call codes (due to violent behaviors) “sometimes only one person shows up.” Staff #8 and #9 confirmed they are short staffed, feel vulnerable and unsafe, and unable to complete all their duties within the 12-hour shift. Staff #8 and #9 stated that they have a walkie talkie at the nurse’s desk to call for help, but they do not take it with them. If they are injured or trapped “we just yell out for help.” Staff # 9 passes the patient medications and requires RN supervision. Staff #8 stated that she was responsible for all patients, staff, patient assessments, all admissions and discharges to the unit, and any other problems as they arise including monitoring patients in restraint and seclusion. Staff #8 was asked if she was able to get any help with admissions or when the unit was full. Staff #8 and #9 confirmed they were told that they could not refuse any admissions and to make it work. Staff #8 stated that she stays 3-4 hours over her shift to finish paperwork on many occasions. Staff #8 was asked about acuity and how the RN was able to determine when the staffing should be increased or decreased. Staff #8 and 9 confirmed there were no acuity levels other than a 1:1 (one staff member within arm’s length of a patient.) Staff #8 confirmed that if a patient was ordered to be on a 1:1 then they would come up with an extra MHT, but it did not increase the RN. Staff #8 confirmed “A” unit would receive very high acuity patients and many individuals with Intellectual and Developmental Disabilities (IDD) causing high risk incidents. Staff #8 stated that she was unable to properly assess the patients when needed or supervise the milieu due to high acuity, and admissions. Staff #8 and #9 were asked who covered when they went on breaks. Staff #8 and #9 stated that they were not allowed breaks. When they needed bathroom breaks, they would just have to leave the unit. Staff #8 confirmed that if she needed to go to the bathroom, she had to leave the unit unattended, leaving the LVN and MHT unsupervised and void of an RN. Staff #8 confirmed the house supervisor did not cover for breaks. Staff #8 and #9 stated they were not allowed lunch breaks. The staff must snack or eat at the nurse’s station when they can. Staff #8 confirmed that when an admission came to the unit they had not been searched for contraband and it was RN’s responsibility to go through the locked doors behind the nurse’s station to search the patient. This action would take sometimes 15-25 minutes leaving the unit without an RN. Staff #9’s timecard was pulled and from 7/13/25 through 8/19/25 staff #9 had not clocked out for any breaks. A tour was conducted of unit D on 8/19/25 in the afternoon hours with Staff #7. Staff #7 stated that unit C was closed but unit D was open. A tour of the units revealed unit C and D were identical to A and B. 15 adolescents were on unit D with locked doors between hallways A and B. Staff #16 confirmed that unit D was staffed with one RN, LVN and MHT for both A&B locked hallways. Staff #16 was asked if she ever had to leave the locked unit unattended. Staff #16 stated that she had patients that were taken over to the closed unit (C) for programming by the therapist. She stated that the patients would stay over there all day, sometimes until bedtime, but the LVN or MHT would go over leaving her unit short. However, Staff #16 confirmed that there were times she would have to go over to the other locked unit to check on the patients, leaving the unit without an RN. Staff #16 confirmed that she was not relieved for any bathroom or meal breaks and would have to leave the unit unattended. A tour was conducted of unit B on 8/20/25 in the afternoon hours. Unit B had locked doors between hallways A and B. Staff #13 stated that she was the only RN and was responsible for both locked units. Staff #13 stated she could not see down both hallways at once and felt the unit was not a safe place. Staff #13 confirmed that she did not get any breaks and was told to eat on the unit without a lunch break, confirmed that she had to leave the unit unattended to go to the bathroom, or assist with a code. A review of the staffing schedule, grid, and the census sheets was conducted on 8/21/25. Staff #5 presented a staffing schedule called the “Staffing Analysis Tool” for each unit, from 6/29/25 through 8/23/25. The tool had the patient census and how many RN’s, LVN’s, and MHT’s were working for three different shifts. There were no names of the staff, patients that were on precautions, or any patient acuity levels on this tool. Staff #5 provided a staffing grid for each unit but had only two shifts on it. Days (7am-7pm) and nights (7pm-7am). Staff #5 was asked what hours and shifts do the staff work. Staff #5 confirmed the facility uses 2 shifts days and nights. The grid was unable to be followed due to the number of patients per unit. The patient census started at seven instead of one. The surveyor was unable to determine, if the unit had only 1 patient what staffing would be required. There was no acuity levels built into the grid, nor was there a complete tool to assist the scheduler in deciding on safe staffing levels. According to the Patient Safety Precautions policy and procedure: 1. All patients who have been clinically identified as having a high risk for safety will be placed on appropriate precautions via an order from a licensed independent practitioner (LIP) to increase awareness of risk to self or others in the areas identified ... a. Suicide b. Assault c. Homicide d. Sexually acting out-victim e. Sexually acting out-predator f. Elopement g. Medical h. Falls These precautions may require extra protective measures and should be identified to adjust scheduling as needed to ensure patient safety. There was no evidence these acuity levels were being factored into the staffing grid or schedule. A review of the Unit Staffing Census Sheet for unit A and unit B revealed there was no documentation when the staff received breaks and who covered them for that break time. There was no information of when someone covered for another employee when they were late or needed to go home early, the patient’s name that was on a 1:1 was written on the sheet but no information on what staff member was on the 1:1, when the 1:1 started, or when it was discontinued. Once a staff member takes on a 1:1 patient they are unable to assist with any other patients or duties. That staff member must be replaced, or the unit is now short staffed. The surveyor was able to determine that units A-H were short at least 1 RN,1 LVN, and 1 MHT each shift. The surveyor was unable to determine if the one hallway had enough staff due to inability to determine patient acuities, times that patients were placed and removed from 1:1’s, any medical needs, staff competencies, and if there were patients on the unit that required hands on care such as developmental delays, and/or behavioral outbursts. Staff #5 confirmed that patient units A-H were all staffed the same. An interview was conducted with Staff #5 on 8/20/25. Staff #5 stated that she was the interim Director of Nurses for the last 4 months. Staff #5 stated that she had previous experience in staffing and had worked in leadership in the past. Staff #5 was asked why the facility was staffing two separate locked units with only one set of staff? Staff #5 stated she did not realize that the locked doors between the unit would require two sets of staff. Staff #5 confirmed that she was staffing for only one unit instead of two and was staffing to the minimum staffing grid. Staff #5 stated that she had flash meetings in the mornings with leadership to make sure that there is enough staff to cover the units. However, she was unable to provide what information she uses to make those decisions except for a staffing grid. Staff #5 confirmed that she had no evidence to show that the RN was being covered when she/he left the unit for a bathroom break or to search a new patient admission for contraband. Staff #5 confirmed that she was aware the staff did not clock out for lunch. Staff #5 stated the staff were expected to eat with the patients. Staff #5 was asked if she thought it was productive and safe for the nurses to not get a break in a 12-hour shift. Staff #5 relayed “that the way it’s been here.” Staff #5 was asked about the bathroom breaks and was she aware the RN had to leave the unit unattended. Staff #5 confirmed that she was aware. A review of the July Performance Improvement Committee notes revealed in June the facility had 483 incidents reported for the month. Physical confrontation/aggression 248, AMA/ discharges 120, 32 boundary violations, and 207 restraints in one month. Staff turn over was reported at 71%. The action to be taken stated, “HR closely tracks turnover and continues the staffing committee to decrease turnover and address staffing issues/concerns.” The facility was unable to provide any information in how the HR department tracks turnover and reports to the Nurse Staffing Committee. Staff #5 was asked if she had any Nurse staffing committee meeting minutes. Staff #5 was able to provide meeting minutes for 6/25/25 and 8/14/25. According to the Nurse Staffing Committee policy and procedure stated, “1. Laurel Ridge Treatment Center will establish a nurse staffing committee as a standing hospital committee. A. The committee will be composed: 1) Members representative of the types of nursing services provided at Laurel Ridge Treatment Center. 2) 60% RN’s who provide direct patient care at least 50% of their work time and are selected by their peers who also provide direct care during at least 50% of their work time; and 3) The Chief Nursing Officer B. Participation on the Nurse Staffing committee by an employee as a committee member is part of the employee’s work time and Laurel Ridge will compensate members for that time accordingly. C. The committee shall meet at least quarterly. D. The committee shall evaluate the effectiveness of the facility’s Nurse Staffing Plan in relation to patient needs, nursing-sensitive quality indicators, nurse satisfaction measures collected by the system, and evidence-based nurse staffing standards. E. The committee shall submit a semiannual report to the facility’s Governing Board on nurse staffing and patient care outcomes, including the committee’s evaluation of the effectiveness of the official nurse services staffing plan and aggregate variations between the staffing plan and actual staffing. 2. The Official nurse staffing plan shall use current standards and shall: A. Set minimum staffing levels for patient care units that are based on multiple nurse and patient considerations and evidence-based safe nursing standards. B. Includes a method for adjusting the staffing plan to meet patient needs, to include calling in or calling off staff based on the patient census, acuity and other hospital activities. C. Includes a contingency plan when patient care needs unexpectedly exceed direct patient care and staff resources; and 3. Laurel Ridge Treatment Center prohibits the use of “mandatory overtime” per policy# NR-1. 4. The governing body of the facility must consider a nurse staffing plan based on input from the Nurse Staffing Committee.” The meeting for 6/25/25 was on multiple topics such as treatment plans, documentation, visitation protocols, and staffing. There was no true dedication for staffing only. Staff #5 stated that she just sent out an email to all nurses if they wanted to come. Staff #5 was asked if she followed the facilities policy and procedure for “60% RN’s who provide direct patient care at least 50% of their work time and are selected by their peers who also provide direct care during at least 50% of their work time.” Staff #5 stated she did not have an election or representatives selected by their peers. Staff #5 confirmed that the LVN’s were not represented in the meetings. The attendees to the meeting did not meet the 60% direct patient care nurses. Staff #5 was unable to provide the surveyor with a semi-annual report to the Governing Board on nurse staffing, patient care outcomes, including the committee’s evaluation of the effectiveness of the official nurse service staffing plan and aggregated variations between the staffing plan and actual staffing. Staff #5 stated that the previous Director of Nursing may have done that, but she was not aware of where that information could be. Staff #5 provided committee meeting minutes on 8/14/25. Only six people were in the meeting. All RN’s. There was no LVN representation. The meeting was consistent with the June meeting including restraints, face to face, attendance policies, holding employees accountable for being on work on time. The meeting was not completely focused on staffing. Staff #5 stated it was just easier to have all of this done in one meeting. Again, staff #5 had no plan in how this information would get back to working staff and how the staff members could participate. The meeting minutes stated that the committee had decided to add another LVN to the grid for units I and J when the census rose above 26 patients. However, there was no other recommendations to ensure other units were staffed appropriatly in high patient risk area’s.”

“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: 21863 Based on observation, record review, and interview, the facility’s Governing Body failed to carry out responsibilities, monitoring, and oversight to ensure facility policies and procedures were followed; and that the Hospital’s Conditions of Participation were met for Patient Rights, Nursing Services, and Special Staff Requirements For Psychiatric Hospitals. Findings included: The facility’s Governing Body failed to ensure: 1.) Patients’ Rights,were protected and promoted in accordance with the facility’s policies and procedures; core staffing grid; and in accordance with State law for 15 of 21 patients reviewed (Patient ’ s #1, Patient #2, Patient #3, Patient #4, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #17, Patient #21 and Patient #21 with patient rights violations. Specifically, the facility’s Governing Body failed to ensure: A.) staff followed the contraband safety search policy for patients being admitted to the facility. On 3/19/25, 16-year-old Patient #1 had a medical change in condition and was transferred to the emergency department of another acute care hospital. It was determined Patient #1 ingested an illegal drug, “meth,” [methamphetamine] that another 14-year-old, Patient (#2) brought into the facility ’ s adolescent unit (A) on 3/17/25. Further documentation indicated Patient #2 also provided the “meth” to other adolescents in the unit. The facility failed to ensure this serious event was thoroughly investigated, corrective action was immediately implemented, and appropriate monitoring was completed which resulted in; Patient #3, 16 years old was found with “contraband,” a cell phone, in the same adolescent unit (A) on 4/16/25. Patient #3 ’ s safety search was completed on 4/4/25. The facility ’ s systemic failure resulted in an identified Immediate Jeopardy when all patients in the facility were placed at risk for potential serious injury, significant harm, or potential death if illegal drugs, ligature items, dangerous items and/or weapons are brought into the units. And, B.) staff implemented emergency interventions including physical restraint, seclusion, and administration of emergency medications according to the facility ’ s policy during a group incident that occurred on 4/6/25 in the adolescent unit (A) where several patients were engaged in physical fighting and property destruction; labeled as a “riot.” Several unidentified Patients were seen on video playback being physically held in restraint without any physical restraint documentation. Patient #12 was placed in seclusion without monitoring or documentation. Patient ’ s #7, #8, #9, #10, #11, and #12 were administered chemical restraints (emergency behavioral medications) without evidence of monitoring or documentation of the facility ’ s HV-114 form for Restraint/Seclusion/EmMeds in accordance with the policy. Patient #17 stated she was physically restrained on 4/6/25 during this event without restraint documentation. The failure to document restraint episodes, seclusion, and provide monitoring after the administration of emergency medications posed significant risks to patient health and safety; and resulted in the inability to provide appropriate oversight. And, C.) adequate staffing during psychiatric behavioral codes (Code Green) and other emergencies; including an RN present at all times in the unit. The failure to maintain adequate staffing during an emergency behavioral code resulted in Patients #17, #20 and #21 eloping from the facility and Patient #21 has not been found. D.) staff documented an incident report according to the facility ’ s policy for Patient #4 who was involved in a physical altercation with another patient on the adolescent unit (A) on 6/1/2024; and was not appropriately assessed and monitored following the incident until the following day after complaints of facial pain and injury. This failure places patients at risk of undetected injury, delay of care, and unmet clinical needs. These deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety, placing all patients at at significant risk of harm, serious injury, or potential death. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Patient Rights. Refer to deficiencies; A0144, A 0160, and 0167 for evidence of specific findings. 2.) Adequate numbers of nursing personnel, other supportive staff to provide care, and ensure the immediate availability of a registered nurse (RN) on each unit to meet the needs of the patients; and in accordance with the facility’s current staffing grid. Specifically, the facility utilizes a core staffing grid to allocate RN’s, Licensed Vocational Nurses (LVN’s), and Mental Health Workers (MHWs) per unit, based on patient census. Review of unit staffing for 4/3/25 and 4/6/25 revealed the facility failed to ensure the minimum staffing requirements were met in accordance with patient census or acuity. A.) Unit A: The staffing grid accounts for up to 25 patients; the number of licensed beds. On 4/3/25 and 4/6/25 the patient census exceeded 25 patients; there were not adequate assigned staffing levels for the patient census and staffing levels were not adjusted accordingly when the census exceeded 25 patients. B.) On 4/6/25 there were 12 of 14 units reviewed (A, C, D, E, F, G, H, I, J, K, L, M) that did not meet the minimum staffing requirements in accordance with the facility’s current Core Staffing Grid and failed to ensure the immediate availability of an RN for each unit. The facility’s failure to provide adequate numbers of nursing personnel resulted in repeated failures to meet minimum care standards, placed staff and patients at risk for harm, delayed care, and resulted in inadequate staff supervision during behavioral emergencies that resulted in patient injuries and patients eloping from the facility. As a result, the facility was not able to meet the requirements for the Condition of Participation, CFR 482.23 Nursing Services, and placed all patients in the facility at risk for the likelihood of harm, serious injury, and potential death. Refer to deficiencies; A0392, A0395, and A1704 for evidence of specific findings. The cumulative effects of these deficient practices and that the Hospital’s Conditions of Participation were not met for Patient Rights, Nursing Services, and Special Staff Requirements For Psychiatric Hospitals; resulted in facility’s inability to meet the Condition of Participation for Governing Body.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 21863 Based on observation of facility video surveillance, review of facility’s policies and procedures, record reviews and interviews, it was determined the facility failed to ensure specific patient rights were protected and promoted in accordance with the facility’s policies and procedures; core staffing grid; and in accordance with State law for 15 of 21 patients reviewed (Patient ’ s #1, Patient #2, Patient #3, Patient #4, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #17, Patient #21 and Patient #21 with patient rights violations. Specifically, the facility failed to ensure: 1.) staff followed the contraband safety search policy for patients being admitted to the facility. On 3/19/25, 16-year-old Patient #1 had a medical change in condition and was transferred to the emergency department of another acute care hospital. It was determined Patient #1 ingested an illegal drug, “meth,” [methamphetamine] that another 14-year-old, Patient (#2) brought into the facility ’ s adolescent unit (A) on 3/17/25. Further documentation indicated Patient #2 also provided the “meth” to other adolescents in the unit. The facility failed to ensure this serious event was thoroughly investigated, corrective action was immediately implemented, and appropriate monitoring was completed which resulted in; Patient #3, 16 years old was found with “contraband,” a cell phone, in the same adolescent unit (A) on 4/16/25. Patient #3 ’ s safety search was completed on 4/4/25. The facility ’ s systemic failure resulted in an identified Immediate Jeopardy when all patients in the facility were placed at risk for potential serious injury, significant harm, or potential death if illegal drugs, ligature items, dangerous items and/or weapons are brought into the units. And, 2.) staff implemented emergency interventions including physical restraint, seclusion, and administration of emergency medications according to the facility ’ s policy during a group incident that occurred on 4/6/25 in the adolescent unit (A) where several patients were engaged in physical fighting and property destruction; labeled as a “riot.” Several unidentified Patients were seen on video playback being physically held in restraint without any physical restraint documentation. Patient #12 was placed in seclusion without monitoring or documentation. Patient ’ s #7, #8, #9, #10, #11, and #12 were administered chemical restraints (emergency behavioral medications) without evidence of monitoring or documentation of the facility ’ s HV-114 form for Restraint/Seclusion/EmMeds in accordance with the policy. Patient #17 stated she was physically restrained on 4/6/25 during this event without restraint documentation. The failure to document restraint episodes, seclusion, and provide monitoring after the administration of emergency medications posed significant risks to patient health and safety; and resulted in the inability to provide appropriate oversight. And, 3.) adequate staffing during psychiatric behavioral codes (Code Green) and other emergencies; including an RN present at all times in the unit. The failure to maintain adequate staffing during an emergency behavioral code resulted in Patients #17, #20 and #21 eloping from the facility and Patient #21 has not been found. 4.) staff documented an incident report according to the facility ’ s policy for Patient #4 who was involved in a physical altercation with another patient on the adolescent unit (A) on 6/1/2024; and was not appropriately assessed and monitored following the incident until the following day after complaints of facial pain and injury. This failure places patients at risk of undetected injury, delay of care, and unmet clinical needs. These deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety, placing all patients at at significant risk of harm, serious injury, or potential death. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Patient Rights. Refer to deficiencies; A0144, A 0160, and 0167 for evidence of specific findings.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 21863 Based on observation, interviews, and document reviews, the facility failed to provide adequate numbers of nursing personnel to provide care, and ensure the immediate availability of a registered nurse (RN) on each unit to supervise and evaluate the nursing care of each patient in accordance with the facility’s policies and procedures and current staffing grid. Specifically, the facility utilizes a core staffing grid to allocate RN’s, Licensed Vocational Nurses (LVN’s), and Mental Health Workers (MHWs) per unit, based on patient census. 1.) On 4/3/25 and 4/6/25 the facility failed to ensure the minimum staffing requirements were met in accordance with patient census or acuity. Unit A: The staffing grid accounts for up to 25 patients; the number of licensed beds. On 4/3/25 and 4/6/25 the patient census exceeded 25 patients; there were not adequate assigned staffing levels for the patient census and staffing levels were not adjusted accordingly when the census exceeded 25 patients. On 4/6/25 there were 12 of 14 units reviewed (A, C, D, E, F, G, H, I, J, K, L, M) that did not meet the minimum staffing requirements in accordance with the facility’s current Core Staffing Grid and failed to ensure the immediate availability of an RN assignment for each unit. 2.) On 4/6/25, RN staff failed to ensure implementation and evaluation of the emergency interventions including physical restraint, seclusion, and administration of emergency medications according to the facility’s policy and procedures during a group incident that occurred in the adolescent unit (A) where several patients were engaged in physical fighting and property destruction; labeled as a “riot.” Several unidentified Patients were seen on video playback being physically held in restraint without any physical restraint documentation. Patient #12 was placed in seclusion by RN #13 without monitoring or documentation. Patient’s #7, #8, #9, #10, #11, and #12 were administered chemical restraints (emergency behavioral medications) without evidence of monitoring or documentation of the facility’s HV-114 form for Restraint/Seclusion/EmMeds in accordance with the policy. Patient #17 stated she was physically restrained on 4/6/25 during this event without restraint documentation. The facility’s failure to provide adequate numbers of nursing personnel resulted in repeated failures to meet minimum care standards, placed staff and patients at risk for harm, delayed care, and resulted in inadequate staff supervision during behavioral emergencies that resulted in patient injuries and patients eloping from the facility. As a result, the facility was not able to meet the requirements for the Condition of Participation, CFR 482.23 Nursing Services, and placed all patients in the facility at risk for the likelihood of harm, serious injury, and potential death. Refer to deficiencies; A0392 and A0395 for evidence of specific findings.”

“Special Staff Requirements CFR(s): Condition of Participation: Special Staff Requirements for Psychiatric Hospitals The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning. This Condition is not met as evidenced by: 21863 Based on observation, interviews, and document reviews, the facility failed to provide adequate numbers of nursing personnel, other supportive staff to provide care, and ensure the immediate availability of a registered nurse (RN) on each unit to meet the needs of the patients; and in accordance with the facility’s current staffing grid. Specifically, the facility utilizes a core staffing grid to allocate RN’s, Licensed Vocational Nurses (LVN’s), and Mental Health Workers (MHWs) per unit, based on patient census. Review of unit staffing for 4/3/25 and 4/6/25 revealed the facility failed to ensure the minimum staffing requirements were met in accordance with patient census or acuity. 1.) Unit A: The staffing grid accounts for up to 25 patients; the number of licensed beds. On 4/3/25 and 4/6/25 the patient census exceeded 25 patients; there were not adequate assigned staffing levels for the patient census and staffing levels were not adjusted accordingly when the census exceeded 25 patients. 2.) On 4/6/25 there were 12 of 14 units reviewed (A, C, D, E, F, G, H, I, J, K, L, M) that did not meet the minimum staffing requirements in accordance with the facility’s current Core Staffing Grid and failed to ensure the immediate availability of an RN for each unit. The facility’s failure to provide adequate numbers of staffing resulted in repeated failures to meet minimum care standards, placed staff and patients at risk for harm, delayed care, and inadequate staff supervision during behavioral emergencies that resulted in patient injuries and patients eloping from the facility. As a result, the facility was not able to meet the requirements for the Condition of Participation, CFR 482.62: Special Staff Requirements, and placed all patients in the facility at risk for the likelihood of harm, serious injury, and potential death. Refer to Tag A1704 for specific evidence.”

“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: 21863 Based on observation of video review, records review and interviews, the facility failed to ensure patients received care in a safe setting for 15 of 21 patients reviewed (Patient ’ s #1, Patient #2, Patient #3, Patient #4, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #17, Patient #21 and Patient #21 . Specifically, the facility failed to ensure: 1.) staff followed the contraband safety search policy for patients being admitted to the facility. On 3/19/25, 16-year-old Patient #1 had a medical change in condition and was transferred to the emergency department of another acute care hospital. It was determined Patient #1 ingested an illegal drug, “meth,” [methamphetamine] that another 14-year-old, Patient (#2) brought into the facility ’ s adolescent unit (A) on 3/17/25. Further documentation indicated Patient #2 also provided the “meth” to other adolescents in the unit. The facility failed to ensure this serious event was thoroughly investigated, corrective action was immediately implemented, and appropriate monitoring was completed which resulted in; Patient #3, 16 years old was found with “contraband,” a cell phone, in the same adolescent unit (A) on 4/16/25. Patient #3 ’ s safety search was completed on 4/4/25. The facility ’ s systemic failure resulted in an identified Immediate Jeopardy when all patients in the facility were placed at risk for potential serious injury, significant harm, or potential death if illegal drugs, ligature items, dangerous items and/or weapons are brought into the units. And, 2.) staff implemented emergency interventions including physical restraint, seclusion, and administration of emergency medications according to the facility ’ s policy during a group incident that occurred on 4/6/25 in the adolescent unit (A) where several patients were engaged in physical fighting and property destruction; labeled as a “riot.” Several unidentified Patients were seen on video playback being physically held in restraint without any physical restraint documentation. Patient #12 was placed in seclusion without monitoring or documentation. Patient ’ s #7, #8, #9, #10, #11, and #12 were administered chemical restraints (emergency behavioral medications) without evidence of monitoring or documentation of the facility ’ s HV-114 form for Restraint/Seclusion/EmMeds in accordance with the policy. Patient #17 stated she was physically restrained on 4/6/25 during this event without restraint documentation. The failure to document restraint episodes, seclusion, and provide monitoring after the administration of emergency medications posed significant risks to patient health and safety; and resulted in the inability to provide appropriate oversight. And, 3.) adequate staffing during psychiatric behavioral codes (Code Green) and other emergencies; including an RN present at all times in the unit. The failure to maintain adequate staffing during an emergency behavioral code resulted in Patients #17, #20 and #21 eloping from the facility and Patient #21 has not been found. 4.) staff documented an incident report according to the facility ’ s policy for Patient #4 who was involved in a physical altercation with another patient on the adolescent unit (A) on 6/1/2024; and was not appropriately assessed and monitored following the incident until the following day after complaints of facial pain and injury. This failure places patients at risk of undetected injury, delay of care, and unmet clinical needs. Findings included: 1.) A.) Review of complaint Intake TX00538159 dated 3/28/25 indicated Patient #1, a 16-year-old female, placed at the facility between 3/16/25 and 3/24/25 was provided and took “meth” [methamphetamine] given by Patient #2, who brought in the meth hidden in her bra. Patient #1 snorted the “meth;” that looked like a rock. Patient #1 had a seizure due to the meth and was taken to the hospital. Patient #1 tested positive for methamphetamine. Facility staff never reported the incident to Child Protective Services (CPS), Patient #1 ’ s legally managing conservator. CPS immediately took custody of Patient #1. Review of the facility ’ s Incident Report dated 03/19/2025 at 09:15 AM for Patient #1 in Unit-A revealed the following, in part: Patient experiencing what appeared to be relentless panic attacks. Vitals taken and Blood Pressure (BP) was 137/97 [elevated] and pulse was 97, with the patient ’ s eyes rolling back. Patient would stop behavior when asked to allow for staff to take vitals. Physician ordered patient to receive Ativan Intermuscular(IM) and send to hospital for further evaluation. Upon further investigation it was discovered patient had possibly ingested meth that was brought in by another patient. Patient returned medically cleared with no acute findings noted. Able to continue treatment. There was no further documentation available upon multiple requests regarding an investigation of how Patient #1 obtained the meth and whether other patients on the unit had also been provided meth. Review of Patient #1 ’ s record titled, Return Assessment and Recommendations dated 03/19/2025 at 12:52 PM, indicated Patient #1 was sent to an acute care hospital on 03/19/25 due to having panic attacks, staring relentlessly and eyes rolled back in her head. Patient #1 returned to the facility at 2:49 PM with lab findings indicating she was positive for meth and benzo [benzodiazepine]. Review of the facility ’ s Incident Report dated 03/19/25 at 09:15 AM for Patient #2 in Unit-A revealed the following, in part: Another peer [Patient #1] was having what appeared to be a panic attack or seizure like activity. When questioned about the source of the change in condition, Patient #1 reported she had ingested a substance given to her by Patient #2. Patient #2 endorsed having brought in ’ meth” hidden inside of her bra. Staff reporting [specific staff unknown] they thoroughly searched Patient #2 ’ s belongings and are not sure how the substance would have made it onto the unit. Thorough room and safety search completed. No additional contraband found. There was no further documentation indicating whether Patient #2 had given meth to other patients on the unit. The Director of Risk Management (DRM) Staff #3 and the Unit Nurse Manager/Staff #5 signed this incident report on 3/24/25 without any further documentation, investigation, or corrective action noted. Review of Patient #2 ’ s Nursing Admission Assessment, dated 03/17/2025 at 2:40 PM revealed Patient #2 was a 14-year-old female, that admitted to using “a lot” of amphetamine and marijuana yesterday, (03/16/2025). Further review of the Nursing Admission Assessment documented the skin assessment and search conducted at 3:47 PM by RN #6 and RN #7. Review of Patient #2 ’ s Physician ’ s MOT Order and Preliminary Plan, dated 03/17/2025 at 6:32 PM revealed she was admitted with the preliminary psychiatric impression of: Amphetamine (or other stimulant use disorder). Admit Patient to Inpatient Program: Substance Use Rehabilitation. Review of Patient #2 ’ s Daily Nursing Progress Note, dated 03/19/2025 at 09:00 PM revealed, “Patient irritable and demanded her clothes after being placed on scrubs. Patient had admitted to smuggling methamphetamines into the unit using it and giving/sharing with peers.” Review of Patient #2 ’ s Discharge Summary dated 03/31/2015 at 11:44 AM, documented Patient #2 “managed to sneak in methamphetamines from the streets. The patient was sharing drugs with other girls on the unit. Safety searches were conducted, and she turned over the illicit drugs.” Interview on 03/31/2025 at 11:00AM with the Director of Performance Improvement (DPI) revealed there was no further documentation regarding the incident of Patient #2 giving Patient #1 meth. She further indicated that all nurses and mental health technicians will be retrained on the following dates: April 8, 9, 10 and 12 on how to conduct admission “searches”. Interview with the Director of Risk Management (DRM) on 3/31/25 at 11:00 AM stated he was on vacation when the incident regarding Patient #1 and Patient #2 was reported. He stated that when he is on vacation, the incident investigations are the responsibility of the unit nurse managers. As of 04/19/2025, the facility did not provide further documentation of an investigation or evidence whether other patients in the unit may have also ingested the meth brought in by Patient #2. Interview on 4/3/25 at 3:15 PM with RN #12 from the intake/admissions unit stated they complete an initial safety search before taking the patients to their assigned unit. RN #12 stated the initial search process included having the patients empty out their pockets and then use the metal detector, security wand around them to check for any concealed contraband/weapons before escorting them to the unit. RN #12 stated they basically completed a limited overall visible search, and after the patient arrives to their assigned unit, the assigned unit staff will complete a “head to toe” search for any contraband. Interview on 4/3/25 at 3:52 PM with the facility ’ s Director of Risk Management (DRM) stated he continues to follow up with staff regarding safety searches in accordance with the facility ’ s policy and procedure for searches. The DRM stated Patient #2 was interviewed and admitted she snuck “meth” into the unit, inside of her bra. The DRM was asked if any other Patient ’ s admitted to Unit -A were interviewed to determine if they were provided meth from Patient #2 as reported, and he responded that he did not because he was on vacation/leave when this incident was reported and, the Unit Director/Staff #5 or the CNO would have been responsible to conduct the investigation. Further interview on 4/18/25 at 2:25 with the DRM stated the facility did not currently have a CNO and the current Unit Director/Staff #5 was also on leave when the incident was reported on 3/19/25 for Patient #1 and Patient #2. The DRM confirmed this incident was classified as a Level III serious event which would require reporting to the Assistant Corporate Risk Manager according to the facility’s policy. The DRM confirmed there were not any further interviews obtained from other patients. Interview on 4/28/25 at 2:50 PM with RN #7 who assisted Patient #2 with her safety search on 3/17/25. RN #7 stated she did not remember Patient #2 ’ s safety search specifically, but the process for searches was to check for a bra with a wire and if they have a bra with a wire, they have to remove the bra and provide them with a sports bra. RN #7 stated the patients have to remove their shirt, and “shake out their bra all the way around while maintaining their privacy at the same time.” RN #7 stated the patients only remove their bra if they have a wire, otherwise they pull out away from their body, all the way around. The surveyor asked RN #7 if she was aware that many bras have an opening in them where the padding can be placed in and out, and she responded that her supervisor recently told her that. RN #7 was asked if the patients remove their underwear during the safety searches and she responded, no; they have the patients “stretch out the waist band, and make sure nothing falls out.” RN #7 stated the patients are given a towel after they remove their top and then their bottom clothing. She said they do not have them totally remove all their clothing. RN #7 stated that patient safety searches are supposed to be done immediately when the patient arrives to the unit from admissions; however, that does not always occur if they are “short staffed, or a crisis is going on; which happens lots of times. You can ’ t always do the searches right when they come to the unit.” Review of Policy and Procedure titled “Searches”, last revised September 2024 revealed the following, in part: 3. Full body searches and process for skin assessment: Full body searches require removal of clothes with a full visual inspection of the patient ’ s body, including the inspection of clothing and property carried by the patient. Full body searches are conducted on all patient admissions during the initial nursing assessment that takes place on the unit. Will be conducted by two staff members; one being a Registered Nurse. Full body searches occur only in the examination room. Any patient requiring a full body search is in full observation of staff prior to this search, to prevent the patient from removing hidden items and storing them in the facility. 6. Certain contraband items such as weapons, illegal drugs, matches, etc., will be confiscated. In all cases where contraband is found, the individual performing the search will report in writing, the action taken, patient response, results and any special events will be documented in the chart, to include progress or nursing notes. This Incident Report will be routed daily to the Risk Manager. Review of Performance Improvement Monitor Monthly Summary for January, February and March 2025 revealed the following: 24 incidents of security/contraband during these three months. Upcoming Improvement Strategies: In our ongoing commitment to enhancing patient safety and quality of care, we are focused on strengthening improvement strategies through staff education and improved processes. The facility has noted several high-risk contraband incidents in the 1st quarter of 2025. In response to this trend during the 2nd quarter the facility will be introducing additional training for all direct care staff on the safety search and environment of care observation rounds. A focus will be placed on thoroughly inspecting the patient ’ s person as well as any personal belongings that may accompany them. B.) Review of Patient #3 ’ s Intake Assessment dated 4/4/25 at 08:28 AM revealed Patient #3 was a 16-year-old female with endorsed chronic episodic suicidality with a plan. Review of Patient #3 ’ s initial Nursing Admission Assessment dated 4/4/25 documented the skin assessment and search was completed at 09:52 AM by RN #8 and Staff #9 on Unit-A. RN #8 documented patient guarded for safety search. Took lots of redirection to cooperate. Patient had padding in pants and bra. Required redirections to remove, along with other contraband. Review of the facility ’ s Incident Report dated 4/16/25 at 4:00 PM for Patient #3 on Unit-A documented, Patient was reported by other patients to have a phone on her. The physician ordered a room search and safety search. Patient extremely guarded and hesitant during search. No contraband found. Approximately 15 minutes later, the patient handed over the phone to peer, who turned it into the Mental Health Worker. Review of the Educational Inservice provided “April 2025” for Unit-A, Unit-B, and Unit-C all child/adolescent units, revealed education and reinforcement provided for the importance of safety searches, ensure staff understand the policy and procedures, and demonstrate the correct method. There was no evidence that RN #8 had been provided re-education regarding the safety search policy and procedures. Interview with RN #8 on 4/17/25 at 3:00 PM in Unit-A indicated the initial skin assessments and safety searches were completed for the patient upon admission to the unit with 2 staff present and, the patients were to “take all clothes off.” RN #8 indicated they have them remove their bottom clothing first, and then their top clothing. They will have the patient go around their underwear band and shake them. RN #8 confirmed that the underwear is not removed all the way off from the patient. RN #8 said they check their bras for wires and give another bra if their bra has wires. They use a screen or sheet to allow the patient privacy during this process. They will ask the patient if there is anything in their pockets or socks. They will have them remove their shoes and check their hair or buns for anything hidden inside. RN #8 confirmed they do not have the patients remove their top and bottoms at the same time, and do not have them remove their undergarments unless the bra has a wire. RN #8 was asked if she received any retraining on the safety searches after the incident with Patient #1 that occurred on 3/19/25 on this unit, and she replied, “No,” she had not. Interview with Patient #3 on 4/17/25 at 3:15 PM in Unit-A ’ s group room stated the following: This was her first inpatient psychiatric admission for treatment, and she was able to sneak a cell phone into the unit by putting it in her bra, stating “I ’ m sneaky.” Patient #3 stated she had the phone almost two weeks, was letting other girls use it, and then another patient “rat me out.” Patient #3 said that during her initial search on the unit, RN #8 did not have her take off her underwear or bra; they just had her “stretch out her waist band” and “pull out her bra” as she demonstrated this process. Patient #3 said she initially kept giving the staff conducting the search “push back” stating she didn ’ t want to and stalled. She was able to move the phone from her pants to her bra during the search and kept pushing back as a distraction to allow her to get away with sneaking the phone in. Patient #3 said she had the cell phone in her bra when she pulled it away from her skin and holding the cell phone at the same time. She further stated that girls bring in contraband all the time and reported a week ago she heard someone brought in a “razor blade.” Patient #3 said the girls report they bring contraband between the soles of their shoes. Patient #3 said the staff need to make sure patients remove their shoes and undergarments; and that staff inspect their undergarments thoroughly. Patient #3 said that girls report bringing in contraband in the pockets of their bras that usually hold the padding and if you do not thoroughly inspect and take out the padding, the staff will miss items. In an interview on 4/17/25 at 5:15 PM with the DPI confirmed that RN #7 who assisted with Patient #2 ’ s safety search and RN #8 who conducted Patient #3 ’ s safety search had not received re training on the safety search policy and procedures; further stating “they are sitting on [interim assistant DON/Staff #4’s] desk to be completed.” 2.) Interview with Patient #3 on 4/17/25 at 3:15 PM in Unit-A ’ s group room stated on her 2nd day there was a “riot and we were on lock down” because there were girls fighting, jumping over the nurses station to get at each other from one side to the other. Observation of the playback video surveillance with the DRM on 4/18/25 at 3:45 PM using his laptop to review the video of the “Riot” that occurred on 4/6/25 revealed the following observations of the video: Two video angles were viewed. The doors had been shut in the common living area which had separated the unit into two sides. At 7:42 PM there were approximately 5 adolescent girls that surrounded 1-2 other girls at these doors which are by the nurses station. There were 2 girls observed repeatedly hitting at another one of the girl ’ s head area with their fists. Further observations revealed several girls jumping over the nurses station and going around to the other side of the common living area to get at other girls on the other side. There also were girls jumping over into the nurses station, knocking down medical equipment and patient records. Multiple staff were seen holding several patients in physical hold restraints. One staff was seen grabbing and holding a patient by her ankle that was attempting to cross over the nurses station. At 7:43 PM Patient #12 was placed in seclusion by staff, (RN #13), the door was closed and a large chair placed in front of the seclusion door preventing egress. The patient remained in the seclusion until 7:51 PM (8 minutes) when the chair was removed and the door opened. During these 8 minutes, there was not a staff member observing this patient in seclusion. Overall, there were an approximate 10 unidentified adolescent girls involved in the altercation; however, these girls were not identified during the time of the video observation because the DRM stated the internal investigation was “ongoing” and they continue to review the video. Review of facility policy and procedure entitled Proper Use and Monitoring of Restraint, Emergency Medications, and Seclusion, last reviewed March 2024, revealed the following, in part; Emergency Medication is defined as a psychoactive medication that is used to treat the signs and symptoms of mental illness in a psychiatric emergency to prevent imminent risk to self/others when other interventions are ineffective or inappropriate. The use of emergency medications will be documented in same manner as physical restraint and seclusion. The RN must assess the patient and the effectiveness of the emergency medication 15 minutes after administration of the medication. A second assessment will be completed after an additional 15 minutes for a total of 30 minutes after administration of the emergency medication. Vital signs will be obtained at each assessment, at the 15-minute and 30-minute patient assessment. If unable to obtain the vital signs, documented a description of the patient’s color and respirations minimally. Any patient placed in seclusion will be continuously observed by staff standing immediately outside the seclusion room. Review of facility form HV-114 Restraint/Seclusion/Emergency Medication Acute Care revised 07/23 revealed but was not limited to the following documentation: Seclusion/Restraint/Emergency Medication Order to include: reason for intervention, less restrictive interventions, any medical conditions/abuse issues that would impact the used of restraint/seclusion, nursing summary and notifications to include time medication given, RN assessment of patient and response to emergency medications completed within 15 minutes of medication administration including vital signs, RN assessment of patient and response to emergency medications completed within 30 minutes of medication administration including vital signs, RN assessment of patient and responses to emergency medications completed within 45 minutes of medication administration including vital signs, RN review of patient response to emergency medication and brief system assessment to be completed within 60 minutes of medication administration, notifications to parent/family/ guardian. Post Intervention, Nursing Summary and Notifications include: face to face evaluation (to be completed within 1 hour of initiation of intervention) and seclusion/restraint/emergency medication patient debriefing to be completed after intervention when patient has calmed but no later than 24 hours. Debriefing. Patient #7: Review of Patient #7 Medication Administration Record (MAR) revealed she received Benadryl 50 mg Intramuscular (IM) and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:35 PM. Review of final physician medication orders for 04/06/25 from 11:07 PM (start) to 11:32 PM (stop); revealed diphenhydramine injectable 50 mg/ml SOLN was prescribed by Physician-A with indication: agitation. Olanzapine intramuscular 10 mg PWDI at 11:07 PM (start) to 11:32 PM (stop) indication: agitation. Further review of Patient #7 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #8: Review of Patient #8 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for aggression on 04/06/2025 at 8:25 PM. Review of final physician medication orders for 04/06/25 from 10:32 PM (start) to 11:59 PM (stop) revealed diphenhydramine infectable 50 mg/ml SOLN was prescribed by Physician A with indication: aggression. Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 10:47 PM (start) to 11:30 PM (stop) indication: agitation/aggression. Further review of Patient #8 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #9: Review of Patient #9 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:50 PM. Review of final physician medication orders for 04/06/2025 from 11:02 PM (start) to 11:26 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physican A with indication: agitation Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 11:02 PM (start) to 11:26 PM (stop) indication: agitation. Further review of Patient #9 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #10 Review of Patient #10 MAR revealed she received Benadryl 50 mg IM for agitation and Zyprexa 10 mg for aggression on 04/06/2025 at 8:55 PM. Review of final physician medication orders for 04/06/25 from 10:59 PM (start) to 11:23 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physician A indication: agitation. Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 10:59 PM (start) to 11:24 PM (stop) indication: aggression. Further review of Patient #10 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #11: Review of Patient #11 MAR revealed she received Zyprexa 10 mg IM at 8:55 PM and Benadryl 50 mg IM at 9:45 PM for agitation on 04/06/2025. Review of final physician medication orders for 04/06/2025 from 08:55 PM (start) to 08:56 PM (stop) revealed Olanzapine intramuscular 10 mg PWDI prescribed by Physician A indication: agitation. Diphenhydramine injectable 50 mg SOLN for 04/06/25 from 09:45 PM (start) to 09:46 PM (stop) indication: agitation. Further review of Patient #11 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #12: Review of Patient #12 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:33 PM. Review of final physician medication orders for 04/06/25 from 11:00 PM (start) to 11:24 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physician A indication: agitation. Olanzapine intramuscular 10 mg PWDI indication: agitation. Further review of Patient #12 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. There was not any documentation of seclusion for 4/6/25 at 7:43 PM on an HV-114 form or within the patient ’ s record. Interview on 4/18/25 at 4:20 PM with the DPI stated that when patients are in seclusion, there has to be continuous observation of the patient. The DPI stated there was no evidence of an incident report or seclusion documentation for Patient #12 that was observed on video dated 4/6/25 in seclusion from 7:43 PM to 7:51 PM and a door in front of the seclusion door. The DPI further confirmed there was no evidence completed by the DRM of video monitoring or documentation review completed for Patient #13 that was placed in Seclusion on 4/4/25, and Patient #14 placed in seclusion on 4/6/25. The DPI confirmed there were no incident reports or restraint documentation for any patients being physically restrained during this incident/riot. The DPI further confirmed the DRM had not been ensuring the Action Plan #5 was being completed for all events of restraints and seclusion. Interview on 5/2/25 at 9:40 AM with DPI was asked about the documentation from DRM for the video observed from the “riot” incident on 4/6/25 in the adolescent unit (A) and she stated there was not any specific documentation from the video and the video is now “deleted,” the system only keeps for “21 days.” The DPI stated the DRM was at the facility over the weekend to review the video to determine who the patient was that was placed in seclusion. The DPI was asked if the video was saved/secured and she stated that it was not saved, it was not available and in addition; the emails had been deleted from the CEO. Further interview on 5/2/25 at 11:30 AM with the DPI stated RN #13 “did not see it as seclusion” when she placed Patient #12 in the Seclusion room on 4/6/25 at 7:43 PM, because the “door was not locked.” However, the DPI confirmed that the staff placed a door in front of the seclusion door where the patient could not exit. DPI indicated RN #13 received a written warning. Interview on 05/02/2025 at 4:36 PM with the DPI indicated that all six Patients (#7, #8, #9, #10, #11, and #12) records were complete as reviewed and confirmed these patients did not have a completed HV-114 form for the administration of emergency medications that were administered on 4/6/25 in response to the “riot.” Interview on 5/13/25 at 4:15 PM with the Chief Executive Officer (CEO) stated on 4/21/25 she provided the DRM with verbal counseling and coaching regarding missing incidents and due to the “state findings.” The counseling included the DRM missing incidents in the facility’s internal reporting process and not reporting Abuse and Neglect incidents of a child to police. The CEO further stated she is now involved in the daily incidents and ensuring the completion of the incidents are done and reviewing each of the incidents. The CEO stated that another DON has been named (Staff #5 ) and that the nursing department was in the process of restructuring. Interview on 5/2/25 at 2:25 PM with Patient #17 in the adolescent unit (A) stated the following regarding the “riot” incident on 4/6/25 in which she was involved: Patient #8 moved over to our side of the unit, and she was cussing at Patient #22. Patient #18 was at the nurses station counter when she and Patient #8 went and pulled her pants down. She said we were all running around and then “people spit in the water” and then Patient #7 threw the cup. Patient #19 “hopped” the nurses counter and started coming over to us and started swinging. Patient #19 was swinging and pulling out my hair. Patient #16 tried jumping over the nurses counter too, but “they held [Patient #16] back. We all got the booty juice [emergency IM medications].” She said later Patient #19 ’ s parents were yelling at the door, but Patient #19 was the one who “swung first” and then her and Patient #21 were like, “oh no, she pulled out our hair.” Patient #17 stated that she, Patient #16, Patient #18, and the girls who jumped over the counter “got booty juice.” Patient #17 said the staff were attempting to hold Patient #19 and she “snagged a badge. They restrained us. I was restrained by a tech with purple and blonde hair with glasses.” Patient #21 and Patient #19 were being held by staff. She said they were “short staff” with only 3 MHW ’ s and wer were able to get away because they were only holding our arms. Patient #18 was able to get back over here herself after she got the door off the hinges. Some windows were busted out. Patient #17 said her head was throbbing from the amount of harm and hair pulling that Patient #19 did. Patient #17 said there was “shoving, some punching, some were bleeding;” mostly from Patient #19. Patient #17 said they “calmed us down, and then we got booty juice.” Patient #17 said they would not let us call anyone, and no one checked us out afterwards, because she was hurt and missing hair. Review of Patient #17 ’ s record revealed there was not any documentation of a physical restraint on 4/6/25. Review of the facility ’ s core staffing grid used to allocate RN’s, Licensed Vocational Nurses (LVN’s), and Mental Health Workers (MHWs) per unit, based on patient census revealed the adolescent unit-A staffing for 4/6/25 failed to ensure the minimum staffing requirements were met in accordance with patient census or acuity. Further review of the staffing grid accounts for up to 25 patients; the number of licensed beds for Unit-A. On 4/6/25 the patient census exceeded 25 patients with 29 patients. There were not adequate assigned staffing levels for the patient census for the 7AM to 7PM shift, and staffing levels were not adjusted accordingly when the census exceeded 25 patients. Unit A: 29 patients; staffed with 1 RN, 1 LVN, and 3 MHW’s. The staffing grid requires 4 MHW’s. 3.) Interview on 5/2/25 at 2:25 PM with Patient #17 in the adolescent unit (A) stated the following she and two other Patients (#20 and #21) eloped last week, Wednesday [4/23/25] when she and Patient #21 took a MHW ’ s badge when there was a code on Unit-B. The MHW was a “young blonde” and the only staff in the living area when Jeanette “grabbed her badge and rammed her head against the pole.” Then Patient # 20 “beat up the staff, I was shocked.” We had been planning an elopement, but the plan was “not to fight.” Patient #17 said she grabbed the badge and went through a window that was broke through out to the dumpsters. Patient #17 said they were able to get glass and was trying to cut off arm bands. And then got a lighter to attempt to burn them off. They went to a local apartment complex and was asking for a “ride downtown.” They hid out and then she and Patient #20 were walking near the highway when she and Patient #20 were “picked up” by the local PD. Patient #17 stated that Patient #21 has not been found. Review of the incident report for Patient #17 dated 4/23/25 at 8:20 PM indicated Patient and 2 other peers attacked staff and took her key badge and eloped from the facility. The patient was then returned to facility by the local Police Department (PD) stating that her feet were aching from eloping without shoes. Patient is resting quietly in bed. Review of the incident report for Patient #20 dated 4/23/25 at 8:20 PM indicated Patient and 2 other peers attacked staff member while nurse was responding to a code on neighboring unit and took the staff member ’ s badge and key and eloped from the facility. Patient was then found and returned to facility to transfer out to another unit for further evaluation and treatment. Patient #20 struck staff several times in the face and took her access badge that was secured in a badge holder worn on her arm. A peer was holding staff by the hair and striking her in the face when she took the armband. The local PD was called to press charges on Patients. The local PD arrived, reviewed video, and determined an assault and robbery took place. Review of the incident report for Patient #21 dated 4/23/25 at 8:20 PM indicated Patient and 2 other peers attacked staff and took her badge and keys and eloped from the facility. The local PD was called and patient has not been found as of yet. The local PD was called and charges were filed on behalf of the staff. After reviewing the video, the local PD determined all Patients involved would be charged with robbery. Interview on 5/2/25 at 4:15 PM with the DPI stated that when an emergency behavioral code (code green) is called on the overhead speaker, all available staff are to respond. There is not a specific code team or strategic plan each shift for specific staff to respond. The DPI stated the facility tried that in the past, and it did not work. 4.) Review of complaint intake TX00532091 dated 1/31/25 indicated the following on behalf of Patient #4: “staff allowed the door between the two age groups to open, which allowed the two older bigger girls to have access to the Patient [#4]. The patient ’ s nose was busted and bleeding. She had two black eyes and was knocked unconscious.” The complainant called the police; and police and EMS were sent to the hospital. The hospital staff did not allow EMS to go into the hospital stating that they had an on-call physician in the facility. Only police were allowed in the facility. The patient was given x-rays but no other tests or medical care. The patient still suffers from migraines to this day regarding the incident. Record review of Patient #4 ’ s Nursing Progress Notes, dated 06/01/2024 at 2:15 PM and 06/02/2024 from 4:25 PM to 6:09 PM completed by RN #10 documented the following, in part; “Patient attacked peer after peer made a face at this patient. Patient pushed peer and peer hit patient back. Staff separated patient and peer. Patient complained the peer had been talking “trash” about her all week and earlier called her stupid.” Patient #4 attacked peer in the dayroom. Staff separated patient and peer and a second peer attacked this patient. Staff removed all aggressors from the area. Nurse Practitioner notified of event. House nursing supervisors notified of event. Neuro check completed. Review of Final Ancillary Orders, dated 06/02/24 at 10:00 PM revealed the following telephone order entered by RN #10: Medical Consult: Struck in head multiple times during physical altercation. On 06/03/24 at 7:51 AM revealed: Mobile X Nasal Bones Comp. Min 3V - (Nasal Bones) and apply cold compresses for 10 minutes. Review of Radiology Report dated 06/03/2024 revealed Normal Nasal Bone. Interview during entrance conference on 03/31/2025 at 11:00 AM with the Director of Performance Improvement and Director of Risk Management indicated there were no incident reports completed for Patient #4. Interview on 4/3/25 at 2:28 PM with RN #10 who provided care for Patient #4 on 6/1/24 indicated he did not remember exactly what occurred on 6/1/24 that involved Patient #4 but stated that she, “may have told the other girl - to hit me.” RN #10 stated that there should have been an incident report completed in the system on 6/1/24 if there was a physical altercation, and the house supervisor, doctor, and guardians should have been notified. Review of Facility Policy and Procedure titled Incident Reporting, last reviewed April 2023, revealed but was not limited to the following: Occurrence (Incident Type): that which is not consistent with the routine care of a patient and/or the desired operations of the facility. The results of this event require or could have required (near miss) unexpected medical intervention, unexpected intensity of care, or causes or had the potential to cause an unexpected physical or mental impairment. Incident types include but are not limited to the following: death, injury/physical harm to patients, staff or third parties (visitors, worker, students, etc.), violence, and possession and/or use of drugs/alcohol or other contraband on or campus. The facility risk manager has primary responsibility for the administrative functions of the IR Reporting System and for coordination and interaction of its operation within the facility. Any facility employee or staff member who discovers, is directly involved in or is responding to an event/occurrence is to complete or direct the completion of an Incident Report (IR) form.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 21863 Based on review of medical records, policy, and interview, the facility failed to ensure chemical restraints/emergency behavioral medications (EBM) administered Intramuscular (IM) for behavioral emergencies were identified and monitored as a restraint for 6 of 11 Patient ’ s reviewed (Patient’s #7, #8, #9, #10, #11, and #12) in the adolescent unit -A that were administered emergency medications on 4/6/25 following an incident labeled as a “riot.” Failure to identify and monitor emergency medications used as restraints could result in the improper ordering and administration of medication by unauthorized staff, improper monitoring of the patient after the medication was given, and improper oversight by the facility which posed significant risks to patient safety. Findings included: Interview with Patient #3 on 4/17/25 at 3:15 PM in Unit-A ’ s group room stated on her 2nd day there was a “riot and we were on lock down” because there were girls fighting, jumping over the nurses station to get at each other from one side to the other. Observation of the playback video surveillance with the DRM on 4/18/25 at 3:45 PM using his laptop to review the video of the “Riot” that occurred on 4/6/25 revealed the following observations of the video: Two video angles were viewed. The doors had been shut in the common living area which had separated the unit into two sides. At 7:42 PM there were approximately 5 adolescent girls that surrounded 1-2 other girls at these doors which are by the nurses station. There were 2 girls observed repeatedly hitting at another one of the girl ’ s head area with their fists. Further observations revealed several girls jumping over the nurses station and going around to the other side of the common living area to get at other girls on the other side. There also were girls jumping over into the nurses station, knocking down medical equipment and patient records. Multiple staff were seen holding several patients in physical hold restraints. One staff was seen grabbing and holding a patient by her ankle that was attempting to cross over the nurses station. At 7:43 PM Patient #12 was placed in seclusion by staff (RN #13). The door was closed and a large chair placed in front of the seclusion door preventing egress. The patient remained in seclusion until 7:51 PM (8 minutes) when the chair was removed and the door opened. During these 8 minutes, there was not a staff member observing this patient in seclusion. Overall, there were an approximate 10 unidentified adolescent girls involved in the altercation; however, these girls were not identified during the time of the video observation because the DRM stated the internal investigation was “ongoing” and they continue to review the video. Review of facility policy and procedure entitled Proper Use and Monitoring of Restraint, Emergency Medications, and Seclusion, last reviewed March 2024, revealed the following, in part; Emergency Medication is defined as a psychoactive medication that is used to treat the signs and symptoms of mental illness in a psychiatric emergency to prevent imminent risk to self/others when other interventions are ineffective or inappropriate. The use of emergency medications will be documented in same manner as physical restraint and seclusion. The RN must assess the patient and the effectiveness of the emergency medication 15 minutes after administration of the medication. A second assessment will be completed after an additional 15 minutes for a total of 30 minutes after administration of the emergency medication. Vital signs will be obtained at each assessment, at the 15-minute and 30-minute patient assessment. If unable to obtain the vital signs, documented a description of the patient’s color and respirations minimally. Review of facility form HV-114 Restraint/Seclusion/Emergency Medication Acute Care revised 07/23 revealed but was not limited to the following documentation: Seclusion/Restraint/Emergency Medication Order to include: reason for intervention, less restrictive interventions, any medical conditions/abuse issues that would impact the used of restraint/seclusion, nursing summary and notifications to include time medication given, RN assessment of patient and response to emergency medications completed within 15 minutes of medication administration including vital signs, RN assessment of patient and response to emergency medications completed within 30 minutes of medication administration including vital signs, RN assessment of patient and responses to emergency medications completed within 45 minutes of medication administration including vital signs, RN review of patient response to emergency medication and brief system assessment to be completed within 60 minutes of medication administration, notifications to parent/family/ guardian. Post Intervention, Nursing Summary and Notifications include: face to face evaluation (to be completed within 1 hour of initiation of intervention) and seclusion/restraint/emergency medication patient debriefing to be completed after intervention when patient has calmed but no later than 24 hours. Debriefing. Patient #7: Review of Patient #7 Medication Administration Record (MAR) revealed she received Benadryl 50 mg Intramuscular (IM) and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:35 PM. Review of final physician medication orders for 04/06/25 from 11:07 PM (start) to 11:32 PM (stop); revealed diphenhydramine injectable 50 mg/ml SOLN was prescribed by Physician-A with indication: agitation. Olanzapine intramuscular 10 mg PWDI at 11:07 PM (start) to 11:32 PM (stop) indication: agitation. Further review of Patient #7 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #8: Review of Patient #8 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for aggression on 04/06/2025 at 8:25 PM. Review of final physician medication orders for 04/06/25 from 10:32 PM (start) to 11:59 PM (stop) revealed diphenhydramine infectable 50 mg/ml SOLN was prescribed by Physician A with indication: aggression. Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 10:47 PM (start) to 11:30 PM (stop) indication: agitation/aggression. Further review of Patient #8 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #9: Review of Patient #9 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:50 PM. Review of final physician medication orders for 04/06/2025 from 11:02 PM (start) to 11:26 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physican A with indication: agitation. Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 11:02 PM (start) to 11:26 PM (stop) indication: agitation. Further review of Patient #9 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #10 Review of Patient #10 MAR revealed she received Benadryl 50 mg IM for agitation and Zyprexa 10 mg for aggression on 04/06/2025 at 8:55 PM. Review of final physician medication orders for 04/06/25 from 10:59 PM (start) to 11:23 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physician A indication: agitation. Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 10:59 PM (start) to 11:24 PM (stop) indication: aggression. Further review of Patient #10 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #11: Review of Patient #11 MAR revealed she received Zyprexa 10 mg IM at 8:55 PM and Benadryl 50 mg IM at 9:45 PM for agitation on 04/06/2025. Review of final physician medication orders for 04/06/2025 from 08:55 PM (start) to 08:56 PM (stop) revealed Olanzapine intramuscular 10 mg PWDI prescribed by Physician A indication: agitation. Diphenhydramine injectable 50 mg SOLN for 04/06/25 from 09:45 PM (start) to 09:46 PM (stop) indication: agitation. Further review of Patient #11 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #12: Review of Patient #12 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:33 PM. Review of final physician medication orders for 04/06/25 from 11:00 PM (start) to 11:24 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physician A indication: agitation. Olanzapine intramuscular 10 mg PWDI indication: agitation. Further review of Patient #12 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. There was not any documentation of seclusion for 4/6/25 at 7:43 PM on an HV-114 form or within the patient ’ s record. Interview on 4/18/25 at 4:20 PM stated there was no evidence of an incident report or seclusion documentation for Patient #12 that was observed on video dated 4/6/25 in seclusion from 7:43 PM to 7:51 PM and a door in front of the seclusion door. The DPI confirmed there were no incident reports or restraint documentation for any patients being physically restrained during this incident/riot on 4/6/25. The DPI further confirmed the DRM had not been ensuring the Action Plan #5 was being completed for all events of restraints and seclusion. Interview on 5/2/25 at 9:40 AM with DPI was asked about the documentation from DRM for the video observed from the “riot” incident on 4/6/25 in the adolescent unit (A) and she stated there was not any specific documentation from the video and the video is now “deleted,” the system only keeps for “21 days.” The DPI stated the DRM was at the facility over the weekend to review the video to determine who the patient was that was placed in seclusion. The DPI was asked if the video was saved/secured and she stated that it was not saved, it was not available and in addition; the emails had been deleted from the CEO. Interview on 05/02/2025 at 4:36 PM with the DPI indicated that all six Patients (#7, #8, #9, #10, #11, and #12) records were complete as reviewed and confirmed these patients did not have a completed HV-114 form for the administration of emergency medications that were administered on 4/6/25 in response to the “riot.” Interview on 5/13/25 at 4:15 PM with the Chief Executive Officer (CEO) stated on 4/21/25 she provided the DRM with verbal counseling and coaching regarding missing incidents and due to the “state findings.” The counseling included the DRM missing incidents in the facility’s internal reporting process and not reporting Abuse and Neglect incidents of a child to police. The CEO further stated she is now involved in the daily incidents and ensuring the completion of the incidents are done and reviewing each of the incidents. The CEO stated that another DON has been named (Staff #5) and that the nursing department was in the process of restructuring. Interview on 5/2/25 at 2:25 PM with Patient #17 in the adolescent unit (A) stated the following regarding the “riot” incident on 4/6/25 in which she was involved: Patient #8 moved over to our side of the unit, and she was cussing at Patient #22. Patient #18 was at the nurses station counter when she and Patient #8 went and pulled her pants down. She said we were all running around and then “people spit in the water” and then Patient #7 threw the cup. Patient #19 “hopped” the nurses counter and started coming over to us and started swinging. Patient #19 was swinging and pulling out my hair. Patient #16 tried jumping over the nurses counter too, but “they held [Patient #16] back. We all got the booty juice [emergency IM medications].” She said later Patient #19 ’ s parents were yelling at the door, but Patient #19 was the one who “swung first” and then her and Patient #21 were like, “oh no, she pulled out our hair.” Patient #17 stated that she, Patient #16, Patient #18, and the girls who jumped over the counter “got booty juice.” Patient #17 said the staff were attempting to hold Patient #19 and she “snagged a badge. They restrained us. I was restrained by a tech with purple and blonde hair with glasses.” Patient #21 and Patient #19 were being held by staff. She said they were “short staff” with only 3 MHW ’ s and we were able to get away because they were only holding our arms. Patient #18 was able to get back over here herself after she got the door off the hinges. Some windows were busted out. Patient #17 said her head was throbbing from the amount of harm and hair pulling that Patient #19 did. Patient #17 said there was “shoving, some punching, some were bleeding;” mostly from Patient #19. Patient #17 said they “calmed us down, and then we got booty juice.” Patient #17 said they would not let us call anyone, and no one checked us out afterwards, because she was hurt and missing hair.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 21863 Based on observation of facility video surveillance, record reviews, and interviews, it was determined the facility failed to ensure staff implemented emergency interventions including physical restraint, seclusion, and administration of emergency medications according to the facility ’ s policy during a group incident that occurred on 4/6/25 in the adolescent unit (A) where several patients were engaged in physical fighting and property destruction; labeled as a “riot.” Several unidentified Patients were seen on video playback being physically held in restraint without any physical restraint documentation. Patient #12 was placed in seclusion without monitoring or documentation. Patient’s #7, #8, #9, #10, #11, and #12 were administered chemical restraints (emergency behavioral medications) without evidence of monitoring or documentation of the facility ’ s HV-114 form for Restraint/Seclusion/EmMeds in accordance with the policy. Patient #17 stated she was physically restrained on 4/6/25 during this event without restraint documentation. The failure to document restraint episodes, seclusion, and provide monitoring after the administration of emergency medications posed significant risks to patient health and safety; and resulted in the inability to provide appropriate oversight. Findings included: Interview with Patient #3 on 4/17/25 at 3:15 PM in Unit-A ’ s group room stated on her 2nd day there was a “riot and we were on lock down” because there were girls fighting, jumping over the nurses station to get at each other from one side to the other. Observation of the playback video surveillance with the DRM on 4/18/25 at 3:45 PM using his laptop to review the video of the “Riot” that occurred on 4/6/25 revealed the following observations of the video: Two video angles were viewed. The doors had been shut in the common living area which had separated the unit into two sides. At 7:42 PM there were approximately 5 adolescent girls that surrounded 1-2 other girls at these doors which are by the nurses station. There were 2 girls observed repeatedly hitting at another one of the girl ’ s head area with their fists. Further observations revealed several girls jumping over the nurses station and going around to the other side of the common living area to get at other girls on the other side. There also were girls jumping over into the nurses station, knocking down medical equipment and patient records. Multiple staff were seen holding several patients in physical hold restraints. One staff was seen grabbing and holding a patient by her ankle that was attempting to cross over the nurses station. At 7:43 PM Patient #12 was placed in seclusion by staff, (RN #13), the door was closed and a large chair placed in front of the seclusion door preventing egress. The patient remained in the seclusion until 7:51 PM (8 minutes) when the chair was removed and the door opened. During these 8 minutes, there was not a staff member observing this patient in seclusion. Overall, there were an approximate 10 unidentified adolescent girls involved in the altercation; however, these girls were not identified during the time of the video observation because the DRM stated the internal investigation was “ongoing” and they continue to review the video. Review of facility policy and procedure entitled Proper Use and Monitoring of Restraint, Emergency Medications, and Seclusion, last reviewed March 2024, revealed the following, in part; Emergency Medication is defined as a psychoactive medication that is used to treat the signs and symptoms of mental illness in a psychiatric emergency to prevent imminent risk to self/others when other interventions are ineffective or inappropriate. The use of emergency medications will be documented in same manner as physical restraint and seclusion. The RN must assess the patient and the effectiveness of the emergency medication 15 minutes after administration of the medication. A second assessment will be completed after an additional 15 minutes for a total of 30 minutes after administration of the emergency medication. Vital signs will be obtained at each assessment, at the 15-minute and 30-minute patient assessment. If unable to obtain the vital signs, documented a description of the patient’s color and respirations minimally. Any patient placed in seclusion will be continuously observed by staff standing immediately outside the seclusion room. Review of facility form HV-114 Restraint/Seclusion/Emergency Medication Acute Care revised 07/23 revealed but was not limited to the following documentation: Seclusion/Restraint/Emergency Medication Order to include: reason for intervention, less restrictive interventions, any medical conditions/abuse issues that would impact the used of restraint/seclusion, nursing summary and notifications to include time medication given, RN assessment of patient and response to emergency medications completed within 15 minutes of medication administration including vital signs, RN assessment of patient and response to emergency medications completed within 30 minutes of medication administration including vital signs, RN assessment of patient and responses to emergency medications completed within 45 minutes of medication administration including vital signs, RN review of patient response to emergency medication and brief system assessment to be completed within 60 minutes of medication administration, notifications to parent/family/ guardian. Post Intervention, Nursing Summary and Notifications include: face to face evaluation (to be completed within 1 hour of initiation of intervention) and seclusion/restraint/emergency medication patient debriefing to be completed after intervention when patient has calmed but no later than 24 hours. Debriefing. Patient #7: Review of Patient #7 Medication Administration Record (MAR) revealed she received Benadryl 50 mg Intramuscular (IM) and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:35 PM. Review of final physician medication orders for 04/06/25 from 11:07 PM (start) to 11:32 PM (stop); revealed diphenhydramine injectable 50 mg/ml SOLN was prescribed by Physician-A with indication: agitation. Olanzapine intramuscular 10 mg PWDI at 11:07 PM (start) to 11:32 PM (stop) indication: agitation. Further review of Patient #7 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #8: Review of Patient #8 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for aggression on 04/06/2025 at 8:25 PM. Review of final physician medication orders for 04/06/25 from 10:32 PM (start) to 11:59 PM (stop) revealed diphenhydramine infectable 50 mg/ml SOLN was prescribed by Physician A with indication: aggression. Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 10:47 PM (start) to 11:30 PM (stop) indication: agitation/aggression. Further review of Patient #8 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #9: Review of Patient #9 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:50 PM. Review of final physician medication orders for 04/06/2025 from 11:02 PM (start) to 11:26 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physican A with indication: agitation. Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 11:02 PM (start) to 11:26 PM (stop) indication: agitation. Further review of Patient #9 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #10 Review of Patient #10 MAR revealed she received Benadryl 50 mg IM for agitation and Zyprexa 10 mg for aggression on 04/06/2025 at 8:55 PM. Review of final physician medication orders for 04/06/25 from 10:59 PM (start) to 11:23 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physician A indication: agitation. Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 10:59 PM (start) to 11:24 PM (stop) indication: aggression. Further review of Patient #10 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #11: Review of Patient #11 MAR revealed she received Zyprexa 10 mg IM at 8:55 PM and Benadryl 50 mg IM at 9:45 PM for agitation on 04/06/2025. Review of final physician medication orders for 04/06/2025 from 08:55 PM (start) to 08:56 PM (stop) revealed Olanzapine intramuscular 10 mg PWDI prescribed by Physician A indication: agitation. Diphenhydramine injectable 50 mg SOLN for 04/06/25 from 09:45 PM (start) to 09:46 PM (stop) indication: agitation. Further review of Patient #11 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #12: Review of Patient #12 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:33 PM. Review of final physician medication orders for 04/06/25 from 11:00 PM (start) to 11:24 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physician A indication: agitation. Olanzapine intramuscular 10 mg PWDI indication: agitation. Further review of Patient #12 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. There was not any documentation of seclusion for 4/6/25 at 7:43 PM on an HV-114 form or within the patient ’ s record. Interview on 4/18/25 at 4:20 PM with the DPI stated that when patients are in seclusion, there has to be continuous observation of the patient. The DPI stated there was no evidence of an incident report or seclusion documentation for Patient #12 that was observed on video dated 4/6/25 in seclusion from 7:43 PM to 7:51 PM and a door in front of the seclusion door. The DPI further confirmed there was no evidence completed by the DRM of video monitoring or documentation review completed for Patient #13 that was placed in Seclusion on 4/4/25, and Patient #14 placed in seclusion on 4/6/25. The DPI confirmed there were no incident reports or restraint documentation for any patients being physically restrained during this incident/riot. The DPI further confirmed the DRM had not been ensuring the Action Plan #5 was being completed for all events of restraints and seclusion. Interview on 5/2/25 at 9:40 AM with DPI was asked about the documentation from DRM for the video observed from the “riot” incident on 4/6/25 in the adolescent unit (A) and she stated there was not any specific documentation from the video and the video is now “deleted,” the system only keeps for “21 days.” The DPI stated the DRM was at the facility over the weekend to review the video to determine who the patient was that was placed in seclusion. The DPI was asked if the video was saved/secured and she stated that it was not saved, it was not available and in addition; the emails had been deleted from the CEO. Further interview on 5/2/25 at 11:30 AM with the DPI stated RN #13 “did not see it as seclusion” when she placed Patient #12 in the Seclusion room on 4/6/25 at 7:43 PM, because the “door was not locked.” However, the DPI confirmed that the staff placed a door in front of the seclusion door where the patient could not exit. DPI indicated RN #13 received a written warning. Interview on 05/02/2025 at 4:36 PM with the DPI indicated that all six Patients (#7, #8, #9, #10, #11, and #12) records were complete as reviewed and confirmed these patients did not have a completed HV-114 form for the administration of emergency medications that were administered on 4/6/25 in response to the “riot.” Interview on 5/13/25 at 4:15 PM with the Chief Executive Officer (CEO) stated on 4/21/25 she provided the DRM with verbal counseling and coaching regarding missing incidents and due to the “state findings.” The counseling included the DRM missing incidents in the facility’s internal reporting process and not reporting Abuse and Neglect incidents of a child to police. The CEO further stated she is now involved in the daily incidents and ensuring the completion of the incidents are done and reviewing each of the incidents. The CEO stated that another DON has been named (Staff # 5) and that the nursing department was in the process of restructuring. Interview on 5/2/25 at 2:25 PM with Patient #17 in the adolescent unit (A) stated the following regarding the “riot” incident on 4/6/25 in which she was involved: Patient #8 moved over to our side of the unit, and she was cussing at Patient #22. Patient #18 was at the nurses station counter when she and Patient #8 went and pulled her pants down. She said we were all running around and then “people spit in the water” and then Patient #7 threw the cup. Patient #19 “hopped” the nurses counter and started coming over to us and started swinging. Patient #19 was swinging and pulling out my hair. Patient #16 tried jumping over the nurses counter too, but “they held [Patient #16] back. We all got the booty juice [emergency IM medications].” She said later Patient #19 ’ s parents were yelling at the door, but Patient #19 was the one who “swung first” and then her and Patient #21 were like, “oh no, she pulled out our hair.” Patient #17 stated that she, Patient #16, Patient #18, and the girls who jumped over the counter “got booty juice.” Patient #17 said the staff were attempting to hold Patient #19 and she “snagged a badge. They restrained us. I was restrained by a tech with purple and blonde hair with glasses.” Patient #21 and Patient #19 were being held by staff. She said they were “short staff” with only 3 MHW ’ s and we were able to get away because they were only holding our arms. Patient #18 was able to get back over here herself after she got the door off the hinges. Some windows were busted out. Patient #17 said her head was throbbing from the amount of harm and hair pulling that Patient #19 did. Patient #17 said there was “shoving, some punching, some were bleeding;” mostly from Patient #19. Patient #17 said they “calmed us down, and then we got booty juice.” Patient #17 said they would not let us call anyone, and no one checked us out afterwards, because she was hurt and missing hair. Review of Patient #17 ’ s record revealed there was not any documentation of a physical restraint on 4/6/25.”

“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: 21863 Based on observation, interviews, and document review, the facility failed to ensure that actions aimed at performance improvement were adequately implemented and monitored to sustain improvements as required under the hospital’s QAPI program. Specifically, following the death of a patient in seclusion on 3/3/2025, the facility conducted a root cause analysis and developed a corrective action plan; however, the facility failed to ensure that the action steps were fully executed and monitored for effectiveness. Staff continued to inaccurately document patient monitoring during seclusion or failed to document physical hold restraints, and the governing body failed to oversee whether the action plan was followed, including verifying the accuracy of documentation, ensuring documentation is completed for patients in restraint and seclusion, and reviewing available video footage for compliance. This failure placed other patients at risk for harm due to unaddressed systemic issues and noncompliance with safety interventions intended to prevent reoccurrence of serious adverse events. Findings included: Review of Intake Information, TX00536658, received 3/10/25 indicated on 3/3/2025, Patient #5 was taken from Unit-C to Unit-D; due to a behavioral event. He was injected with medications, possibly sedative. Patient #5 was placed in the seclusion room in an effort to allow the medication to work. No one checked on Patient #5 for about 55 to 60 minutes, until staff found him unresponsive and bleeding from his mouth. Patient #5 expired. Patient #5 was “not aggressive, only annoying.” The facility was not in ratio as there were four staff for 25 patients. There is supposed to be one staff for every five patients. Patient #5 was a 44-year-old Hispanic male with mild IDD (Intellectual and Developmental Disability), with no signs of physical problems. Patient #5 never presented a threat to himself or others. Review of the facility incident report dated 03/03/2025 at 3:30 PM, documented Patient #5 “out of control, 27.” Patient at nursing station voicing delusional though process. Attempted to remove from nurse station. Patient continued delusional behavior in day area, running around. Attempted to remove from stimuli, where patient pushed staff. Then escorted to seclusion. Patient noted lying down in seclusion room. Review of the facility incident report dated 03/03/2025 at 6:25 PM, revealed Patient #5 died while he was sleeping in seclusion. Patient #5 ’ s Incident report was reviewed by interim assistant CNO/Staff #4 on 03/04/2025 at 8:30 AM and the Director of Risk Management (DRM)/Staff #3 on 03/04/2025 at 08:30 AM with the following comments: On 03/03/2025 at 6:28 PM, staff enter the unlocked seclusion room where patient is laying down. After entering and calling the patient ’ s name, he is unresponsive to the verbal cue. Staff then retrieve the nurse who entered the seclusion room, turns the patient onto his back and attempts to arouse him via verbal cues and a sternal rub with no response. Code blue called and CPR initiated at 6:31 PM. Code blue bag arrives, and AED is put in place. Patient #5 remains unresponsive, and CPR is continued. Fire Department arrives at 6:42 PM and takes over CPR. Fire Department ceases CPR and calls time of death at 7:03 PM. Review of facility form HV-114 Restraint/Seclusion/Emergency Meds Acute Care Revised 07/2023, for Patient #5 dated 03/03/2025 revealed but was not limited to the following: Patient was in seclusion from 3:40 PM to 4:20 PM. Patient was listed as laying on mattress sleeping at 3:45 PM. Post Intervention, Face to Face Evaluation was completed by registered nurse at 4:57 PM with continued need for restraint/seclusion checked as, no. Review of Physician Preadmission Evaluation Review and Admitting orders, dated 03/02/2025 at 6:54 PM revealed Patient #5 was admitted with an observation level of every five minutes (q5). Interview with Director of Performance Improvement (DPI) on 04/17/2025 at 11:26 AM revealed the facility terminated employment for all staff who were on duty on the unit (D) where the Patient #5 ’ s death occurred, including two registered nurses, one licensed vocational nurse and two mental health workers. The DPI stated a root cause analysis (RCA) was completed with recommended terminations due to misleading or falsifying documentation, and failure to follow policies and procedures. Action plans were implemented to address the issues identified in the RCA. Review of the RCA completed 4/8/2025 found in part, for Patient #5; -continuous observation when the patient was locked in the seclusion room did not occur per policy and procedure. - there was a 23-minute gap between the patient observation rounds. -observation rounds were documented without staff actually visualizing the patient. -the Q5-minute observations ordered upon admission in accordance with the physician orders were not being followed. -there were discrepancies in the documentation versus what was observed in the camera review. -no vital signs were obtained during the entire event timeline. Review of the plan of correction/action plan revealed the following, in part: Action Plan #2: Daily observation reports will be reviewed and distributed to the respective nursing director for review and to complete follow up action for all late rounds greater than 20 minutes effective 04/01/2025. Action #3: Evening supervisor will conduct at minimum two in person rounds on all patient care units auditing all observation tablets for rounding compliance and forced errors effective 04/01/25. Action #5: All events of restraints and seclusion will be reviewed by the Director of Risk Management and respective unit nursing director for compliance. Completion Date: 03/19/2025. Review of Seclusion/Restraint/Emergency Medication Order dated 04/04/2025 at 10:20 AM for Patient #13 revealed he was placed in seclusion from 10:29 AM to 10:41 AM. Review of his Patient Observation Sheet for 04/04/2025 for this time (10:29-10:41 AM), revealed documentation Patient #13 was in the “day room,” as opposed to the “seclusion room”. Review of Seclusion/Restraint/Emergency Medication Order dated 04/06/2025 at 12:33 PM for Patient #14 revealed she was placed in seclusion from 12:33 PM to 12:40 PM. Review of Patient #14 ’ s Observation Sheet for 04/06/2025 for this time (12:33 -12:40 PM) revealed documentation she was in the “day room” as opposed to the “seclusion room.” Interview with Patient #3 on 4/17/25 at 3:15 PM in Unit-A ’ s group room stated on her 2nd day there was a “riot and we were on lock down” because there were girls fighting, jumping over the nurses station to get at each other from one side to the other. Observation of the playback video surveillance with the DRM on 4/18/25 at 3:45 PM using his laptop to review the video of the “Riot” that occurred on 4/6/25 revealed the following observations of the video: Two video angles were viewed. The doors had been shut in the common living area which had separated the unit into two sides. At 7:42 PM there were approximately 5 adolescent girls that surrounded 1-2 other girls at these doors which are by the nurses station. There were 2 girls observed repeatedly hitting at another one of the girl ’ s head area with their fists. Further observations revealed several girls jumping over the nurses station and going around to the other side of the common living area to get at other girls on the other side. There also were girls jumping over into the nurses station, knocking down medical equipment and patient records. Multiple staff were seen holding several patients in physical hold restraints. One staff was seen grabbing and holding a patient by her ankle that was attempting to cross over the nurses station. At 7:43 PM Patient #12 was placed in seclusion by staff (RN #13). The door was closed and a large chair placed in front of the seclusion door preventing egress. The patient remained in seclusion until 7:51 PM (8 minutes) when the chair was removed and the door opened. During these 8 minutes, there was not a staff member observing this patient in seclusion. Overall, there were an approximate 10 unidentified adolescent girls involved in the altercation; however, these girls were not identified during the time of the video observation because the DRM stated the internal investigation was “ongoing” and they continue to review the video. Interview on 4/18/25 at 4:20 PM with the DPI stated that when patients are in seclusion, there has to be continuous observation of the patient. The DPI stated there was no evidence of an incident report or seclusion documentation for Patient #12 that was observed on video dated 4/6/25 in seclusion from 7:43 PM to 7:51 PM and a door in front of the seclusion door. The DPI further confirmed there was no evidence completed by the DRM of video monitoring or documentation review completed for Patient #13 that was placed in Seclusion on 4/4/25, and Patient #14 placed in seclusion on 4/6/25. The DPI confirmed there were no incident reports or restraint documentation for any patients being physically restrained during this incident/riot. The DPI further confirmed the DRM had not been ensuring the Action Plan #5 was being completed for all events of restraints and seclusion. The DPI stated the DPM is supposed to include his monitoring, recommendations, or action plans on the incident reports review. Further interview on 5/2/25 at 11:30 AM with the DPI stated RN #13 “did not see it as seclusion” when she placed Patient #12 in the Seclusion room on 4/6/25 at 7:43 PM, because the “door was not locked.” However, the DPI confirmed that the staff placed a door in front of the seclusion door where the patient could not exit. DPI indicated RN #13 received a written warning. Interview on 5/13/25 at 4:15 PM with the Chief Executive Officer (CEO) stated on 4/21/25 she provided the DRM with verbal counseling and coaching regarding missing incidents and due to the “state findings.” The counseling included the DRM missing incidents in the facility’s internal reporting process and not reporting Abuse and Neglect incidents of a child to police. The CEO further stated she is now involved in the daily incidents and ensuring the completion of the incidents are done and reviewing each of the incidents.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 21863 Based on observation, interviews, and document reviews, the facility failed to provide adequate numbers of nursing personnel, other personnel to provide care, and ensure the immediate availability of a registered nurse (RN) on each unit to meet the needs of the patients, and in accordance with the facility’s current staffing grid. Specifically, the facility utilizes a core staffing grid to allocate RN’s, Licensed Vocational Nurses (LVN’s), and Mental Health Workers (MHWs) per unit, based on patient census. Review of unit staffing for 4/3/25 and 4/6/25 revealed the facility failed to ensure the minimum staffing requirements were met in accordance with patient census or acuity. 1.) Unit A: The staffing grid accounts for up to 25 patients; the number of licensed beds. On 4/3/25 and 4/6/25 the patient census exceeded 25 patients; there were not adequate assigned staffing levels for the patient census and staffing levels were not adjusted accordingly when the census exceeded 25 patients. 2.) On 4/6/25 there were 12 of 14 units reviewed (A, C, D, E, F, G, H, I, J, K, L, M) that did not meet the minimum staffing requirements in accordance with the facility’s current Core Staffing Grid and failed to ensure the immediate availability of an RN for each unit. The facility’s failure to provide adequate numbers of staffing resulted in repeated failures to meet minimum care standards, placing patients at risk for harm, delayed care, and inadequate supervision. Findings included: 1.) Observation on 4/3/2025 at 2:30 PM on Unit A (the adolescent female unit) with the interim Assistant- Director of Nurses (A-DON)/Staff#4 present revealed the following: RN #10 was in charge, there was a medication nurse (RN instead of LVN), and 3 MHW’s assigned to the unit. There were 28 patients total on the unit, 27 assigned and 1 “programming from another unit”. There had been 2 admissions since 7:00 AM and RN #10 was working on the daily nursing assessments. The surveyor attempted an interview with RN #10 at the nurses’ station but was continuously interrupted by patients with requests, phone calls from parents and providers, staff reporting lab results, staff asking for guidance, and staff coming and going. Review of the unit Core staffing grid for Unit A, revealed there must be 4 MHW’s for a census of 25 patients. The staffing grid did not account for patient census exceeding 25. During an interview conducted on 4/3/25 at 2:35 PM with the assigned RN #10 stated: There were 28 patients on the unit today. The census is 27 and there is another patient programming on the unit. RN #10 said he is responsible for completing a nursing assessment on all 27 patients during his 12-hour shift. 2.) A.) Review of the Patient Census, Daily Staffing Report for 4/6/25 7:00 AM - 7:00 PM and corresponding Unit 2025 Core Staffing Grid revealed the following: o Unit A: 29 patients; staffed with 1 RN, 1 LVN, and 3 MHW’s. The staffing grid requires 4 MHW’s. This is a female adolescent unit. o Unit C: 16 patients; staffed with only 1 MHW. The staffing grid requires 2 MHW’s. o Unit E: 15 patients; staffed with only 1 MHW. The staffing grid requires 2 MHW’s. o Unit F: 15 patients; no RN provided/staffed. The staffing grid requires 1 RN. o Unit G: 20 patients; no MHW’s staffed. The staffing grid requires 2 MHW’s. o Unit H: 22 patients; staffed with 2 MHW’s. The staffing grid requires 3 MHW’s. o Unit I: 20 patients; no RN provided/staffed. The staffing grid requires 1 RN. o Unit J: 13 patients; no LVN provided/staffed. The staffing grid requires 1 LVN. o Unit K: 17 patients; staffed with only 1 MHW. The staffing grid requires 2 MHW’s. o Unit L: 19 patients; staffed with only 1 MHW. The staffing grid requires 2 MHW’s. This equates to at least 11 staff this shift not provided affecting 10 units that were not adequately staffed according to the minimal staffing. There was no consideration taken for patient acuity or increased supervision levels. B.) Review of the Patient Census, Daily Staffing Report for 4/6/25 7:00 PM - 7:00 AM and corresponding Unit 2025 Core Staffing Grid revealed the following: o Unit D: 22 patients; staffed with 2 MHW’s. The staffing grid requires an additional MHW for 8 hours (0.75 MHW). o Unit E: 15 patients; staffed with 1 MHW. The staffing grid requires an additional MHW for 4 hours (0.25 MHW). o Unit F: 15 patients; no LVN provided/staffed. The staffing grid requires 1 LVN. o Unit G: 20 patients; no LVN provided/staffed and staffed with only 1 MHW. The staffing grid requires 1 LVN and an additional MHW for 4 hours (0.25 MHW). o Unit I: 20 patients; no LVN provided/staffed and staffed with only 1 MHW. The staffing grid requires 1 LVN and an additional MHW for 4 hours (0.25 MHW). o Unit J: 13 patients; no RN provided/staffed. The staffing grid requires 1 RN. o Unit K: 17 patients; staffed with 1 MHW. The staffing grid requires an additional MHW for 4 hours (0.25 MHW). o Unit M: 13 patients; no RN. The staffing grid requires 1 RN. This is a child unit with patients 5 years old to 12. This equates to at least 7 staff this shift not provided affecting 8 units that were not adequately staffed according to the minimal staffing. There was no consideration taken for patient acuity or increased supervision levels. An interview was conducted with Patient #3 on 4/17/25 at 3:15 PM in Unit-A’s group room and stated that most of the time she is unable to go to the cafeteria to eat her meals because there is not enough staff available to escort the patients. Patient #3 reported that there must be at least one staff member available to accompany every seven patients to the cafeteria, and staffing is frequently insufficient to meet this requirement. Patient #3 further stated that staff frequently say they are “short-staffed,” and staffing shortage often results in patients being unable to go to the cafeteria for meals or participate in outdoor activities. Patient #3 expressed that she feels the staff are not compassionate and lack empathy, further contributing to her dissatisfaction with the care provided at times. Patient #3 said that on her 2nd day there was a “riot and we were on lock down” because there were girls fighting, jumping over the nurses station to get at each other from one side to the other. She said they mix the13 and 17-year-old girls together, and they should be kept separate. An interview was conducted with Patient #17 on 5/2/25 at 2:30 PM in Unit-A. The patient reported that on April 6, 2025, there was a “riot” on Unit A. Patient #17 stated that the unit was “short-staffed” on the day of the incident. During the riot, Patient #17 stated she was “restrained” and administered an emergency injection, referred to by the patient as “booty juice.” Patient #17 also disclosed that on April 23, 2025, she and two other patients (#20 and #21) eloped from the facility. She explained that they had been planning it in advance. They waited until there was a code announced on the adjacent male adolescent unit (B), at which point most staff responded, leaving only one mental health worker behind on her unit (A). According to the patient, they jumped the remaining staff member, took her badge, and used it to exit the facility. Patient #17 stated she and Patient #20 were later apprehended by the local police department and returned, but that Patient #21 who also escaped has not been found or returned. Review of the last Nursing Staff Committee (NSC) Meeting, dated 3/25/25 chaired by the interim Assistant Director of Nursing (A- DON)/Staff #4 revealed the members present included an RN House Supervisor, The RN educator, The RN infection control nurse, The child and adolescent RN unit director, and one LVN “floor nurse.” This was the first meeting under the new ADON(ACNO)/Staff #4. The new business discussion included the Nursing 12-hour shift template. Proposals to rotate shifts to address staff burnout-particularly for staff working 3/4 shifts in a two-week period. Strategies were discussed to rotate schedules and avoid 4 shifts consecutively. PRN pool management and part-time roles to support full-time staff. In an interview with the new ADON(ACNO)/Staff #4 on 4/3/25 at 3:30 PM indicated he was recently placed as the interim assistant CNO (DON) of the facility and would be reviewing the staffing grid with other administrative staff. There was not any documentation that discussed focusing on meeting minimal staffing ratios in relation to patient census, or a review of the actual staffing grid compliance. This supports concerns that staffing shortages were not being formally evaluated or addressed in structured leadership meetings. The NSC did not include a composition of at least 60% of RN’s with direct care roles in accordance with Texas State Law requirements. Interview on 5/13/25 at 4:15 PM with the Chief Executive Officer (CEO) and the Director of Performance Improvement (DPI) revealed the CEO confirmed there was supposed to be an RN assigned to every unit for every shift. The DPI indicated the previous facility’s CNO allowed this practice. The CEO stated that another DON has been named (Unit Director/Staff #5) and that the nursing department was in the process of restructuring.”

“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: 21863 Based on observation, interviews, and document reviews, the facility failed to provide adequate numbers of nursing personnel to ensure the immediate availability of a registered nurse (RN) assigned on each unit to supervise and evaluate the nursing care of each patient; and in accordance with the facility’s policies and procedures, and current staffing grid. Specifically, on 4/6/25: 1.) There were 4 of 14 units reviewed (F, I, J, M) that did not meet the minimum staffing requirements in accordance with the facility’s current Core Staffing Grid to ensure the immediate availability of an RN for each unit, and 2.) RN staff failed to ensure implementation and evaluation of the emergency interventions including physical restraint, seclusion, and administration of emergency medications according to the facility’s policy and procedures during a group incident that occurred on 4/6/25 in the adolescent unit (A) where several patients were engaged in physical fighting and property destruction; labeled as a “riot.” Several unidentified Patients were seen on video playback being physically held in restraint without any physical restraint documentation. Patient #12 was placed in seclusion by RN #13 without monitoring or documentation. Patient’s #7, #8, #9, #10, #11, and #12 were administered chemical restraints (emergency behavioral medications) without evidence of monitoring or documentation of the facility’s HV-114 form for Restraint/Seclusion/EmMeds in accordance with the policy. Patient #17 stated she was physically restrained on 4/6/25 during this event without restraint documentation. The facility’s failure to provide adequate numbers of nursing personnel and ensure nursing personnel supervised and evaluated patients care provided resulted in repeated failures to meet minimum care standards, placed staff and patients at risk for harm, delayed care, and resulted in inadequate nursing staff supervision during medical and behavioral emergencies that can result in patient harm, injury and potential death. Findings included: 1.) A.) Review of the Patient Census, Daily Staffing Report for 4/6/25 7:00 AM - 7:00 PM and corresponding Unit 2025 Core Staffing Grid revealed the following: o Unit F: 15 patients; no RN provided/staffed. The staffing grid requires 1 RN. o Unit I: 20 patients; no RN provided/staffed. The staffing grid requires 1 RN. B.) Review of the Patient Census, Daily Staffing Report for 4/6/25 7:00 PM - 7:00 AM and corresponding Unit 2025 Core Staffing Grid revealed the following: o Unit J: 13 patients; no RN provided/staffed. The staffing grid requires 1 RN. o Unit M: 13 patients; no RN provided/staffed. The staffing grid requires 1 RN. This is a child unit with patients 5 years old to 12. An interview was conducted with Patient #17 on 5/2/25 at 2:30 PM in Unit-A disclosed that on April 23, 2025, she and two other patients (#20 and #21) eloped from the facility. She explained that they had been planning it in advance. They waited until there was a code announced on the adjacent male adolescent unit (B), at which point most staff responded (including the RN), leaving only one mental health worker behind on her unit (A). According to the patient, they jumped the remaining staff member, took her badge, and used it to exit the facility. Patient #17 stated she and Patient #20 were later apprehended by the local police department and returned, but that Patient #21 who also escaped has not been found or returned. Review of the incident report for Patient #20 dated 4/23/25 at 8:20 PM indicated Patient and 2 other peers attacked staff member while nurse was responding to a code on neighboring unit and took the staff member’s badge and key and eloped from the facility. Patient was then found and returned to facility to transfer out to another unit for further evaluation and treatment. Patient #20 struck staff several times in the face and took her access badge that was secured in a badge holder worn on her arm. A peer was holding staff by the hair and striking her in the face when she took the armband. The local PD was called to press charges on Patients. The local PD arrived, reviewed video, and determined an assault and robbery took place. Review of the last Nursing Staff Committee (NSC) Meeting, dated 3/25/25 chaired by the interim Assistant Director of Nursing (A- DON)/Staff #4 revealed the members present included an RN House Supervisor, The RN educator, The RN infection control nurse, The child and adolescent RN unit director, and one LVN “floor nurse.” This was the first meeting under the new ADON(ACNO)/Staff #4. The new business discussion included the Nursing 12-hour shift template. Proposals to rotate shifts to address staff burnout-particularly for staff working 3/4 shifts in a two-week period. Strategies were discussed to rotate schedules and avoid 4 shifts consecutively. PRN pool management and part-time roles to support full-time staff. In an interview with the new ADON(ACNO)/Staff #4 on 4/3/25 at 3:30 PM indicated he was recently placed as the interim assistant CNO (DON) of the facility and would be reviewing the staffing grid with other administrative staff. There was not any documentation that discussed focusing on meeting minimal staffing ratios in relation to patient census, or a review of the actual staffing grid compliance. The This supports concerns that staffing shortages were not being formally evaluated or addressed in structured leadership meetings. The NSC did not include a composition of at least 60% of RN’s with direct care roles in accordance with Texas State Law requirements. Interview on 5/13/25 at 4:15 PM with the Chief Executive Officer (CEO) and the Director of Performance Improvement (DPI) revealed the CEO confirmed there was supposed to be an RN assigned to every unit for every shift. The DPI indicated the previous facility’s CNO allowed this practice. The CEO stated that another DON has been named (Unit Director/Staff #5) and that the nursing department was in the process of restructuring. 2.) Interview with Patient #3 on 4/17/25 at 3:15 PM in Unit-A ’ s group room stated on her 2nd day there was a “riot and we were on lock down” because there were girls fighting, jumping over the nurses station to get at each other from one side to the other. Observation of the playback video surveillance with the DRM on 4/18/25 at 3:45 PM using his laptop to review the video of the “Riot” that occurred on 4/6/25 revealed the following observations of the video: Two video angles were viewed. The doors had been shut in the common living area which had separated the unit into two sides. At 7:42 PM there were approximately 5 adolescent girls that surrounded 1-2 other girls at these doors which are by the nurses station. There were 2 girls observed repeatedly hitting at another one of the girl ’ s head area with their fists. Further observations revealed several girls jumping over the nurses station and going around to the other side of the common living area to get at other girls on the other side. There also were girls jumping over into the nurses station, knocking down medical equipment and patient records. Multiple staff were seen holding several patients in physical hold restraints. One staff was seen grabbing and holding a patient by her ankle that was attempting to cross over the nurses station. At 7:43 PM Patient #12 was placed in seclusion by staff, (RN #13), the door was closed and a large chair placed in front of the seclusion door preventing egress. The patient remained in the seclusion until 7:51 PM (8 minutes) when the chair was removed and the door opened. During these 8 minutes, there was not a staff member observing this patient in seclusion. Overall, there were an approximate 10 unidentified adolescent girls involved in the altercation; however, these girls were not identified during the time of the video observation because the DRM stated the internal investigation was “ongoing” and they continue to review the video. Review of facility policy and procedure entitled Proper Use and Monitoring of Restraint, Emergency Medications, and Seclusion, last reviewed March 2024, revealed the following, in part; Emergency Medication is defined as a psychoactive medication that is used to treat the signs and symptoms of mental illness in a psychiatric emergency to prevent imminent risk to self/others when other interventions are ineffective or inappropriate. The use of emergency medications will be documented in same manner as physical restraint and seclusion. The RN must assess the patient and the effectiveness of the emergency medication 15 minutes after administration of the medication. A second assessment will be completed after an additional 15 minutes for a total of 30 minutes after administration of the emergency medication. Vital signs will be obtained at each assessment, at the 15-minute and 30-minute patient assessment. If unable to obtain the vital signs, documented a description of the patient’s color and respirations minimally. Any patient placed in seclusion will be continuously observed by staff standing immediately outside the seclusion room. Review of facility form HV-114 Restraint/Seclusion/Emergency Medication Acute Care revised 07/23 revealed but was not limited to the following documentation: Seclusion/Restraint/Emergency Medication Order to include: reason for intervention, less restrictive interventions, any medical conditions/abuse issues that would impact the used of restraint/seclusion, nursing summary and notifications to include time medication given, RN assessment of patient and response to emergency medications completed within 15 minutes of medication administration including vital signs, RN assessment of patient and response to emergency medications completed within 30 minutes of medication administration including vital signs, RN assessment of patient and responses to emergency medications completed within 45 minutes of medication administration including vital signs, RN review of patient response to emergency medication and brief system assessment to be completed within 60 minutes of medication administration, notifications to parent/family/ guardian. Post Intervention, Nursing Summary and Notifications include: face to face evaluation (to be completed within 1 hour of initiation of intervention) and seclusion/restraint/emergency medication patient debriefing to be completed after intervention when patient has calmed but no later than 24 hours. Debriefing. Patient #7: Review of Patient #7 Medication Administration Record (MAR) revealed she received Benadryl 50 mg Intramuscular (IM) and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:35 PM. Review of final physician medication orders for 04/06/25 from 11:07 PM (start) to 11:32 PM (stop); revealed diphenhydramine injectable 50 mg/ml SOLN was prescribed by Physician-A with indication: agitation. Olanzapine intramuscular 10 mg PWDI at 11:07 PM (start) to 11:32 PM (stop) indication: agitation. Further review of Patient #7 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #8: Review of Patient #8 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for aggression on 04/06/2025 at 8:25 PM. Review of final physician medication orders for 04/06/25 from 10:32 PM (start) to 11:59 PM (stop) revealed diphenhydramine infectable 50 mg/ml SOLN was prescribed by Physician A with indication: aggression. Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 10:47 PM (start) to 11:30 PM (stop) indication: agitation/aggression. Further review of Patient #8 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #9: Review of Patient #9 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:50 PM. Review of final physician medication orders for 04/06/2025 from 11:02 PM (start) to 11:26 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physican A with indication: agitation. Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 11:02 PM (start) to 11:26 PM (stop) indication: agitation. Further review of Patient #9 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #10 Review of Patient #10 MAR revealed she received Benadryl 50 mg IM for agitation and Zyprexa 10 mg for aggression on 04/06/2025 at 8:55 PM. Review of final physician medication orders for 04/06/25 from 10:59 PM (start) to 11:23 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physician A indication: agitation. Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 10:59 PM (start) to 11:24 PM (stop) indication: aggression. Further review of Patient #10 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #11: Review of Patient #11 MAR revealed she received Zyprexa 10 mg IM at 8:55 PM and Benadryl 50 mg IM at 9:45 PM for agitation on 04/06/2025. Review of final physician medication orders for 04/06/2025 from 08:55 PM (start) to 08:56 PM (stop) revealed Olanzapine intramuscular 10 mg PWDI prescribed by Physician A indication: agitation. Diphenhydramine injectable 50 mg SOLN for 04/06/25 from 09:45 PM (start) to 09:46 PM (stop) indication: agitation. Further review of Patient #11 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. Patient #12: Review of Patient #12 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:33 PM. Review of final physician medication orders for 04/06/25 from 11:00 PM (start) to 11:24 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physician A indication: agitation. Olanzapine intramuscular 10 mg PWDI indication: agitation. Further review of Patient #12 ’ s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. There was not any documentation of seclusion for 4/6/25 at 7:43 PM on an HV-114 form or within the patient ’ s record. Interview on 4/18/25 at 4:20 PM with the DPI stated that when patients are in seclusion, there has to be continuous observation of the patient. The DPI stated there was no evidence of an incident report or seclusion documentation for Patient #12 that was observed on video dated 4/6/25 in seclusion from 7:43 PM to 7:51 PM and a door in front of the seclusion door. The DPI further confirmed there was no evidence completed by the DRM of video monitoring or documentation review completed for Patient #13 that was placed in Seclusion on 4/4/25, and Patient #14 placed in seclusion on 4/6/25. The DPI confirmed there were no incident reports or restraint documentation for any patients being physically restrained during this incident/riot. The DPI further confirmed the DRM had not been ensuring the Action Plan #5 was being completed for all events of restraints and seclusion. Interview on 5/2/25 at 9:40 AM with DPI was asked about the documentation from DRM for the video observed from the “riot” incident on 4/6/25 in the adolescent unit (A) and she stated there was not any specific documentation from the video and the video is now “deleted,” the system only keeps for “21 days.” The DPI stated the DRM was at the facility over the weekend to review the video to determine who the patient was that was placed in seclusion. The DPI was asked if the video was saved/secured and she stated that it was not saved, it was not available and in addition; the emails had been deleted from the CEO. Further interview on 5/2/25 at 11:30 AM with the DPI stated RN #13 “did not see it as seclusion” when she placed Patient #12 in the Seclusion room on 4/6/25 at 7:43 PM, because the “door was not locked.” However, the DPI confirmed that the staff placed a door in front of the seclusion door where the patient could not exit. DPI indicated RN #13 received a written warning. Interview on 5/2/25 at 2:25 PM with Patient #17 in the adolescent unit (A) stated the following regarding the “riot” incident on 4/6/25 in which she was involved: Patient #8 moved over to our side of the unit, and she was cussing at Patient #22. Patient #18 was at the nurses station counter when she and Patient #8 went and pulled her pants down. She said we were all running around and then “people spit in the water” and then Patient #7 threw the cup. Patient #19 “hopped” the nurses counter and started coming over to us and started swinging. Patient #19 was swinging and pulling out my hair. Patient #16 tried jumping over the nurses counter too, but “they held [Patient #16] back. We all got the booty juice [emergency IM medications].” She said later Patient #19 ’ s parents were yelling at the door, but Patient #19 was the one who “swung first” and then her and Patient #21 were like, “oh no, she pulled out our hair.” Patient #17 stated that she, Patient #16, Patient #18, and the girls who jumped over the counter “got booty juice.” Patient #17 said the staff were attempting to hold Patient #19 and she “snagged a badge. They restrained us. I was restrained by a tech with purple and blonde hair with glasses.” Patient #21 and Patient #19 were being held by staff. She said they were “short staff” with only 3 MHW ’ s and we were able to get away because they were only holding our arms. Patient #18 was able to get back over here herself after she got the door off the hinges. Some windows were busted out. Patient #17 said her head was throbbing from the amount of harm and hair pulling that Patient #19 did. Patient #17 said there was “shoving, some punching, some were bleeding;” mostly from Patient #19. Patient #17 said they “calmed us down, and then we got booty juice.” Patient #17 said they would not let us call anyone, and no one checked us out afterwards, because she was hurt and missing hair. Review of Patient #17 ’ s record revealed there was not any documentation of a physical restraint on 4/6/25. Interview on 05/02/2025 at 4:36 PM with the DPI indicated that all six Patients (#7, #8, #9, #10, #11, and #12) records were complete as reviewed and confirmed these patients did not have a completed HV-114 form for the administration of emergency medications that were administered on 4/6/25 in response to the “riot.” Interview on 5/13/25 at 4:15 PM with the Chief Executive Officer (CEO) stated on 4/21/25 she provided the DRM with verbal counseling and coaching regarding missing incidents and due to the “state findings.” The counseling included the DRM missing incidents in the facility’s internal reporting process and not reporting Abuse and Neglect incidents of a child to police. The CEO further stated she is now involved in the daily incidents and ensuring the completion of the incidents are done and reviewing each of the incidents. Further interview with the CEO and DPI present, stated that another DON has been named (Staff # 5) and that the nursing department was in the process of restructuring. The CEO and DPI both confirmed there was supposed to be an RN assigned to every unit for every shift. The DPI indicated the previous facility’s CNO allowed this practice.”

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 21863 Based on observation, interviews, and document reviews, the facility failed to provide adequate numbers of nursing personnel, other personnel to provide care, and ensure the immediate availability of a registered nurse (RN) on each unit to meet the needs of the patients, and in accordance with the facility’s current staffing grid. Specifically, the facility utilizes a core staffing grid to allocate RN’s, Licensed Vocational Nurses (LVN’s), and Mental Health Workers (MHWs) per unit, based on patient census. Review of unit staffing for 4/3/25 and 4/6/25 revealed the facility failed to ensure the minimum staffing requirements were met in accordance with patient census or acuity. 1.) Unit A: The staffing grid accounts for up to 25 patients; the number of licensed beds. On 4/3/25 and 4/6/25 the patient census exceeded 25 patients; there were not adequate assigned staffing levels for the patient census and staffing levels were not adjusted accordingly when the census exceeded 25 patients. 2.) On 4/6/25 there were 12 of 14 units reviewed (A, C, D, E, F, G, H, I, J, K, L, M) that did not meet the minimum staffing requirements in accordance with the facility’s current Core Staffing Grid and failed to ensure the immediate availability of an RN for each unit. The facility’s failure to provide adequate numbers of staffing resulted in repeated failures to meet minimum care standards, placed staff and patients at risk for harm, delayed care, and inadequate staff supervision during behavioral emergencies that resulted in patient injuries and patients eloping from the facility. Findings included: 1.) Observation on 4/3/2025 at 2:30 PM on Unit A (the adolescent female unit) with the interim Assistant- Director of Nurses (A-DON)/Staff#4 present revealed the following: RN #10 was in charge, there was a medication nurse (RN instead of LVN), and 3 MHW’s assigned to the unit. There were 28 patients total on the unit, 27 assigned and 1 “programming from another unit”. There had been 2 admissions since 7:00 AM and RN #10 was working on the daily nursing assessments. The surveyor attempted an interview with RN #10 at the nurses’ station but was continuously interrupted by patients with requests, phone calls from parents and providers, staff reporting lab results, staff asking for guidance, and staff coming and going. Review of the unit Core staffing grid for Unit A, revealed there must be 4 MHW’s for a census of 25 patients. The staffing grid did not account for patient census exceeding 25. During an interview conducted on 4/3/25 at 2:35 PM with the assigned RN #10 stated: There were 28 patients on the unit today. The census is 27 and there is another patient programming on the unit. RN #10 said he is responsible for completing a nursing assessment on all 27 patients during his 12-hour shift. 2.) A.) Review of the Patient Census, Daily Staffing Report for 4/6/25 7:00 AM - 7:00 PM and corresponding Unit 2025 Core Staffing Grid revealed the following: o Unit A: 29 patients; staffed with 1 RN, 1 LVN, and 3 MHW’s. The staffing grid requires 4 MHW’s. This is a female adolescent unit. o Unit C: 16 patients; staffed with only 1 MHW. The staffing grid requires 2 MHW’s. o Unit E: 15 patients; staffed with only 1 MHW. The staffing grid requires 2 MHW’s. o Unit F: 15 patients; no RN provided/staffed. The staffing grid requires 1 RN. o Unit G: 20 patients; no MHW’s staffed. The staffing grid requires 2 MHW’s. o Unit H: 22 patients; staffed with 2 MHW’s. The staffing grid requires 3 MHW’s. o Unit I: 20 patients; no RN provided/staffed. The staffing grid requires 1 RN. o Unit J: 13 patients; no LVN provided/staffed. The staffing grid requires 1 LVN. o Unit K: 17 patients; staffed with only 1 MHW. The staffing grid requires 2 MHW’s. o Unit L: 19 patients; staffed with only 1 MHW. The staffing grid requires 2 MHW’s. This equates to at least 11 staff this shift not provided affecting 10 units that were not adequately staffed according to the minimal staffing. There was no consideration taken for patient acuity or increased supervision levels. B.) Review of the Patient Census, Daily Staffing Report for 4/6/25 7:00 PM - 7:00 AM and corresponding Unit 2025 Core Staffing Grid revealed the following: o Unit D: 22 patients; staffed with 2 MHW’s. The staffing grid requires an additional MHW for 8 hours (0.75 MHW). o Unit E: 15 patients; staffed with 1 MHW. The staffing grid requires an additional MHW for 4 hours (0.25 MHW). o Unit F: 15 patients; no LVN provided/staffed. The staffing grid requires 1 LVN. o Unit G: 20 patients; no LVN provided/staffed and staffed with only 1 MHW. The staffing grid requires 1 LVN and an additional MHW for 4 hours (0.25 MHW). o Unit I: 20 patients; no LVN provided/staffed and staffed with only 1 MHW. The staffing grid requires 1 LVN and an additional MHW for 4 hours (0.25 MHW). o Unit J: 13 patients; no RN provided/staffed. The staffing grid requires 1 RN. o Unit K: 17 patients; staffed with 1 MHW. The staffing grid requires an additional MHW for 4 hours (0.25 MHW). o Unit M: 13 patients; no RN provided/staffed. The staffing grid requires 1 RN. This is a child unit with patients 5 years old to 12. This equates to at least 7 staff this shift not provided affecting 8 units that were not adequately staffed according to the minimal staffing. There was no consideration taken for patient acuity or increased supervision levels. An interview was conducted with Patient #3 on 4/17/25 at 3:15 PM in Unit-A’s group room and stated that most of the time she is unable to go to the cafeteria to eat her meals because there is not enough staff available to escort the patients. Patient #3 reported that there must be at least one staff member available to accompany every seven patients to the cafeteria, and staffing is frequently insufficient to meet this requirement. Patient #3 further stated that staff frequently say they are “short-staffed,” and staffing shortage often results in patients being unable to go to the cafeteria for meals or participate in outdoor activities. Patient #3 expressed that she feels the staff are not compassionate and lack empathy, further contributing to her dissatisfaction with the care provided at times. Patient #3 said that on her 2nd day there was a “riot and we were on lock down” because there were girls fighting, jumping over the nurses station to get at each other from one side to the other. She said they mix the13 and 17-year-old girls together, and they should be kept separate. An interview was conducted with Patient #17 on 5/2/25 at 2:30 PM in Unit-A. The patient reported that on April 6, 2025, there was a “riot” on Unit A. Patient #17 stated that the unit was “short-staffed” on the day of the incident with only 3 MHW ’ s and we were able to get away because they were only holding our arms. Patient #18 was able to get the door off the hinges. Some windows were busted out. Patient #17 said her head was throbbing from the amount of harm and hair pulling that Patient #19 did. Patient #17 said there was “shoving, some punching, some were bleeding;” mostly from Patient #19. During the “riot,” Patient #17 stated she was “restrained” and administered an emergency injection, referred to by the patient as “booty juice.” Patient #17 also disclosed that on April 23, 2025, she and two other patients (#20 and #21) eloped from the facility. She explained that they had been planning it in advance. They waited until there was a code announced on the adjacent male adolescent unit (B), at which point most staff responded, leaving only one mental health worker behind on her unit (A). According to the patient, they jumped the remaining staff member, took her badge, and used it to exit the facility. Patient #17 stated she and Patient #20 were later apprehended by the local police department and returned, but that Patient #21 who also escaped has not been found or returned. Review of the incident report for Patient #20 dated 4/23/25 at 8:20 PM indicated Patient and 2 other peers attacked staff member while nurse was responding to a code on neighboring unit and took the staff member’s badge and key and eloped from the facility. Patient was then found and returned to facility to transfer out to another unit for further evaluation and treatment. Patient #20 struck staff several times in the face and took her access badge that was secured in a badge holder worn on her arm. A peer was holding staff by the hair and striking her in the face when she took the armband. The local PD was called to press charges on Patients. The local PD arrived, reviewed video, and determined an assault and robbery took place. Interview on 5/2/25 at 4:15 PM with the DPI stated that when an emergency behavioral code (code green) is called on the overhead speaker, all available staff are to respond. There is not a specific code team or strategic plan each shift for specific staff to respond. The DPI stated the facility tried that in the past, and it did not work. Review of the last Nursing Staff Committee (NSC) Meeting, dated 3/25/25 chaired by the interim Assistant Director of Nursing (A- DON)/Staff #4 revealed the members present included an RN House Supervisor, The RN educator, The RN infection control nurse, The child and adolescent RN unit director, and one LVN “floor nurse.” This was the first meeting under the new ADON(ACNO)/Staff #4. The new business discussion included the Nursing 12-hour shift template. Proposals to rotate shifts to address staff burnout-particularly for staff working 3/4 shifts in a two-week period. Strategies were discussed to rotate schedules and avoid 4 shifts consecutively. PRN pool management and part-time roles to support full-time staff. In an interview with the new ADON(ACNO)/Staff #4 on 4/3/25 at 3:30 PM indicated he was recently placed as the interim assistant CNO (DON) of the facility and would be reviewing the staffing grid with other administrative staff. There was not any documentation that discussed focusing on meeting minimal staffing ratios in relation to patient census, or a review of the actual staffing grid compliance. The This supports concerns that staffing shortages were not being formally evaluated or addressed in structured leadership meetings. The NSC did not include a composition of at least 60% of RN’s with direct care roles in accordance with Texas State Law requirements. Interview on 5/13/25 at 4:15 PM with the Chief Executive Officer (CEO) and the Director of Performance Improvement (DPI) revealed the CEO confirmed there was supposed to be an RN assigned to every unit for every shift. The DPI indicated the previous facility’s CNO allowed this practice. The CEO stated that another DON has been named (Unit Director/Staff #5) and that the nursing department was in the process of restructuring.”

“FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION CFR(s): §482.58(b)(3) Freedom from abuse, neglect, and exploitation (§483.12(a)(1), (a)(2), (a)(3)(i), (a)(3)(ii), (a)(4), (b)(1), (b)(2), (c)) • §483.12(a)(1): The facility must (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. • §483.12(a)(2): Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. • §483.12(a)(3)(i): Not employ or otherwise engage individuals who (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. • §483.12(a)(3)(ii): Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. • §483.12(a)(4): Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. • §483.12(b)(1): The facility must develop and implement written policies and procedures that: (1)Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. • §483.12(b)(2): Establish policies and procedures to investigate any such allegations. • §483.12(c): In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This Standard is not met as evidenced by: 08686 Based on record reviews and interview, the facility failed ensure an allegation of physical abuse against a minor (Patient #1)by a facility staff member (Nurse #1) during a restraint was reported to local law enforcement in accordance with their abuse and neglect policy. Findings included: Review of facility incident report, dated 01/01/2025 at 5:00 PM revealed the following: Patient #1 reported to the physician the nurse had grabbed her hair and pulled her across the ground during a restraint the previous night. After video review, it was determined the nurse (Nurse #1) did utilize restraint techniques not authorized by CPI (Crisis Prevention Intervention). The staff involved was terminated after the video review was completed. Review of facility camera timeline report, dated 01/01/2025, revealed but was not limited to the following: “1639:59 - (Patient #1) attempts to jump over the nurse’s station. Then scratching staff, verbal aggression continues. 1642:35 - (Patient #1) grabs staff badge off staff shirt, then throws badge back at staff. 1642:47 - (Nurse #1) grabs (Patient #1) by the arms, (Patient #1) attempts to get free of hold. (Nurse #1) then grabs (Patient #1) by the hair and pulls her to the ground. 1643:00 - (Nurse #1) can be observed with (Patient #1’s) in her hand, holding her head on the ground with force. 1644:37 - (Nurse #1) falls to the floor due to (Patient #1) holding her leg. (Nurse #1) grabs (Patient #1) by the hair while attempting to get her leg free. 1645:00 - (Nurse #1) gets her leg free. Attempts to drag (Patient #1) into seclusion by her right arm unsuccessfully Review of facility policy entitled “Reporting Abuse, Neglect & Exploitation, effective November 2010 and last reviewed and revised September 2024 revealed but was not limited to the following: “The adult patient has the right to make a police report. (Facility) is obligated to report any criminal act perpetrated upon a minor by staff to the (city) police department. Review of email, dated 03/07/2025 at 2:45 PM from the Director of Performance Improvement confirmed that the Director of Risk Management failed to make a police report regarding the 01/01/25 1700 PM restraint described above.”

“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: 08686 Based on interviews and facility documentation, the facility failed to document and maintain a log for one of one patients reviewed, (Patient #1) who came to the facility emergency department (known as an admissions department at this psychiatric hospital) for an assessment. Findings included: Interview on 04/17/2024 with facility Director of Performance Improvement revealed that Patient #1 is not listed on the facility admissions department log. Interview on 04/21/2024 with Patient #1’s mother revealed but was not limited to the following information: Patient #1’s mother stated that she had finally obtained an appointment (02/29/2024) at a private psychiatrist’s office for her son (Patient #1). She drove him to the appointment and was told by a psychiatric nurse practitioner that he needed to be evaluated for possible inpatient admission due to his current level of mania associated with his bipolar diagnosis. The nurse practitioner gave her the option of calling an ambulance to take him to the facility for the evaluation or driving him there. She chose to drive him to the facility. The nurse practitioner told her she would call the facility and the police to meet them at the facility. It is noted that this surveyor attempted to confirm this with the nurse practitioner and she did not respond to the email asking her if she did contact the facility regarding Patient #1 coming there for an evaluation. Patient #1’s mother stated that when they arrived at the facility, no one knew they were coming for an assessment to determine if he needed inpatient treatment. She stated Patient #1 was given paperwork to complete prior to being assessed. She stated that “almost as soon as they got to the facility, Patient #1 “regretted coming for the evaluation and began freaking out”. She stated a young woman in blue scrubs came and told them they would evaluate him but he would have to wait for a bed if it was determined that he needed inpatient admission. She also told Patient #1’s mother that in order to get him to stay, he would need a “police escort” referring to an emergency detention. Patient #1’s mother stated that emergency detention by the police was not explained to her at this facility. She and Patient #1 left this facility and drove to another facility (acute care hospital) emergency room where he was evaluated and it was determined that he would benefit from inpatient admission to a psychiatric hospital but he refused to stay. The police were called but they would not instigate an emergency detention to force him to stay for inpatient admission as they did not think he was suicidal or homicidal. Interview on 04/17/2024 with the facility assistant director of admissions revealed but was not limited to the following: She stated that when a person walks in needing an assessment, the front desk staff give them a “lobby sheet” to complete and they come into the waiting area to complete the “lobby sheet”. Once they completed the “lobby sheet”, the front desk staff email the admissions staff that the patient is ready for an assessment. She stated that if the patient leaves before completing the paperwork, he is listed on the admissions log as Jane or John Doe. Review of Admissions Log for 02/29/2024 did not reveal a John Doe listed on this date. In addition, the review of the Admissions Log from 10/17/2023 to 04/17/2024 did not reveal anyone listed as a Jane or John Doe. Review of facility EMTALA training summary: What you need to know: revealed but was not limited to the following: The EMTALA log is a legal document we are required to update and keep accurate. Every person in the department is responsible for updating the EMTALA log. Triage is ultimately responsible for making sure the EMTALA log is complete and accurate at the end of a shift.”