Westpark Springs LLC

“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: 38387 Based on observations, interviews, and record reviews, the facility failed to meet the Conditions of Participation for Governing Body when the facility’s Governing Body failed to monitor and ensure the contracted security door services provided the safe functioning of the security doors; the monitoring did not include the manufacturer’s recommended preventative measures placing patients at risk of elopement at risk for harm. Refer to A083”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38387 Based on observations, interviews, and record reviews, the facility failed to meet the Condition of Participation for Patients Rights when it failed to provide care in a safe setting and/or uphold patient rights as evidenced by: The facility failed to prevent eleven patients (Patient #A, G, O, C3, VV, YY, LL, PP, MM, A4, Z3) patients from eloping. Refer to A0144 The above deficient practice was identified under the following Condition of Participation §482.13 Patient’s Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death. An immediate jeopardy [IJ] was called on 3/27/2026 at 3:02 pm for the elopements. The facility submitted an acceptable abatement plan on 3/27/2026 but the surveyors were unable to verify the implementation of the plan prior to the exit on 04/14/2026. Based on observations, interviews, and record reviews, the facility failed to meet the Condition of Participation for Patients Rights when it failed to provide care in a safe setting: The facility failed to remove identified safety hazards and failed to maintain the facility’s security doors. Refer to A0144 The facility’s failure to ensure that adolescent patients were provided with a safe environment. Specifically, the facility failed to ensure that eleven (11) suicidal patients were provided bedrooms that were free of anchor tie-off points. Refer to A0144 The above deficient practices were identified under the following Condition of Participation §482.13 Patient’s Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death. An acceptable plan of removal was received on 03/30/2026 at 4:00 pm which included facility implementation of the following: Pick Proof Caulk was applied to seal the gaps between furniture (nightstands, shelving and beds) and the walls in the facility, eliminating the identified tie-off points. A tour of the units on 03/31/2026 at 10:00 am confirmed the facility abated the IJ for the environmental safety. Based on observations, interviews, and record reviews, the facility failed to meet the Condition of Participation for Patients Rights when it failed to provide care in a safe setting and/or uphold patient rights as evidenced by: The facility failed to uphold the rights of two (2) patients to make informed decisions regarding their care and treatment [Patients E, EE]. Refer to A0131 The facility failed to ensure that 1 of 1 patient (Patient #C) was kept safe from head banging resulting in three (3) transfers to an Emergency Room for medical clearance over a four (4) day period. Refer to A0144 The facility failed to ensure that an RN obtained an order from a physician for the seclusion of a 13-year-old adolescent female. Refer to A0168”

“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: 38015 Based on observation, interview and document review, the facility failed to meet the Condition of Participation requirements for QAPI (Quality Assessment and Performance Improvement). This failure had the potential to affect all patients receiving services in the hospital. The facility failed to ensure their QAPI program addressed the safety of patients and focused on high-risk, high-volume and problem-prone areas, as evidenced by not collecting, tracking, analyzing and addressing multiple past incidents of security door breaches. This failure of action likely contributed to multiple adverse events consisting of several patient elopements from facility through malfunctioning security doors. (refer to tag A-286 and tag A-283)”

“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: 38387 Based on record review and staff interviews, the facility failed to meet the Conditions of Participation for Nursing Services as evidenced by: The facility failed to ensure that the dietary needs of one of one patient (Patient B) were assessed properly by a Registered Nurse. Refer to A0395 The facility failed to prevent patients from eloping and gaining access to restricted areas. Refer to A0396”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 33326 Based on observation, record review, and interview, the facility failed to meet the condition of participation when it failed to develop and maintain the physical environment to assure the safety and well-being of patients as evidenced by, - Leaking water on the adult unit day room was not corrected for two days. - Cracked sharp laminate, accessible to adolescent males was not corrected for two days. - Broken air-conditioning covers, exposing rusty, sharp metal had not been identified or corrected. - Security doors were not maintained to ensure security resulting in multiple elopements. Cross refer to A0701”

“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: 35028 . Based on observations, interviews, and record review, the facility failed to ensure that the Willows and Cedars Units, adolescent male and female units respectively, were adequately staffed with qualified mental health professionals to protect and promote the physical and mental health of the patients and to create a milieu with maximum therapeutic benefit. There were numerous staff that reported fear of the patients and fear of being seen on video surveillance footage using improper behavior management techniques. Staff members interviewed reported that they had less than the required 8 hours of training in a behavior management system with training timeframes ranging from 1 to 6 hours. There were two incidents in which both staff and patients were injured when multiple adolescent patients got into fights that could not be contained by the staff present in the hospital. During this two-week period, 11 staff members were injured when emergency interventions were needed to bring orderliness and control to the units. See A1704 - Adequate Staffing . 38387 Furthermore, based on record review, observations, and interviews, the facility failed to provide the necessary care when the facility’s staffs did not prevent patients from eloping from the facility and the facility assigned units. The facility failed to provide staff to prevent eleven patients (Patient #A, G, O, C3, VV, YY, LL, PP, MM, A4, Z3) patients from eloping. The deficient practices were identified under the following Condition of Participation Special Staff Requirements, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death. An IJ was called on 4/1/2026 at 3:30 pm. The facility was provided an opportunity to submit a Plan of Removal for the Immediate Jeopardy. There was no acceptable plan of removal received prior to the exit on 04/14/2026.”

“LICENSURE OF HOSPITAL CFR(s): 482.11(b) The hospital must be - o Licensed; or o Approved as meeting standards for licensing established by the agency of the State or locality responsible for licensing hospitals. This Standard is not met as evidenced by: 38387 Based on observations and confirmed in interview, the facility failed to comply with all applicable state laws as part of the Conditions of Participation (CoPs) to participate in Medicare and Medicaid programs. Facility replaced corridor doors without notifying the state as required. Findings included: Review of the Texas Administrative Code, Title 26, Chapter 510: §510.121 (a)(2) revealed “remodeling of existing facilities. All requirements listed in this chapter relating to new construction are applicable to renovations, additions and alterations unless stated otherwise.” Furthermore, Texas Administrative Code, Title 26, Chapter 510: §510.121 (2)(C) states “Minor remodeling or alterations. All remodeling or alterations which do not involve alterations to load bearing members or partitions, change functional operation, affect fire safety (e.g. modifications to the fire, smoke, and corridor walls), add or subtract beds or services for which the facility is licensed, and do not involve changes listed in subparagraph (B) of this paragraph, shall be submitted for approval without submitting contract documents. Such approval shall be requested in writing with a brief description of the proposed changes and a simple floor plan for evaluation and determination of disposition.” Moreover, Texas Administrative Code, Title 26, Chapter 510: §510.123 (n)(3)(A)(vii) states “Special fixtures, hardware, and tamper-proof screws. Special fixtures, hardware, and tamper-proof screws shall be used throughout the patient nursing suites.” And finally Texas Administrative Code, Title 26, Chapter 510: §510.123 (n)(3)(A)(vii)(I) states “All exposed and accessible fasteners shall be tamper-resistant.” During the tour of the facility on the morning of 4/13/2026 with the Director of Maintenance (Staff #35), several opposite swing, egress corridor doors are being replaced. However, the state was not informed of the door replacement. No documentation of the notification to the state was provided by the end of survey on 04/14/2026.”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 33326 Based on observation, record review, and interview, the facility failed to monitor and ensure the contracted security door services provided the safe functioning of the security doors; the monitoring did not include the manufacturer’s recommended preventative measures placing patients at risk of elopement, at risk for harm. 1.) The facility’s contracted preventative Maintenance for the security doors and Magnalock’s were not being maintained according to the manufacturer’s recommendations. 2.) The facility failed to ensure the Door contractor had correctly installed the Magnalocks onto the new metal doors; the magnets were not aligned and did not provide covers to the doors closure mechanisms, leaving a ligature risk. Due to these failures the facility doors failed to provide the manufacturer’s MM15 series Dual-Action Magnalock’s holding force of 4,000 pounds. Findings include: 1.) During an interview and tour on the morning of 4/01/26, on the in-patient unit, when asked how the facility ensures the security doors are maintained for safety Staffs #11 EOC director stated, “We contract with 4M door services, they come out once a month.” Review of the facility provided contract, “Preventive Maintenance Proposal Client: Westpark Springs Service Provider: 4M Door Services Date: 10/9/2025 Scope of Work 4M Door Services proposes a comprehensive Preventive Maintenance (PM) program for all 177-man doors located throughout the Westpark Springs facility. The PM program will include: - Inspection and Testing: Each door will be tested to ensure proper closing and latching functionality. - Minor Adjustments: Technicians will make small adjustments to door closers as needed to maintain optimal performance. - Reporting: Any major repairs or replacements identified during the PM will be documented and submitted in a separate proposal for approval. Frequency We recommend performing this PM service once per month to ensure consistent door functionality, reduce long-term repair costs, and maintain safety and compliance standards. Review of the facility provided manufacture’s installation manual for Securitron® M32 | M62 | M80 Magnalock Installation & Operating Instructions (undated) reflected: “5 ENSURE the Magnalock and strike plate are in proper alignment (see Diagram 14). NOTE: When installing the Magnalock and strike plate, each should be in proper alignment to the other (see Diagram 14). This is considered critical for the operation of both the Bond STAT and DPS. However, there are alignment tolerances, see table in Diagram 14, for each model of Magnalock, but these should be viewed as the extreme- the installation desire is always total alignment. CAUTION: The Magnalock and strike plate must be in proper alignment or the Bond STAT and DPS functions will not operate correctly. Perform an Inspection 1. CHECK the rubber washers for elasticity and proper pivoting: THIGHTEN as required. 2. CHECK for the build-up of debris on the Magnalock and strike armature. CLEAN as required. 3. CHECK for rust on the Magnalock and strike plate armature; CLEAN as required. Cleaning the Magnalock 1. CLEAN the Magnalock at the following intervals: - Once a year for normal maintenance. - Every 6 months when minor rusting occurs - Every 3 months if rust conditions are severe 2. APPLY rubbing alcohol onto a clean cloth and thoroughly WIPE DOWN the Magnalock and strike plate armature (indoor applications) 3. APPLY a silicone-based cleaner/lubricant onto a clean cloth and thoroughly WIPE DOWN the Magnalock and strike plate armature (outdoor applications). 4. USE a plastic dishwashing scrub pad to aid in the removal of rust. TROUBLE SHOOTING Reduced holding force: - CHECK DC power source is full-Wave rectified (Half-wave Rectifier or AC Power unacceptable) - CHECK for specified voltage at Magnalock. - CHECK strike mounting for proper installation. - CHECK the Magnalock and strike for obstructions and that contact surfaces are properly cleaned. Review of the facility provided by 4M Door Services monthly door checks documents reflected: The document did not reflect the manufacture’s preventative maintenance recommendations or how the doors were inspected. The documents, for the last year, did not include any repair recommendations.” Review of the facility provided by 4M Door Services monthly door checks documents revealed: The documents were checked off for latching and swinging open. The document did not reflect the manufacture’s preventative maintenance recommendations or how the doors were inspected. The documents, for the last year, did not include any repair recommendations. Review of the Governing Body minutes for 2025 did not reflect issues or concerns with the services provided through the 4M door services. 2.) Observation made during a tour of the facility’s inpatient units on the afternoon of 4/13/26 revealed the following: - The Magnalock on the door leading into the adult unit was not in alignment, the magnet was not flush with the casing. - The Magnalock on the door dividing the adolescent male and female units was not in alignment, the magnet was not flush with the casing, additionally the doors closure fixture was missing the casing, leaving a ligature risk accessible to any male adolescent with suicidal ideation. - The Magnalock on the door leading from the intake hallway out to the Lobby, the magnet was not flush with the casing, additionally the doors closure fixtures were missing the casing, leaving a ligature risk accessible to any patient at risk of suicidal ideation. Review of the facility provided MM15 Series Dual-Action Magnalock specifications (undated) reflected, “Mounting plate provides easy and accurate installation ...Holding force: 4000lbs ....MM15 finishes are determined by snap-on-metal dress covers. The Brushed Stainless dress cover is provided standard with the MM15. During an interview, on the morning of 4/13/26, in an administrative conference room. Staff #11, EOC director stated in part, the facility was purchasing the manufacturer’s recommended brackets for the magnets; they had not been installed when the magnets were originally put in.”

“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: 23032 Based on interview and record review, the facility failed to uphold the rights of two (2) patients to make informed decisions regarding their care and treatment [Patients E, EE] a) Two (2) patients were admitted to the facility under an “involuntary” legal status. The facility failed to follow Texas Health & Safety Code (HSC) Chapter 573 requirements regarding emergency detention of individuals. The facility failed to follow through with all required steps to obtain an Order of Protective Custody (OPC), resulting in the denial of these patients’ right to due process and informed consent. b) The facility’s policy on “Involuntary Emergency Detention” failed to address the process to follow if the physician exam determined involuntary admission criteria is met for emergency detention. Findings included: Review of selected, relevant portions of Texas Health & Safety Code, Chapter 573 showed: Sec. 573.021. PRELIMINARY EXAMINATION. :A facility shall temporarily accept a person for whom an application for detention is filed or for whom a peace officer or emergency medical services personnel of an emergency medical services provider transporting the person in accordance with a memorandum of understanding executed under Section 573.005 files a notification of detention completed by the peace officer under Section 573.002(a). (b) A person accepted for a preliminary examination may be detained in custody for not longer than 48 hours after the time the person is presented to the facility unless a written order for protective custody is obtained. The 48-hour period allowed by this section includes any time the patient spends waiting in the facility for medical care before the person receives the preliminary examination.(c) A physician shall examine the person as soon as possible within 12 hours after the time the person is apprehended by the peace officer or transported for emergency detention by the person’s guardian. Sec. 573.022. EMERGENCY ADMISSION AND DETENTION. (a) A person may be admitted to a facility for emergency detention only if the physician who conducted the preliminary examination of the person makes a written statement that: (1) is acceptable to the facility; (2) states after a preliminary examination it is the physician’s opinion that: (A) the person is a person with mental illness and because of that mental illness the person evidences: (i) a substantial risk of serious harm to the person or to others; (ii) severe emotional distress and deterioration in the person’s mental condition; or (iii) an inability to recognize symptoms or appreciate the risks and benefits of treatment; (B) the described risk of harm is imminent unless the person is immediately restrained; and (C) emergency detention is the least restrictive means by which the necessary restraint may be accomplished; and (3) includes: (A) a description of the nature of the person’s mental illness; (B) a specific description of the risk of harm the person evidences to the extent that the person cannot remain at liberty; and (C) the specific detailed information from which the physician formed the opinion in Subdivision . Sec. 573.023. RELEASE FROM EMERGENCY DETENTION. (a) A person apprehended by a peace officer or transported for emergency detention under Subchapter A or detained under Subchapter B shall be released on completion of the preliminary examination unless the person is admitted to a facility under Section 573.022. (b) A person admitted to a facility under Section 573.022 shall be released if the facility administrator determines at any time during the emergency detention period that one of the criteria prescribed by Section 573.022(a)(2) no longer applies. ~~~~~~~~~~~~~~~~~~ Review on 3/31/2025 of the facility policy titled “Physician Review of Patients on Involuntary Detention Order (EDO),”dated 03/2026, failed to address the process to follow if the physician exam determined involuntary admission criteria is met. ~~~~~~~~~~~~~~~~ During an interview on 4/01/2026 at 1:30 PM with Staff-6, facility court liaison, she provided an overview of the processes related to involuntary admissions. The discussion included: patients brought in by law enforcement on “emergency detention;” preliminary medical exams; Order of Protective Custody; attorney ad litem duties; and required court hearings [probable cause & application ]. Surveyor informed Staff-6 the facility policy on involuntary emergency detention did not address much of the information she presented in her overview. ~~~~~~~~~~~~~~~~~ On 4/01/2026 , review of the clinical records of Patients E, EE showed the following: Patient - E: Patient E was transferred to West Park Springs (WPS ) Hospital on 4/4/2025 from an acute care hospital for “higher level of care / psychiatric care.” Review of the Memorandum of Transfer (MOT) showed she was an “involuntary “ patient; on an “EDO “(emergency detention order). She was admitted to WPS on 4/4/2025 at 225 AM. Continued review of the record showed a “Protective Custody Transfer Order,” dated 4/3/2025, signed by a Harris County judge. This order authorized constables to transport Patient -E from the acute care hospital to WPS Hospital. The order read: “...to West Park Springs, who shall continue the detention of [Patient-E] pursuant to this court’s previous Order Of Protective Custody, dated 1st April 2025.” During a follow-up telephone interview on 4/8/2026 at 2 PM with Staff-6, facility court liaison, she said :”when a patient comes in with a “Protective Custody Transfer Order,” our hospital physician must complete a preliminary exam within 12 hours to determine if the criteria for involuntary admission was still present.” There was no preliminary medical exam by the WPS medical provider that showed Patient -E had mental illness; was at substantial risk of serious harm to the person or to others; and other required components per HSC 573.022 for emergency detention. Further review of the record failed to show that Patient-E signed a consent for voluntary admission. This was verified on 4/01/2026 by Staff -51, Health Information Management (HIM) Director. The “Consent for Treatment “ in the record showed “pt. refused/ INVOL.” Patient-E remained an “involuntary inpatient “until discharge on 4/24/2025 . There was no documentation in the record to show that an Order of Protective Custody (OPC) had been requested by WPS. Per HSC 573.021 (b), a patient cannot be held longer than 48 hours, unless a written order for an OPC is obtained. [HSC stipulations noted for weekends & holidays]. Patient- EE Patient EE was transferred to West Park Springs (WPS ) Hospital on 01/16/2026 from an acute care hospital . Review of the Memorandum of Transfer (MOT) showed she was an “involuntary “ patient; on an “EDO “(emergency detention order). She was admitted to WPS on 1/16/2026 at 337 AM. Continued review of the record showed a “Protective Custody Transfer Order,” dated 1/15/2026 , signed by a Harris County judge. This order authorized constables to transport Patient -EE from the acute care hospital to WPS Hospital. The order read: “...to West Park Springs, who shall continue the detention of [Patient-EE] pursuant to this court’s previous Order Of Protective Custody, dated 15 January 2026.” During a follow-up telephone interview on 4/8/2026 at 2 PM with Staff-6, facility court liaison, she said : “when a patient comes in with a “Protective Custody Transfer Order,” our hospital physician must complete a preliminary exam within 12 hours to determine if the criteria for involuntary admission was still present.” There was no preliminary medical exam by the WPS medical provider that showed Patient -EE had mental illness; was at substantial risk of serious harm to the person or to others; and other required components per HSC 573.022 for emergency detention. Further review of the record failed to show Patient-EE signed a consent for voluntary admission. This was verified on 4/1/2026 by Staff -51, Health Information Management (HIM) Director. Consent for Treatment in record showed “pt. refused / INVOL.” Patient-EE remained an “involuntary inpatient “until discharge on 1/26/2026 at 1200. There was no documentation in the record to show that an Order of Protective Custody (OPC) had been requested by WPS. Per HSC 573.021 (b), a patient cannot be held longer than 48 hours., unless a written order for an OPC is obtained. [HSC stipulations noted for weekends & holidays].”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 38387 Based on review of facility policy, patient records, and confirmed in interviews, the facility failed to uphold the privacy and safety of five of five patients (Patient S3, I, B, T3, U3) reviewed. Facility failed to follow its overflow capacity policy to document all the requirements the facility took to provide the patient with an inpatient bed for their treatment. Findings included: Review of facility policy Wait List and Over Capacity Admission Policy for IP, PHP and IOP (PolicyStat ID 18132637, effective 06/2025), it stated, “When patients are assessed and the Psychiatric Medical Provider determines the patient requires inpatient admission to the Hospital and there is not an inpatient bed available, the Assessment Department will begin to locate alternative placement for the patient. However, if alternative arrangements cannot be secured for the patient, the patient shall be admitted to the hospital utilizing the Over-Capacity Emergency Admissions Checklist. This process is as follows: 1. Documentation reflecting capacity status of Hospital at time of decision. 2. Documentation reflecting efforts to accommodate patient with local option. 3. Documentation reflecting the On-Call Psychiatric Medical Provider recommends or agrees that the patient’s condition warrants admission despite the limited capacity at the Hospital. 4. Documentation that the Director of Nursing or designee is notified to discuss census and acuity to determine need for additional staffing. 5. Documentation that the patient will be accommodated in a manner that will ensure safety, privacy, access to bathroom facilities and all other essentials including a comfortable, safe bed option. 6. Documentation reflecting that the AOC or designee has spoken with the patient/and or family to explain the situation and obtains their understanding and approval. This should include: a. that the arrangement states that the patient will not occupy a patient room for the night, b. the details of the patient’s accommodation, c. assurance that all patient safety and privacy rights will be in compliance throughout the accommodation time, d. both patient and or guardian/family will have access to AOC/Patient Advocate for questions or concerns. 7. Documentation that the Hospital CEO or their designee has been notified and agrees to the alternative accommodation.” Random review of patient records from March 2026 who were offered the over capacity cot beds had no documentation of the above checklist available for review for five of five records (Patient S3, I, B, T3, U3) reviewed. Patient S3 Patient S3 is a 17 year old male who was transferred via ambulance to the facility for homicidal ideation and depression. He was assessed on 03/03/2026 and admitted. Review of the bed census for 03/03/2026 and 03/04/2026 revealed Patient S3 had an overflow cot in the boys adolescent unit day room. Patient I Patient I is a 32 year old female who presented to the facility on an EDO for suidical ideation on 03/10/2026 and admitted. Review of the bed census for 03/10/2026 revealed Patient I was in an overflow cot on 03/10/2026 Patient B Patient B is a 15 year old female who presented to the facility for suicidal ideation with a plan on 03/23/2026 and admitted. Review of the bed census for 03/23/2026 revealed Patient B was in an overflow cot. Patient T3 Patient T3 is a 13 year old female who presented to the facility via ambulance for self harm and suicidal ideation and admitted on 03/23/2026. Review of the bed census for 03/23/2026 revealed Patient T3 was in an overflow cot. Patient U3 Patient U3 is a 16 year old female who presented to the facility via ambulance for suicidal ideation and admitted on 03/19/2026. Review of the bed census for 03/19/2026 revealed Patient U3 was in an overflow cot. In an interview with Staff 4 on 03/31/2026 at 12:40 PM in the conference room confirmed the above findings. She stated that the required information would be a progress note but none were found for the above patients.”

“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: 33326 Based on record review, observations, and interviews, the facility failed to provide patients care in a safe setting. Facitliy failed to prevent patients from eloping from the facility and the facility assigned units when, 1.) On 3/21/26, Patient #A went through 5 secured doors in 3 minutes to elope from the facility; Patient A was an adolescent and was not located following the elopement. 2.) On 3/24/26, Patient #G went through 5 secured doors in 1 minute to elope from the facility. 3.) On 3/26/26, Patient #O went through 2 secured doors before being stopped and brought back to the unit. 4.) On 4/03/26, Patient #A4 went through a secured door separating the adult inpatient unit from the adolescent female’s unit; there were three adolescent females in the dayroom’s unit that needed to be removed for safety. 5.) On 4/06/26, Patient #Z3 went through 5 secured doors to elope from the facility; he attacked a female passerby, out walking her dog. Patient #Z3 put the female in a headlock; the staffs had to physically remove the female from Patient #Z3 when he started to choke her. 6.) Six additional patients eloped from the facility units within the past 4 months. (Patients C3, VV, YY, LL, PP, MM) This failure places patients and the public at risk for harm or serious injury. Findings include: 1.) Review of Patient #A’s medical records reflected a voluntary admission on 3/18/26 at 11:33 am for suicidal ideation, he was going to run in front of a vehicle with thoughts of running away from his group home; he had made ‘many attempts to vacate his RTC’ (residential treatment center). Patient #A is a 17-year-old-adolescent male with a diagnosis of IDD, Autism, conduct disorder, Depression and Prenatal alcohol and drug exposure, learning disability PTSD, ADD/ADHD, and reactive attachment disorder. Review of Patient A’s Psychiatric exam, dated 3/19/26 at 10:00 am reflected: Judgment: Poor based on patient’s behavior/ HPI Insight: Poor based on patient’s understanding severity of illness/ HPI ... Suicide Risk in the Community: High Due to Mitigating Circumstances, Suicide Risk in the Hospital: Low Level of Observations: Q15 Precautions: Suicide. The patient was not identified as an elopement risk upon admission. Review of the facility provided video 3/19/26 at 5:00 pm first incident reflected, 2:45 minutes, Patient #A is seen walking over to the door and pushing the door open with his right shoulder. He opens the door and holds it open for a few seconds, then he comes back into the room. Two unnamed adolescents are seen jumping up and down and giving him high-fives for opening the doors. Review of the nurse’s notes dated 3/19/26 at 5:35 pm reflected, “Patient started getting agitated punching holes in walls and hitting doors trying to break through ...” The facility did not identify or initiate Elopement risk precautions following Patient #A opening the security doors. The facility did not complete an incident report or report the incident to the EOC director. The door’s integrity was not checked. Review of the facility provided video dated 3/21/2026 at 9:00 pm reflected, 00:45 sec, Patient #A opens the first door and exits the adolescent male unit. 00:51 sec, a Staff member is seen walking out the door to follow Patient #A, a second staff stands at the door. 01:08 sec, a second staff member is seen leaving the unit. 1:13 minutes, Patient #A hits the second door two times and is unable to open it. The female staff is seen talking to him. Patient #A then kicks the bottom of the door six times and opens the door. 1:18 sec Patient #A kicks the metal doors 4 times and exits. 1:21 sec. Patient #A opens the Intake doors, enters the lobby and pushes the front door open and exits. The two staff are seen walking to the exit door but not following him out. During an interview, on the morning of 3/26/26, Staff #11, EOC director confirmed the five door’s integrity was not checked according to the manufacture’s recommendations following the elopements. 2.) Review of Patient #G’s medical records reflected a 49-year-old-male admitted voluntarily on 3/25/26 on 10:45 pm for suicidal ideation without a plan. Nursing note dated 3/25/26 at 10:00 pm reflected, “pt got off the Unit, he hit the double door and ran out, code brown was called Pt was brought back to the unit ...” Nursing assessment on 3/25/26 at 10:00 pm, reflected, property destruction, “broke the unit door”. Level of observation q 15 minutes, level of observation: Precautions: Suicide Precautions and Aggression Precautions. Review of the nurse note dated 3/26/26 at 2:00 pm reflected, “This pt continued yelling and screaming demanding his belongings so he could leave. Pt started kicking the exit door. Pt kicked opened the exit door and moved staff that was guarding the door out of the way and started walking out of the unit. Pt again kicked open another exit door and started walking to intake. Staff was following pt, calling codes and trying to redirect pt. Pt was redirected back on the unit.” Review of the facility provided video of the Adult mixed unit dated 3/26/26 at 2:00 pm reflected, 00:22 sec, Patient #G pushes the door open with his shoulder, ten staff members follow him out the door, and a staff in the hall, joins them. 00:30 sec, as the staffs leave the unit, two male patients jump over the nurse’s counter and a female in a wheelchair, enters the nurse’s station through non-locking swinging half-doors, one staff comes back into the room, and another is blocking the patients from exiting the nurse’s station. 1:30 sec, Patient #G exits the facility. The facility did not provide incident reports for the patients climbing over the nurse’s station and the wheelchair bound patient entering the nurse’s station. 3.) Review of Patient O’s medical records revealed a 17-year-old-male, was admitted on 3/11/26 for suicidal ideation and aggression. Review of the treatment plan dated 3/12/26 at 09:23 am, reflected, “Hit a peer. Eloped from Hospital. LOS (line of sight) 1:1 at night.” Nurses note dated 3/13/26 at 11:50 pm reflected, “Patient tried to elope from the ambulance stretcher. Review of the facility provided video dated 3/14/2026 at 9:00 pm reflected, 00:10 sec, Patient O pushes the Adult mixed unit door open, entering the shared hallway, six staff are observed following him. He then, with two shoves, pushes the second door open. 00:46 sec, the hallway is empty at this point, an unknown male patient is seen kicking open the Adult mixed unit exit door, the door opens on the far end of the hallway and the patient then goes back into the unit. 01:02 sec, Patient O is escorted back to the unit by a male staff member. 4.) Review of Patient # A4’s medical records reflected an admission assessment record dated 4/1/26 at 12:20 pm reflected, admission of a 30-year-old male, “History per intake staff: Per staff: SI, Psychosis-AH; Hx schizophrenia. Patient stated he sees demons and “the one day the devil grabbed me and I was scratching the floor” Patient is restless and pacing in hallway. Responding to internal stimuli. Based on currently available information, there is evidence of: Severe mental/physical deterioration or incompetence. Review of Patient A4’s nursing notes in the medical record dated 4/3/26 at 6:00 pm reflected, “Patient became agitated and kicked the exit door leading towards the cedar’s unit; in attempt to elope. Staff immediately intervened. The patient was redirected to his room and education was provided. The patient verbalized understanding. Dr. was notified. An order was received to put the patient on elopement and aggression precautions. Currently, the patient denies pain and no other concerns. During assessment, no injuries were found by RN or reported by the patient. The patient denies suicidal and homicidal ideations. The patient denies visual and auditory hallucinations. Prior to the incident, the patient was given hydroxyzine at 1746 for anxiety. RN and staff will continue to monitor the patient. Observations of the facility provided video dated 4/3/26 at 6:00 pm revealed Patient #A4, an approximately 250 lb. male patient is seen running into the nursing station, he then ran into the juice machine counter twice, then he ran into the exit doors leading into the Cedars, adolescent female’s unit. A view from the Cedars unit of the camera revealed 3 female patients are present in the dayroom, the nursing staff are seen directing the female patients to another room for safety. Three male MHT are seen getting in front of the female patients and staff and immediately physically restraining the patient, then walking him back to the adult unit. Review of the Nursing notes reflected on 4/3/26 q 15 checks, and on 4/4/26, 4/5/26, 4/6/26, 4/7/26, 4/8/26 aggression and elopement risks were marked. Review of Patient #A4 MHT’s level of observation sheets reflected on 4/3/26, 4/4/26, and 4/5/26 sheets there were no restrictions for the am and pm shift. On 4/6/2/, 4/7/26, and 4/8/26 the MHT’s level of observation sheets reflect Aggression and Elopement precautions; three days after the patient had eloped from the unit. 5.) Review of Patient # Z3’s admission medical record dated 4/2/2026 at 7:00 am reflected, HISTORY OF PRESENT ILLNESS:16-year-old psychotic male presents with worsening symptoms of mania and psychosis. Observations of the facility provided video dated 4/6/26 at 10:00 pm revealed Patient #Z3 quickly went through 4 security doors. When he reaches the last exit door, the patient is unable to open the doors. He repeatedly tries to slam into the door with his shoulder; the door bends, showing daylight at the bottom half of the door each time he hits the door. Three large male staff are observed attempting to de-escalate the situation; they are talking to him and motioning him to come inside the lobby. The patient then grabs Staff #58’s shirt, Staff #58 attempts to restrain him, holding him for a few seconds. Patient #Z3 pulls away and brings Staff #8 with him, hitting the front exit door. The door opens and Patient #Z3 runs out the door; the staff are not able to get a hold of him. During a telephone interview, on the afternoon of 4/13/26, when asked about the elopement of Patient #Z3, Staff #8, Mental Health Tech stated, “We tried to talk him into coming back to his unit. He grabbed Staff #37, I tried to intervene. When I grabbed him (Patient #G7), we both fell toward the exit door. When we hit it (the door), it opened and the patient ran out. We (Staff #58 and Staff #8) followed him in my car. We didn’t follow too close because we didn’t want to make him run out into traffic. We had to make a U-turn to get back to him, that’s when he grabbed the lady and put her in a head lock. We had to physically remove the lady. When CIT (police crisis intervention team) arrived, the patient was handcuffed and taken back to the facility.” 6.) Review of the facility provided patient Elopement Incidents in the last 4 months reflected, - Patient C3, on 6/24/2025 at 9:17 am. “Patient was in courtyard. Patient pushed open gate in courtyard and eloped from the facility”. - Patient VV, on 11/29/25 trying to elope. - Patient YY, on 12/21/25, busted two security doors - Patient L, on 3/31/26, “Patient attempted to elope form [sic] the unit - Patient PP, 11/13/25 on the adult psych unit, “Patient kicked the door that separated meadow and Cedars and got in between the unit. - Patient MM, 1/13/26 on the adult psych unit, reflected, “Patient became aggressive, jumped out of the line and burst the exit door open and ran to the cafeteria.” 35028 Based on observation, interviews, and record review, the facility failed to ensure that patients received care in a safe setting - a setting that protected the emotional and physical health and safety of behavioral health patients. This was evidenced by the facility’s failure to follow their policies to ensure that 11 of 11 patients on suicide precautions (Patient H, P, Q, R, V, W, X, AA, BB, CC, and F3) were placed in bedrooms that were free of anchor tie-off points, a risk that had the potential of serious harm, injury, and/or death to patients. Based on observation, interviews, and record review, the facility failed to ensure that 1 of 1 patients (Patient C) was kept safe from head banging resulting in three transfers to an Emergency Room for medical clearance. These three ER visits took place over a four-day period. Additionally, the Multidisciplinary Treatment Plan showed no modifications in the interventions following the episodes Seclusion and Restraint for head banging. Findings included: Ligatures. Review of policy 17919182, “Room Assignments and Responsibilities,” last approved 4/2025, showed: “Purpose - The ... room assignments ... promote patient safety ... Policy - Patient room assignments occur based on clinical appropriateness, always considering the level of a patient’s clinical acuity, individual clinical needs, and safety.” Review of policy 18040290, “Levels of Observation and Precautions,” last approved 4/2025, showed: “Level of observation and any precautions are defined as intensified levels of staff awareness and attention to patient safety/security needs.” Review of policy 17833451, “Patient Bill of Rights,” last approved 4/2025, showed: “You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity ... “You have the right to be free from mistreatment, abuse, neglect, and exploitation.” Review of policy 18221100, “Safe and Functional Environment,” last approved 06/2025, showed: “The organization designs, constructs, and maintains features of the environment to promote patient safety.” During a tour of the Willows and Cedars units with Staff #1 (Quality Coordinator) on 3/30/2026 beginning at 10:50am, multiple anchor tie-off points were found in the patient bedrooms. In room 502, a knot was tied in one corner of a flat sheet and wedged into the gap between a bedside table and the wall. When the sheet was pulled across the table, the knot held in the gap, creating a ligature risk. This knot was then wedged into the gap at the top of a shelving unit and the wall. Again, the knot held firmly in the gap when pulled straight down on, creating a ligature risk. In an interview with Staff #1 during the tour, she stated that the sheet created a ligature that could be tied around the neck and used to strangulate / hang self. The following anchor tie-off points were found in the patient bedrooms on the Willows Adolescent Male Unit. “ Room 501 - the tops of two shelving units and two bedside tables. The bed assignment sheet showed Patient V was assigned to this room and on Suicide Precautions. “ Room 502 - the top of one bedside table. The bed assignment sheet showed Patients W and X both were assigned to this room, and both on Suicide Precautions. “ Room 504 - the tops of two shelving units and one bedside table. The bed assignment sheet showed Patients AA and BB were assigned to this room, and both were on Suicide Precautions. “ Room 505 - the top of one shelving unit. The bed assignment sheet showed Patients CC and F3 were assigned to this room, and both were on Suicide Precautions. The following anchor tie-off points were found in the patient bedrooms on the Cedars Adolescent Female Unit. “ Room 510 - the top of one bedside table. The bed assignment sheet showed Patients H and R were assigned to this room, and both were on Suicide Precautions. “ Room 512 - the top of one shelving unit. The bed assignment sheet showed Patients P and Q were assigned to this room, and both were on Suicide Precautions. Again, in an interview at the end of the tour (12:10pm), Staff #1 stated that the gaps found between furniture and the wall in patient bedrooms on the Willows and Cedars adolescent units created ligature tie-off points that could be used to strangulate / hang self. On 3/30/26 at 12:10pm Staff #11 (PED) observed the findings outlined above and stated that the gaps between furniture and the wall in patient bedrooms on the Willows and Cedars adolescent units created ligature tie-off points that could be used to strangulate / hang self. Review of the Physician’s Orders for Patient H, P, Q, R, V, W, X, AA, BB, CC, and Patient F3, showed that all eleven patients were ordered Suicide Precautions. Patient C not kept safe. Review of the “Inpatient Comprehensive Psychiatric Evaluation” by Staff #24 (Attending Physician) dated 3/17/26 at 8:57am showed Patient C was a 13-year-old female with plans to shoot self. She was placed on suicide precautions at 6:36am. Review of Seclusion & Restraint Initiation of Intervention / Order by Staff #24 (MD) dated 3/17/26 at 4:40pm showed Patient C was banging her head on the wall. Verbal redirection by staff was not effective in curtailing the self-harm behavior. She was given Zyprexa Xydis 5mg by mouth. She refused to participate in the debriefing assessment. Review of Physician Orders by Staff #24 (MD) dated 3/17/26 at 5:35pm showed Level of Observation: Line of Sight - “banging her head and suicidal ideation endorsed.” Review of the 7:00AM-7:00PM Shift Nursing Assessment by Staff 22 (RN) dated 3/17/26 at 6:00pm showed suicidal ideation and “agitated at time and banging head.” Review of Physician Orders by Staff #24 (MD) dated 3/18/26 at 7:27pm showed Level of Observation: Line of Sight. Review of Physician Orders by Staff #45 (NP) dated 3/18/26 at 7:28pm showed Level of Observation: 1:1. Review of Seclusion & Restraint Order by Staff #24 (MD) dated 3/20/26 at 1:45pm showed Patient C began pacing on the unit. She then began banging her head on the wall. Verbal redirection by staff was not effective in curtailing the self-harm behavior - she began banging her head harder and physically threatened staff. She was given Thorazine 50mg IM and Ativan 2mg IM. Instead of participating in the debriefing assessment, she began to scream more. Review of Seclusion & Restraint Order by Staff #41 (MD) dated 3/21/26 at 11:16am showed Patient C became aggressive towards a peer. When taken to seclusion for “quiet time,” she began striking her forehead on the wall, reopening a previous injury. She was given Thorazine 50mg IM and Ativan 2mg IM. Review of Physician Orders dated 3/21/26 at 12:57pm showed Staff #32 (NP) ordered Patient C to be transferred to an Emergency Room for medical clearance. Review of Seclusion & Restraint Order by Staff #41 (MD) dated 3/22/26 at 11:00am showed Patient C became agitated and began banging her head on the wall. She was given Thorazine 50mg IM and Ativan 2mg IM. She complained of a headache. Review of Physician Orders dated 3/22/26 at 11:17am showed Staff #43 (NP) ordered Patient C to be transferred to an Emergency Room for medical clearance. Review of Seclusion & Restraint Order by Staff #24 (MD) dated 3/23/26 at 11:15am showed Patient C became aggressive and began banging her head on the wall. This behavior was “unprovoked.” Verbal de-escalation techniques were not effective in calming the patient. She was given Haldol 10mg IM, Ativan 2mg IM, and Benadryl 50mg IM. Physician Orders dated 3/23/26 at 12:08pmam showed Staff #44 (PA) ordered Patient C to be transferred to an Emergency Room for medical clearance. Review of the Multidisciplinary Treatment Plan showed no modifications in the goals or interventions following the episodes Seclusion and Restraint for head banging behaviors that required emergency medications. The following areas are blank: Progress/lack of progress toward each objective/short-term goals, Changes/revisions to Treatment Plan, and Timeframes to achieve goal. . 38015 Based on observation and interview, the facility failed to ensure patients’ right to receive care in a physically and emotionally safe environment due to ineffective environmental and safety rounds, as evidenced by the presence of numerous environmental safety issues, most of which were previously cited. Findings included: Review of facility policy #19754865 last revised 2/22 and titled “Environmental Rounds” showed that environmental tours were conducted only on a weekly basis. Review of facility policy #20050809 last approved 3/26 and titled “Patient Bill of Rights” showed that each individual patient had the right to be protected from harm and live in a humane and safe environment. Observation of facility on 3/30/26 starting at 10:45 am, accompanied by DON Staff #7 showed the following on the adolescent male Willows unit: -Two racially offensive graffiti present written in bold, black marker, located in the common area dayroom. One was by the exit door leading to an outside courtyard and the other was located by a different exit door leading outside. All patients on the unit were exposed to the graffiti and clearly able to visualize them. In addition, inappropriate sexually explicit graffiti was present in the bathroom inside Room 502. Nursing staff on unit were unaware how long the graffiti were present. During a previous survey on 4/24/24, this same issue of numerous graffiti on the walls was cited. -Room 505 had a sharp ‘golf’ type pencil present on top of a night table. Patients could use these pencils for self-harm or harm to others. Patient #F3 and #CC, who were currently residing in this room, were both on suicide precautions. During two previous surveys, one on 10/29/24 and another on 10/7/25, this same issue was cited with the identical type of sharp pencils. -Room 502 had a 1.5-inch sharp metal bolt present on top of a night table. Patient #W and Patient #X were currently residing in this room; both were on suicide precautions. The metal bolt could be swallowed or used to cut self or others. -Rooms 506 and 507 (room 507 was located in Willow’s unit) had patient bed frames missing entire plastic protective side rail portions, exposing very sharp edges as well as exposed particle board. These sharp edges could cause intentional or unintentional injury to patients. In addition, the exposed particle board were infection control issues, as they were unable to be sanitized. Patients #N & #H3 were residing in Room 507 and both on suicide precautions. Patient #I3 & #J3, who were residing in Room 507, were also both on suicide precautions. In an interview at the time of these findings, DON Staff #7 acknowledged that the pencil, bolt, and sharp bed edges were safety issues, the graffiti was inappropriate, and all these findings should not have been present. Observation on 3/31/15 at 10:20 am of facility’s Sunrise unit with DQS Staff #3 present revealed: -A drink dispenser machine was present in the common area dayroom for patients to use. This drink dispenser had rectangular areas of protective plastic covers missing, approximately 12” x 3”, exposing very sharp metal frames. These metal edges posed intentional or accidental self-harm risks. In addition, Observation of facility’s Meadows unit, the psychiatric intensive care unit, had the same machine present in the same condition, exposing very sharp metal edges. These drink dispenser machines with the exact same safety issue were previously cited during a survey on 10/7/25, in the Meadows and Cedars units. In an interview at the time of these findings, DQS Staff #3 stated that these machines needed to be addressed because they posed safety risks to all patients.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 33326 Based on record review, and interview, the facility failed to ensure that restraint orders where authenticated (signed) by the physician or licensed independent Practioner responsible for care of the patient for five out of five (Patient #X3, W3, Z3, A, O) patients reviewed for restraint orders. This deficient practice has the potential to affect all patients requiring restraints. Findings: Review of the following patient restraint orders reflected the verbal telephone orders for emergency medication were obtained for physical and chemical restraints. Further review reflected the orders were not signed by the physician within 48 hours. Patient #X3, on 3/25/26 at 9:30 pm and on 3/25/26 at 4:50 pm. Patient #A, on 03/19/26 at 5:17 pm and on 03/20/26 at 10:55 am. Patient #W3, on 3/24/26 at 10:35, 3/24/26 at 11:37 pm, 3/25/26 at 4:50 pm, and on 3/25/26 at 9:31 pm. Patient #O, on 3/14/26 at 9:40 pm, electronically signed on 3/26/26 at 11:22 am. Patient #Z3, on 4/6/26 at 10:50 pm. Additionally, the MHT’s level of observation sheets for Patient #Z3 reflected the patient was place in the seclusion room; there was no order for the seclusion. Review of the facility provided GOVERNING BOARD (Q3) Minutes of Monday, December 18, 2025 reflected, “a. Performance parameters - PI Indicators- Reports attached. - Summary of hospitalization (33%) reasons for admission, treatment achieved, a baseline psychiatric physical and social functioning at time of discharge and evidence of patient response to treatment interventions. - Verbal Orders inpatient signed within 48 hours (57%) i. Telephone order authenticated within 48 hours. The CNO, Nurse Manager and DQS conduct daily audits and the CNO has incorporated This metric into the supervisor’s shift audit. Current compliance is 56.1% below the 90% target. Review of the facility provided Seclusion and Restraint Policy (effective 2/2026) reflected, “Practitioners/Providers/Physicians C. authenticates T/O order in the medical record within 48 hours ...The performance Improvement process and treatment plan includes information from the patient and staff debriefings in order to reduce the use of seclusion and restraints.” Review of the facility provided Quality Council Monthly Minutes 3/4/26 reporting for January 2026 reflected, “Restrictive Intervention (Order authentication) The issue: emergency medication package are not signed within 48 hrs. Action Plan: Implement an automated “Pending signature” alert in the EMAR (electronic medical record) and conduct a daily 10:00 am check by a supervisor to notify physicians of outstanding orders before they leave for the day.” During an interview on the morning of 3/26/26, Staff #24, MD confirmed the physicians are required to sign the orders within 48 hours and that the signatures were delinquent. Staff #24 stated, “We (physicians) have been asking that the orders be added to the electronic medical record.” 35028 . Based on observation, interviews, and record review, the facility failed to ensure that an RN obtained an order from a physician for the seclusion of 1 of 1 patients (Patient C), a 13-year old adolescent female. This failure resulted in Patient C being secluded for the last 5 hours of her inpatient stay, with no order by a physician to authorize the intervention. There is conflicting documentation by the RN - some of which does not support an emergency application situation. Findings included: Review of the policy 19845992, “Seclusion and Restraint,” last approved 2/2026, shows: “Seclusion - any involuntary confinement of a patient alone in a room or area where he/she is physically prevented from leaving. This includes situations where a staff physically prevents the patient from leaving or gives the perception that threatens the patient with physical intervention if he/she attempts to leave the room ... “All patients have the right to be free from seclusion/restraint of any form that is imposed as a means of coercion, discipline, convenience or retaliation by staff ... “Seclusion/restraint procedures are considered to be unusual, high-risk events that warrant timely assessment and continuous monitoring. “Practitioners/Providers/Physicians ... provide verbal and written order for the employment of seclusion/restraint. The order is documented on the Seclusion/Restraint. “Qualified Trained RN reassesses for continuation of seclusion/restraint on the One Hour Face-to-Face Evaluation ... “RN (who initiated) documents seclusion/restraint information on the Seclusion/Restraint Order/Progress Note form.” Review of the “Seclusion and Restraint Philosophy & Acknowledgment” for Patient C showed it was dated and signed by the patient’s caregiver on 3/17/26 at 5:00am. The form states, “The Hospital promotes the use of non-physical interventions and seclusion/restraint is used as the last resort to support the safety of the patient and/or others ... Seclusion and restraints are used when it has been determined the patient is in imminent danger of harming him/herself or others ... Seclusions and restraints require a physician’s order and are never used as a form of discipline or convenience for the staff.” In an interview with Staff #1 on 3/31/26 at 10:45am, Staff #1 was questioned about Patient C’s seclusion on 3/25/26. Staff #1 stated that Patient C was in seclusion on 3/25/26 from 12:07pm until 2:07pm and 2:09pm until 4:07pm. She also stated that there was not a seclusion packet in the chart, adding that a seclusion packet, which includes an order for seclusion, should have been completed by the nurse. Review of an Interdisciplinary Progress Note by Staff #52 (RN) shows a date and time of 3/25/26 at 5:10pm. The time has been written over repeatedly making it impossible to read the original recorded time. The note reads, “Patient discharged from the unit. Picked up by group home at 12:10pm. [illegible] to discharge patient was observed to be easily irritable needing constant redirection. At 12:07pm, patient was observed to be aggressive towards peers. Staff intervened immediately de-escalating but patient needed to be secluded for safety. At 12:07pm, patient was allowed to use the restroom, drinks offered to patient. Food was also offered to patient. Patient left the seclusion at 2:07pm.” Review of the following Interdisciplinary Progress Note by Staff #52 (RN) shows a date and time of 3/25/26 at 2:09pm - that’s three (3) hours BEFORE the previous note. The note reads, “Patient was observed to be aggressive to peers. Order gotten for the doctor with patient secluded at 2:09pm. Patient was offered to use the restroom but refused. Fluid and food was offered to patient. Patient left seclusion at 4:07pm. Patient was still observed to be irritable and aggressive towards peer. For safety [illegible] patient was in seclusion at 4:09pm. Patient was observed to remain calm to the time of discharge.” Review of Physician Orders by Staff #24 (MD) for 3/25/26 at 11:41am showed the following orders for Patient C: Discharge unplanned regular. Level of Observation: every 15 minutes. Precautions: none. Review of the “Patient Observation Sheet” dated 3/25/26 for Patient C shows: 1:00am until 9:30am - Observations every 15 minutes with the patient in her bedroom sleeping. 9:45am - Patient in the day room. 10:00am - Patient in the shower. 10:15am until 11:15am - Observations every 15 minutes with the patient in the day room. She was eating calmly. On 2/25/26, Staff #42 (PCA) documented: 11:30am: Patient “SC,” identified on the Location Key as “Seclusion Room.” 11:30am, 11:45am, 12 noon, 12:15pm, 12:30pm, and 12:45pm: Patient “calm.” 12:50pm, 12:55pm, 1:00pm and 1:05pm: Restlessness, irritability. 1:15pm, 1:30pm, and 1:45pm: Sleeping. 2:00pm: Agitated. At this point, the “Patient Observations Sheet” ends and the “Seclusion and Restraint Monitor Activities” form begins. Review of the “Seclusion and Restraint Monitor Activities” form by Staff #42 (PCA) for Patient C showed: Patient C was in the seclusion room on 3/25/26 from 12:07pm until 5:17pm. 12:07pm: kicking/striking, making verbal threats, attempting self-injury, and struggling. 12:12pm - 12:17pm: kicking/striking, verbal threats, attempting self-injury. 12:22pm - 12:32pm: kicking/striking, verbal threats, attempting self-injury, struggling. 12:37pm: kicking/striking, attempting self-injury, struggling. 12:42pm - 12:47pm: kicking/striking, struggling. [NOTE the conflicting information found on the “Patient Observation Sheet from 12 noon until 12:45pm. Staff #42 documented that the patient was “calm” not “kicking/striking” as is indicated on the “Seclusion and Restrains Monitor Activities” form.] 12:52pm - 13:07: resting quietly. 13:12 - 13:32: kicking/striking, verbal threats. 13:37 - 14:02: kicking/striking, attempting self-injury. 14:07: processing, refusing to talk. 14:12 - 14:37: kicking/striking. 14:42 - 16:12: resting quietly. 16:17 - 16:22: resting quietly, processing. 16:27 - 16:32: resting quietly. 16:37: resting quietly, refusing to talk. 16:42 - 15:17: resting quietly. [last entry] Review of the Physician Orders showed there were no orders for seclusion or restraint for Patient C on 3/25/26. Patient C WAS SECLUDED FOR FIVE (5) HOURS WITHOUT A PHYSICIAN’S ORDER. Further review of the chart did not produce a Seclusion and Restraint order for 3/25/26. There was no One Hour Face-to-Face Evaluation by a Qualified Trained RN. There was no documentation of the seclusion/restraint information on the Seclusion/Restraint Order/Progress Note form. Review of the Discharge Summary by Staff #24 (MD) dated 3/25/26 at 11:39am showed: Discharged back to her CPS caseworker. Mental status on discharge - “assaultive, aggressive, poor insight.” Condition on discharge: “ aggressive.” Prognosis: poor - “refusal to engage in treatment.” Discharge diagnosis: Disruptive Mood Dysregulation Disorder. .”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 33326 Based on interview, observations, and record reviews, the facility’s Quality Assessment Performance Improvement program failed to collect data and focus on high-risk, high-volume or problem-prone areas, and ensure that improvements are sustained as evidenced by, 1.) The facility did not investigate why the facility’s security doors were easily opened by patients, allowing for multiple elopements from the facility and off the patient units, and patients were jumping over the nursing counters, accessing the patient restricted areas. 2.) The facility did not complete an incident report or conduct a comprehensive investigation, when two adolescent males and 7 adolescent females gained access to each other’s restricted units, 3.) The facility’s environmental rounding logs did not identify patient safety issues, unlocked air-conditioning covers, cracked laminate, and leaking water lines. 4.) The facility failed to identify and eliminate a ligature risk in the patient intake hallway. Findings include: Review of the facility provided Organizational Quality and Improvement Plan (effective 03/2026) reflected, “Purpose A. The Hospital’s organizational Quality Improvement Plan is to ensure the governing Board, Medical Staff and professional service staff demonstrate a consistent endeavor to deliver, safe, effective, optimal patient care and services in an environment of minimal risk ...allows the Facility to identify and resolve any breakdowns that may result in suboptimal patient care and safety ... Goals: 8. Track the status of identified problems and action plans to ensure improvement or problem resolution, if not improvement has been identified. 9. Utilize information from department/services and the findings of performance improvement activities and adverse patient events to detect trends, patterns of performance or potential problems ... The scope of the organizational quality improvement program includes ...Management of the Environment of Care ... d. Performance measures for processes that are known to jeopardize the safety of patients or associated with sentinel events will be routinely monitored. At a minimum, performance measures related to the following processes, as appropriate to care and services provided, are monitored with approval and at the suggested frequency of the Quality Committee: i. Management of hazardous conditions 1.) Review of the facility provided patient Elopement Incidents in the last 4 months reflected, - Patient C3, on 6/24/2025 at 9:17 am. “Patient was in courtyard. Patient pushed open gate in courtyard and eloped from the facility.” - Patient VV, on 11/29/25 trying to elope. - Patient YY, on 12/21/25, busted two security doors - Pateint LL, on 3/31/26, “Patient attempted to elope form [sic] the unit - Patient PP, on 11/13/25 on the adult psych unit, “Patient kicked the door that separated meadow and Cedars and got in between the unit. - Pateint MM, on 1/13/26 on the adult psych unit, reflected, “Patient became aggressive, jumped out of the line and burst the exit door open and ran to the cafeteria.” Review of the facility Incident Reports for Patients Jumping Over the Nursing Counters reflected in the last 4 months reflected, - on 1/24/26, “Patient KK started climbing the nursing station and started knocking things over the counter. Order was given to give emergency medication.” - on 3/2/26, “patient ZZ jumped nurses’ station and attacked staff.” - on 2/1/26, “Pt A3 got upset, attempted to jump through nurse station. Threatening to hit staff, unable to redirect.” - on 11/22/25, “Patient QQ was agitated, climbed nurses table, yelling, jumping, running and hitting the door leading to cedar with his body 3 times.” - on 11/18/25, “RN in nurse’s station when patient E3 became agitated and jumped into nurse’s station, when the RN opened the door to get the patient out, another pt came running across the nurse’s station and pushed the RN and hit the back by the door, struck w/bottle.” During an interview, on the morning of 3/31/26, Staff #1, Risk manager confirmed the facility was aware of the patients eloping and jumping over the counters. Staff #1 did not provide evidence of the facility’s efforts to analyze and mitigate the safety risks. 2.) During an interview on the morning of 3/26/26 at 9:25 am, in the adolescent conference room, 15-year-old-female patient #B when asked about the incident on the evening of 3/25/26 stated, “I was there in the commotion. We all jumped the nurse’s counter and went over to the boys’ unit.” When asked why? Patient B stated, “I don’t know. It was just we all wanted to do something; we were bored.” When asked, did the staff try to stop it? Patient B stated “They didn’t do a very good job of it. But I think most of the commotion was caused because everybody is mad because one of our peers keeps causing fights and they never do anything about it. The only thing they do is put her in seclusion or put her out of the room, out of the unit, and like she’s still a threat to most people because she keeps trying to fight everybody and she’s thirteen years old, she’s a child, and everybody else here is like fourteen, fifteen, sixteen. And she keeps trying to fight all of us. We don’t feel safe with her in our unit, and they keep saying ‘We can’t do anything. Well, that’s like blocked up higher.’ And I’m like, well, you should be able to talk to your boss and tell them that we children don’t feel safe because we have a right to that, it’s the fifteenth amendment right, rights of the patients. They (staff) tried to block us, and it didn’t work because we were all successfully able to get over it (nurse counter).” When asked how many of you girls were there? Patient B stated, “I think it was six of us that were, oh, seven. The boys came over first. Not all the boys, one came over because one of those staff members hit one of the girls. So, then she went to go complain to her boyfriend, and her boyfriend was so mad, so he jumped over the counter, and he was about to fight her (the nurse).” Did anybody see this staff member hit the girl? Patient B stated, “Yes, I saw it. But what had happened was that the peer and the peer who always causes the problems were in a fight. So, then they (staff) were trying to pull them off, but I didn’t see any reason why she (staff) smacked her on the neck. I don’t know if she smacked her on the neck or kind of grabbed her on the neck, but it was something on the neck, and then I heard a smack. She (staff) kept claiming it was an accident, but she wouldn’t apologize for it. It was so hard for her to apologize, which I didn’t understand. They got him back over. He’s in Juve (police juvenile detention) now, I believe, the police came and he was taken.” During an interview, on 3/26/26 at 9:15 am, in the adolescent unit conference room, Patient Z3, a 13-year-old female patient when asked about the incident on 3/25/26 stated, “I was like, Whoa, what just happened?” When asked, did you see any boys over on this side? “That kind of freaked me out, he came over, I couldn’t tell if it was her brother or boyfriend or something. But he kept coming over, hugging her and stuff like that. And then this one guy in a white shirt came over. And we don’t know who he was or what he was doing, but he just like came over.” When asked where were the staff? Patient Z3 stated, “I think they (staff) probably could have handled it better, it was like they were kind of disorganized about it. They (the staff) didn’t have a plan because the cops showed up, it was chaos. I think the important part is that they haven’t seen that in a while. Because I know a lot of the staff members have said this is a stressful unit. We’ve never seen something like this in a while, so I think they probably didn’t know what to do. Because I couldn’t imagine that everybody’s going to come over. I know the girls jumped over the counter and went into the boy’s area. That one white shirt guy, I don’t know how he got in, he had those dilated crazy eyes.” During an interview on the afternoon on 3/27/2026, the surveyor shared the patient’s interviews with the Staff #1, Risk manager. Staff #1 stated she had not had time to conduct the investigation, and the staff had not filled out an incident report. On the afternoon of 3/30/26, Staff #1 confirmed the incident reports had not been completed. On 4/7/2026, Staff #7, DON was contacted to obtain the incident reports and the investigation; the facility did not provide the incident reports or evidence of the facility’s efforts to analyze and mitigate the safety risks. Review of the facility provided INCIDENT REPORT PROTOCOL & SAFETY EVENTS POLICY (effective 2/2026) reflected the following: “The levels for Incident Reports are defined as follows: ...iv. Level 4: The potential for litigation/gov’t investigation could be initiated at anytime Level 3 and 4 incidents: Must be investigated and leveled within 24 hours by the Director of Quality and Risk Management or their designee. Must be reported to HSC BH Quality Department as soon as practicable but no later than 24 hours after notification of the event. Note: This organization supports the concept that errors occur due to a breakdown in systems and processes, and will focus on improving systems and processes, rather than disciplining those responsible for errors and occurrences. The effectiveness of the safety information system depends on the active participation of all staff and is not to be viewed as punitive.” 3.) During a tour of the facility’s inpatient units on the morning of 3/30/26, witnessed and confirmed by Staff #1, the facility’s Risk manager, environmental safety issues were identified, cracked laminate, air-conditioning control covers missing locks, water leaking onto floor from the dayroom sink, numerous large holes in the walls, and misshaped security doors. Review of the facility provided 2 rounding logs dated 3/20/26 reflected, Meadows, physical plant findings reported to EOC, N/A (not applicable), and dated 3/26/26, Maples, hole in wall by Patio exit door; the facility did not provide rounding logs for each unit or day. During an interview on the morning of 3/30/26, on the adolescent male Meadows unit, Staff #11 EOC director, when asked if he conducts an EOC rounding each day, stated in part, “The nurses will put in workorders, I will see things and try to repair them when I find them. We are only a 2-man team.” The facility did not provide evidence of the facility’s efforts to ensure accurate rounding of the facility for safety risks. 4.) An observation made during a tour of the facility’s intake hallway on 4/13/26, revealed that the closures did not have a cover and were not flush with the door, providing enough room to put a ligature device through the openings. Further observations revealed, the intake workroom was across the hall from the patient intake rooms. Large windows faced intake room’s hallway. The admission Staff were busy working on admitting two patients. Across the room a large video monitor showed the inside of the intake rooms; there was no one sitting in front of the monitor, the intake coordinator had his back to the monitor. Review of Patient #B4’s medical records reflected, a 15-year-old- female with a history of suicidal ideation, was left alone in an intake room with a blanket; the room was within 5 feet of the exposed door closure arms. During an interview on the morning of 4/13/26, Staff #4, Director of Admission stated in part, the monitoring starts during the intake. The level of observation is left blank until the physician orders the level. We monitor and document on the observation sheets q 15 minutes. During an interviews on the morning of 4/13/26, Staff #11, EOC director confirmed the covers were missing from the door closures and Staff #3, Director of Quality confirmed the closures would be a ligature risk.”

“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: 33326 Based on observations, interviews, and record reviews, the facility’s administrative officials failed to ensure the expectations for safety were established and met when 1.) The inpatient units had safety hazards identified to the facility that had not been identified through the facility’s environmental roundings; the security doors Magnalocks were not aligned to prevent patients from eloping, there was water leaking on the floor from a hand sink in a patient dayroom, cracked sharp laminate in front of a nursing station, and broken air conditioning covers with sharp edges in patient’s rooms. 2.) A 15-year-old female, awaiting admission with a history of suicide attempt was left unmonitored in an area with a ligature risk; the security door closures were uncapped, leaving the exposed closure arms as a ligature risk. (Patient G9) Findings include: 1.) During a tour of the facility’s inpatient units, accompanied by Staff #1, Risk manager on the morning of 3/30/26 revealed, WILLOW, ADOLESCENT MALE UNIT on 3/30/26 at 11:00 am: - The wooden security door, leading out of the unit, had been hit by a patient and had cracked the door. A large, unsanded thick piece of plywood had been attached to the patient side of the door for reinforcement. - Throughout the unit there were multiple severely damaged wall boards in the hallways and in patient rooms 501 and 503; derogatory racial words had been drawn on the walls. - In front of the nursing station an approximately 3-inch x 2-inch piece of cracked, sharp laminate was sticking out at the base of the cabinet, along with a 2-inch crack to the left of the exposed laminate. - Rooms 501, 502, 503, and 504 metal air-conditioner covers did not lock shut, allowing suicidal patients into the control panel housing breakable hard plastic, electrical wiring and sharp metal edges. The unlocked covers also allowed patients a place to hide contraband. ADULT MIXED MALE/FEMALE unit on 3/30/26 at 11:30 am: - The unit’s exit door, leading to an outside patio, was able to be pushed open approximately 2-inches at the base; possibly compromising the integrity of the door. The facility was made aware of the door gap. -The patient handwashing sink had a pool of water at the base and was pooling out onto the patient’s dayroom laminate floor. The wallboard paint, under the sink, was bubbled up and wet, indicating the leak was not new. The facility was made aware of the infection control and safety risk. During an interview on the morning of 3/30/26, Staff #11 EOC director, when asked if he conducts an EOC rounding each day, stated in part, “The nurses will put in work orders, I will see things and try to repair them when I find them. We are only a 2-man team.” On 3/31/26 at 10:45 am, the water was observed pooling under the handwashing sink out onto the patient’s dayroom laminate floor; paper bags had been placed over the area where the water was leaking. The facility was made aware of the infection control and safety risk. During an interview and tour on the morning of 4/01/26, on the Adult unit, Staff #11 EOC director stated, “It was the juice machine that was leaking.” Observations during a tour of the facility’s patient intake area, on the morning of 4/13/26 revealed the doors exiting the intake hall, entering the adult unit, separating the adolescent male and female units, and the door entering a patient hallway had misaligned magnets. Review of the facility provided Patient Bill of Rights (effective 3/2026) reflected, “In receiving all services, each individual has the right to: 3. Live in a humane, safe, sanitary environment.” Review of the facility provided Patient’s Rights policy reflected, “C. In services provided in an inpatient setting, each individual has the right to: 3. Live in a humane, safe, sanitary environment ...” 2.) An observation made during a tour of the facility’s intake hallway on 4/13/26, revealed that the closures did not have a cover and were not flush with the door, providing enough room to put a ligature device through the openings. Further observations revealed, the intake workroom was across the hall from the patient intake rooms. Large windows faced intake room’s hallway. The admission Staff were busy working on admitting two patients. Across the room a large video monitor showed the inside of the intake rooms; there was no one sitting in front of the monitor, the intake coordinator had his back to the monitor. Review of Patient G9’s medical records reflected, a 15-year-old- female with a history of suicidal ideation, was left alone in an intake room with a blanket; the room was within 5 feet of the exposed door closure arms. During an interviews on the morning of 4/13/26, Staff #11, EOC director confirmed the covers were missing from the door closures and Staff #3, Director of Quality confirmed the closures would be a ligature risk. 38015 Based on observation, interview and record review, the facility failed to: 1. Ensure an investigation was conducted with subsequent corrective action taken after a patient safety incident of breaching locked and secured doors, as shown by: a) Not generating an incident report and doing an investigation after a violent adult male patient (Patient #O) was able to push through two sets of magnetically locked double doors on 3/14/26 and enter an occupied female adolescent unit, and; b) Not reporting the incident to the facility safety committee for the QAPI program to analyze, track and prevent future recurrences to ensure patient safety. This likely contributed to the subsequent successful elopements of two other patients though similar types of malfunctioning doors on 3/21/26 and 3/24/26 (Patients #A and #G3); 2. Have their QAPI program analyze and track at least four other prior incidents of patients breaching locked doors occurring several months before the event on 3/14/26 (Patients #C3, #PP, #YY, #MM), as evidenced by their failure to address this issue in their QAPI (Quality Council) meetings. Findings included: Review of facility policy #19880130, last reviewed 2/27 and titled “Incident Report Protocol & Patient Safety Events”, showed it defined “Patient Safety Event” as an incident that could have resulted or did result in harm to a patient, which could be the result of equipment failure. The policy also showed that it was the responsibility of all staff to report all safety incidents by filling out an incident report as soon as possible, then to notify their supervisor, who then would notify the Director of Quality and Risk Management, who would then lead an investigation, then report the results to the facility’s Safety Committee. This committee then uses the details of the investigation to analyze the events to help reduce or prevent unsafe conditions. Review of facility policy #20195375, last revised 6/21 and titled “Organizational Quality Improvement Plan”, showed that one of the policy’s purposes was to ensure safe and effective patient care services in an environment of minimal risk. Also, one of the primary functions of this plan was for appropriate management of the environment of care. In addition, it showed that hazardous conditions which were known to jeopardize the safety of patients would be corrected and adequately monitored. 1. No investigation or corrective action taken after Patient #O breached doors: Record review of Patient #O’s clinical chart showed the following: 17-year-old male, date of birth 3/14/08, admitted to adolescent boy’s unit of facility on 3/11/26 due to aggression and suicidal ideation. He was placed on assault precautions due to high risk of aggression and given a 1:1 close observation sitter. On 3/14/26, he was transferred to the adult Psychiatric Intensive Care Unit (PICU) because he turned 18 years of age. Physician progress notes from Dr. Staff #37 dated 3/15/26 showed “Patient passed through dolls (‘doors’) [on 3/14/26] in unit and went to the kids unit and had to be restrained and also was sent out to the ER where he received Versed, Haldol, Ativan and Benadryl ....continue 1:1 observations”. However, all other multidisciplinary progress notes, including nursing notes for both the day and evening shifts on 3/14/26, failed to mention anything about the patient breaching the doors. In an interview on 3/30/26 at 10:00 am, DPO Staff #11 stated that all the secured doors on the patient units were locked magnetically, designed to withstand 600 pounds of pressure, and people should not have been able to forcefully get through any of the doors unless they were malfunctioning. Review of facility’s incident reports involving Patient #O failed to show an reports describing him breaching unit doors and entering other units. There was only one incident report generated on 3/14/26 on behalf of Patient #O with the description of the incident showing that he was aggressive towards another patient, “kicked an exit door”, and hit his forehead against a door multiple times. Review of facility video footage on 3/31/26 at 12:30 pm with DQS Staff #3, DPO Staff #11, and DON Staff #7 showed the following: On 3/14/26 at approximately 9:37 pm, Patient #O was seen pushing through a set of locked double doors that exited out of the adult Meadows PICU unit, and into a room that led to another set of double doors leading into the female adolescent Cedars unit. Patient #O was then seen pushing through a second set of the locked doors that led into the Cedars unit and he entered, without being restrained by staff who were next to him. Several of the girls were seen running away from the patient. In addition, approximately 20 seconds later, another patient from the Meadows unit (unidentified) was visualized kicking the same double doors open, but did not enter the room. In an interview after video review on 3/31/25, DON Staff #7 and DQS Staff #3 confirmed there was no incident report generated and no subsequent investigation. There was no evidence produced which showed the malfunctioning doors were addressed. Review of facility incident reports showed there were at least two more breaches of locked doors after the 3/14/26 incident which resulted in patient elopements from facility: On 3/21/26, Patient #A eloped and and on 3/24/26, Patient #G3 eloped. 2. QAPI program failing to analyze and track at least four other incidents of door breaches prior to 3/14/26 event: Review of facility incident report log showed the following: On 6/25/25, Pt #C3 pushed through a magnetically locked door similar to other doors in the facility, located in an outside courtyard. He was then able to elope. On 11/13/25, Pt #PP kicked open and breached the doors of the adult Meadows PICU unit that led to the Cedars unit. Note-this was the same set of doors that Patient #O later breached on 3/14/26. On 12/21/25, Patient #YY breached two doors in the facility. On 1/13/26, Patient #MM was able to push through an exit door and enter the cafeteria. Review of facility’s QAPI meeting minutes, called “Quality Council Monthly Minutes”, showed the following: For November of 2025, December of 2025, and January of 2026, there was no information noted about the doors. Under the category “EOC” (Environment of Care), for all three months, it only stated “All indicators met” without any other explanation.”

“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: 35028 . Based on observations, interviews, and record review, the facility failed to ensure that the dietary needs of patients were assessed properly by a Registered Nurse. This failure was evidenced by a regular diet being ordered for 1 of 1 patients (Patient B) who had a documented gluten allergy with possible anaphylaxis. Even though there was documentation on the “Preadmission Evaluation & Medical Clearance Screening,” “Physician’s Preadmission Examination Orders,” “Ancillary Orders” and the nurse’s own “Nursing Admission Assessment” that Patient B had an allergy to gluten with anaphylaxis, the nurse accepted and input an order for a regular diet. Findings included: Review of Policy #18132601, “Nutritional Screening / Consults,” last approved 6/2025, showed: “Purpose - to identify patients for whom nutritional intervention is an integral part of their diet therapy ... Policy - All patients ... will be screened to identify nutritional risk and the need for nutritional assessment ... The initial screen is part of the ... Nursing Admission Assessment ... If the nutritional assessment score is a 3 or more, a consult with a Registered Dietitian is required ... The nurse may also contact the RD if there are special diet concerns or requests, such as unique special diets, allergies ... The nurse is responsible to ensure the consult occurs in a timely manner.” Patient B. Review of the “Preadmission Evaluation & Medical Clearance Screening” by Staff #46 (MD) showed a 15-year-old female with intrusive, consistent suicidal thoughts: Consult Date and Time: 3/23/2026 at 4:00pm Allergy: Food/Environmental Allergies - Gluten. Review of the “Physician’s Preadmission Examination Orders with Preliminary Plan of Care” by Staff #46 (MD) showed: Arrival Date and Time: 3/23/2026 at 1:30pm Physician Evaluation: 3/23/2026 at 4:02pm Diet: Regular diet. Food/Environmental Allergies - Gluten. Review of the “Ancillary (non-medication) Orders” by Staff #46 (MD) on 3/23/2026 at 6:45pm showed: Allergies: Gluten (Anaphylaxis) Regular Diet. The order was entered on 3.23.2026 at 6:38pm by Staff #14 (RN) and e-Signed on 3/24/2026 at 9:07am by Staff #24 (MD). Review of the “Nursing Admission Assessment” by Staff #31 (RN) on 3/23/2026 at 6:48pm showed: “Nutritional Risk Screening ... Gluten allergy Celiac related - 2 risk points.” The following questions were not addressed: Does the patient follow a specific diet? Is a nutritional consult indicated? Review of the “Ancillary (non-medication) Orders” by Staff #32 (NP) on 3/24/2026 at 1:46pm showed an order for a Dietary Consult. Review of the “Ancillary (non-medication) Orders” by Staff #46 (MD) on 3/25/2026 at 9:06am showed an order for a Special Diet Gluten Free [due to] “severe allergy.” Review of the “Dietary Assessment” by Staff #33 (Registered Dietician) on 3/25/2026 at 1:00pm showed: Gluten food allergy with an anaphylaxis reaction. Plan: Vegan, gluten free diet. Review of the literature found on the Mayo Clinic website showed: “Wheat allergies happen when your body produces antibodies to proteins found in wheat. In celiac disease, a specific protein in wheat - gluten - causes a(n) ... immune system reaction ... For some people, wheat allergy may cause a life-threatening reaction called anaphylaxis ... [with symptoms of] swelling or tightness of the throat, chest pain or tightness, serious trouble breathing, trouble swallowing ... Anaphylaxis is a medical emergency that requires immediate care.” https://www.mayoclinic.org/diseases-conditions/wheat-allergy/symptoms-causes/syc-20378897 .”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 33326 Based on record review and staff interviews, the facility failed to develop and keep current appropriate care plan for each patient that reflects the patient’s goals and the nursing care to be proved to meet the patints’s needs when, The patient’s initial treatment plan did not reflect his past elopements. Patient A eloped from his unit; there were no changes to his treatment plan. Patient A then successfully eloped from the facility on his second attempt. This failure places all patients with high risks and requring updated treatment plans at risk of harm. Findings: Review of Patient A’s medical records reflected on 3/18/26 at 11:33 a 17-year-old-adolescent male with a diagnosis of Intellectual disability disorder, Autism, conduct disorder, Depression and Prenatal alcohol and drug exposure, learning disability, and reactive attachment disorder was admitted voluntary for suicidal ideation, he was going to run in front of a vehicle. During the intake process Patient A had voiced thoughts of running away from his group home; he had made ‘many attempts to vacate his RTC’ (residential treatment center). Review of Patient A’s treatment plan dated 3/19/26 did not reflect the risk for elopement. Review of the facility provided video 3/19/26 at 5:00 pm Patient A’s first incident reflected, 2:45 minutes, Patient A is seen walking over to the door and pushing the door open with his right shoulder. He opens the door and holds it open for a few seconds, then he comes back into the room. Two unnamed adolescents are seen jumping up and down and giving him high-fives for opening the doors. Review of the nurse’s notes dated 3/19/26 at 5:35 pm reflected, “Patient started getting agitated punching holes in walls and hitting doors trying to break through ...” The notes did not report his opening the doors. Observations made during the review of the facility provided video dated 3/21/2026 a 9:00 pm reflected, 00:45 sec, Patient A opens the first door and exits the adolescent male unit. 00:51 sec, a Staff member is seen walking out the door to follow Patient A, a second staff stands at the door. 01:08 sec, the second staff member is seen following out the door, leaving the unit. 1:13 minutes, Patient A hits the second door two times and is unable to open it. The female staff is seen talking to him. Patient A then kicks the bottom of the door six times and opens the door. 1:18 sec Patient A kicks the metal doors 4 times and exits. 1:21 sec. Patient A opens the Intake doors, enters the lobby and pushes the front door open and exits out of the facility. The two staff are seen walking to the exit door but not following him out of the facility. Review of the facility provided Levels of Observation and Precautions policy (effective 11/2025) reflected, “The nursing staff and medical providers will assess patients for risk level and make level of observation and precaution recommendations based on the risk level assessment findings and patient behavior ...It is critical that patient observation level and precautions are documented on the Close Observation ... Level of Observation and Precautions Procedure: Level of observation and any precautions are defined as intensified levels of staff awareness and attention to patient safety/security needs requiring varying levels of observing patients and the initiation of specific protocols and supplemental documentation, when warranted ...6. During the course of treatment, any clinical professional may determine an increase in observation and/or the addition of a precaution is warranted and clinically necessary. The charge nurse and the Provider are notified when an increase in level of observation and/or precaution is indicated. Orders should be obtained for increased observation and/or precautions as noted above ... During an interview on 3/30/26, Staff # 1, QA, confirmed the facility’s nursing staff did not identify or initiate Elopement risk or aggression interventions to the treatment plan upon admission and following Patient A’s opening the security doors on 3/19/26.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 33326 Based on observation, record review, and interview, the facility failed to develop and maintain the physical environment to assure the safety and well-being of patients when, - Leaking water on adult unit day room - Cracked sharp laminate on nursing station wall, on the adolescent male unit - Broken air-conditioning covers, exposing rusty, sharp metal - Security doors not maintained to ensure security Findings include: During a tour of the facility’s inpatient units, accompanied by Staff #1, Risk manager on the morning of 3/30/26 revealed, WILLOW, ADOLESCENT MALE UNIT on 3/30/26 at 11:00 am: - The wooden security door, leading out of the unit, had been hit by a patient and had cracked the door. A large, unsanded thick piece of plywood had been attached to the patient side of the door for reinforcement. - Throughout the unit there were multiple severely damaged wall boards in the hallways and in patient rooms 501 and 503; derogatory racial words had been drawn on the walls. - In front of the nursing station an approximately 3-inch x 2-inch piece of cracked, sharp laminate was sticking out at the base of the cabinet, along with a 2-inch crack to the left of the exposed laminate. - Rooms 501, 502, 503, and 504 metal air-conditioner covers did not lock shut, allowing suicidal patients into the control panel housing breakable hard plastic, electrical wiring and sharp metal edges. The unlocked covers also allowed patients a place to hide contraband. ADULT MIXED MALE/FEMALE unit on 3/30/26 at 11:30 am: - The unit’s exit door, leading to an outside patio, was able to be pushed open approximately 2-inches at the base; possibly compromising the integrity of the door. The facility was made aware of the door gap. -The patient handwashing sink had a pool of water at the base and was pooling out onto the patient’s dayroom laminate floor. The wallboard paint, under the sink, was bubbled up and wet, indicating the leak was not new. The facility was made aware of the infection control and safety risk. During an interview on the morning of 3/30/26, Staff #11 EOC director, when asked if he conducts an EOC rounding each day, stated in part, “The nurses will put in workorders, I will see things and try to repair them when I find them. We are only a 2-man team.” On 3/31/26 at 10:45 am, the water was again observed pooling under the handwashing sink out onto the patient’s dayroom laminate floor; paper bags had been placed over the area where the water was leaking. The facility was made aware of the infection control and safety risk. During an interview and tour on the morning of 4/01/26, on the Adult unit, Staff #11 EOC director stated, “It was the juice machine that was leaking.” Observations during a tour of the facility’s patient intake area, on the morning of 4/13/26 revealed the doors exiting the intake hall, entering the adult unit, separating the adolescent male and female units, and the door entering a patient hallway had misaligned magnets. An observation made during a tour of the facility’s intake hallway on 4/13/26, revealed that the closures did not have a cover and were not flush with the door, providing enough room to put a ligature device through the openings as well as the door closure on the adolescent male’s unit. Further observations revealed, the intake workroom was across the hall from the patient intake rooms. Large windows faced intake room’s hallway. The admission Staff were busy working on admitting two patients. Across the room a large video monitor showed the inside of the intake rooms; there was no one sitting in front of the monitor, the intake coordinator had his back to the monitor. Review of the facility provided Patient Bill of Rights (effective 3/2026) reflected, “In receiving all services, each individual has the right to: 3. Live in a humane, safe, sanitary environment.” Review of the facility provided Patient’s Rights policy reflected, “C. In services provided in an inpatient setting, each individual has the right to: 3. Live in a humane, safe, sanitary environment ...””

“STANDARD: BUILDING SAFETY CFR(s): (c) Standard: Building safety. Except as otherwise provided in this section, the hospital must meet the applicable provisions and must proceed in accordance with the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and TIA 12-6). (1) Chapters 7, 8, 12, and 13 of the adopted Health Care Facilities Code do not apply to a hospital. (2) If application of the Health Care Facilities Code required under paragraph (c) of this section would result in unreasonable hardship for the hospital, CMS may waive specific provisions of the Health Care Facilities Code, but only if the waiver does not adversely affect the health and safety of patients. This Standard is not met as evidenced by: 38387 Based on surveyor observations and confirmed in interview, the facility failed to meet the standards of the Health Care Facilities Code (NFPA) and provide building safety. Facility replaced 18 secured doors and each failed to latch and maintain proper security. The secure doors with electrical locks had misaligned strike plates, preventing its positive latch from operating properly. Findings included: Review of the the NFPA 101, 2012 ed.; 18.2.2.2.2, it states “Locks shall not be permitted on patient sleeping room doors, unless otherwise permitted by one of the following: (2)Locks complying with 18.2.2.2.5 shall be permitted.” NFPA 101, 2012 ed.; 18.2.2.2.5 Door-locking arrangements shall be permitted in accordance with either 18.2.2.2.5.1 or 18.2.2.2.5.2. NFPA 101, 2012 ed.; 18.2.2.2.5.1 Door-locking arrangements shall be permitted where the clinical needs of patients require specialized security measures or where patients pose a security threat, provided that staff can readily unlock doors at all times in accordance with 18.2.2.2.6. NFPA 101, 2012 ed.; 18.2.2.2.5.2 Door-locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety, provided that all of the following criteria are met: (1)Staff can readily unlock doors at all times in accordance with 18.2.2.2.6. (2)A total (complete) smoke detection system is provided throughout the locked space in accordance with 9.6.2.9, or locked doors can be remotely unlocked at an approved, constantly attended location within the locked space. (3)The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with 18.3.5.1. (4)The locks are electrical locks that fail safely so as to release upon loss of power to the device. (5)The locks release by independent activation of each of the following: (a)Activation of the smoke detection system required by 18.2.2.2.5.2(2) (b)Waterflow in the automatic sprinkler system required by 18.2.2.2.5.2(3) NFPA 101, 2012 ed.; 18.2.2.2.6 Doors that are located in the means of egress and are permitted to be locked under other provisions of 18.2.2.2.5 shall comply with both of the following: (1)Provisions shall be made for the rapid removal of occupants by means of one of the following: (a)Remote control of locks from within the locked smoke compartment (b)Keying of all locks to keys carried by staff at all times (c)Other such reliable means available to the staff at all times (2)Only one locking device shall be permitted on each door. During the tour of the facility on the morning of 4/13/2026 with the Director of Maintenance (Staff #35), 18 secured doors were being replaced due to failure to latch and maintain proper security. The secure doors with electrical locks have misaligned strike plates, preventing its positive latch from operating properly.”

“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: 35028 . Based on observations, interviews, and record review, the facility failed to follow their policies on staffing the units as evidenced by: “ Each adolescent unit was not staffed with a Lifeguard [sometimes referred to as a Safety Guard] as outlined in the policy, “Adolescent Unit - Unit Management: Patient Care Assistant (PCA) Lifeguard and Unit Separation.” 5 of 5 shifts were inadequately staffed (3/24/26 - 7AM-7PM, 3/24/26 - 7PM-7AM, 3/25/26 - 7AM-7PM, 3/26/26 - 7AM-7PM, and 3/30/26 - 7A-7P) . “ An acuity system was not utilized in the determination of adequate coverage as outlined in the policy, “Plan for the Provision of Nursing Care in Psychiatric Specialty Areas.” This failure has put patients and staff at risk of serious injury and harm. Additionally, the facility failed to ensure that the staff on the Willows Adolescent Boy’s Unit and the Cedars Adolescent Girl’s Unit were adequately staffed with properly trained, qualified mental health staff. This failure put patients and staff at risk of serious injury and harm. This was evidenced by: “ Numerous staff reported fear of the patients, as well as fear of being seen on video surveillance footage using improper behavior management techniques. “ Staff members interviewed reported 1 to 6 hours of training in Handle with Care, a behavior management system, instead of the required 8 hours. Some staff members were not clear about all HWC physical interventions such as the prone and supine positions. “ Both staff and patients were injured during two (2) instances when multiple adolescent patients got into fights that could not be contained by the staff present in the hospital. “ 11 of 11 staff members (Staff #8, 10, 11, 13, 14, 18, 21, 23, 29, 37, and Patient #38) were injured when emergency interventions were needed to bring about orderliness and control to the units during a two (2) week period. Findings included: Staffing Policies, Lifeguards, and Acuity. Review of the policy 17919210, “Adolescent Unit - Unit Management: PCA Lifeguard and Unit Separation,” last approved 4/2025, showed: “Scope of Policy - All Behavioral Health Adolescent Inpatient Units ... This role functions outside of the prescribed staffing ratios and this function is the sole job of the Lifeguard. “Lifeguard assignment by the Registered Nurse ... “Maintain accountability for: Not permitting distractions that pull the Lifeguard away from Lifeguard duties. Not engaging the Lifeguard in ... emergency situations ... [on] other units.” “Lifeguard duties ... Never abandon your Lifeguard assignment ... Continuously round throughout the unit ... Document unit rounding activities.” Review of the policy 18132605, “Plan for the Provision of Nursing Care in Psychiatric Specialty Areas,” last approved 8/2025, showed: “Staffing Plan Guidelines: In striving to ensure ... quality nursing care and a safe patient environment, nursing staffing and patient assignment shall be based upon identified minimum staffing requirements by the unit and the following: ... The Nursing Department shall define, implement, and maintain a system for determining patient requirements for nursing care on the basis of demonstrated patient needs, appropriate nursing intervention, and priority for care. THIS ACUITY STAFFING SYSTEM [Caps are the emphasis of the writer] shall be based upon objective assessment tools that qualify the number of nursing staff members needed to fulfill patient needs on each unit. The Assessment Coordinator utilizes input from the Chief Executive Officer, the unit charge nurses, or designee prior to admission placement decisions so that patient care needs can be coordinated with available resources ... “Staffing is based upon patient census, acuity, and relevant treatment needs ... Based on census and patient acuity, the needs of each unit are evaluated collaboratively on a shift or partial shift basis between the House Supervisor RN, the nurse manager, and DON to provide optimal patient care that is fiscally sound.” Review of policy 18040290, “Levels of Observation and Precautions,” last approved 4/2025, showed: “Line of sight observation: This level of observation is very restrictive and involves continuous visual monitoring at all times ... Staff must be within visual contact of the patient at all times ... “1-to-1 observation at all times: This is the most restrictive level of observation for the patient. Staff must be within arm’s length to the patient at all times.” Observation of the Willows Adolescent Male Unit and Cedars Adolescent Female Unit on 3/30/26 at 10:50am - 12:10pm showed six patient bedrooms on each unit. Each bedroom had two beds, giving each unit a bed capacity of 12 patients. Willows Unit - rooms 501, 502, 503, 504, 505, and 506. Cedars Unit - rooms 507, 508, 509, 510, 511, and 512. In an interview with Staff #7 (CNO) on 3/30/26 at 12:30pm, she stated that there is a Staffing Grid for each adolescent unit. The Staffing Grid for the Willows and Cedars units was reviewed with Staff #7 who offered commentary. She stated that each adolescent unit had 12 beds. Record review of the Staffing Grid (last reviewed on 12/8/25) showed: Census 1-12 - 1 RN, 1 tech, and 1 Lifeguard for each unit. Census 13-16 - 2 RNs, 2 PCAs, and 1 Lifeguard for each unit. Review of the Willows and Cedars Staffing Sheets showed inadequate staffing for 5 of 5 shifts: 3/24/26 - 7AM-7PM. Willows 7AM-7PM - Census 10. 1RN and 1 PCA. No Lifeguard. Cedars 7AM-7PM - Census 15. 2 RNs (Staff #53 and Staff #54), 1 PCA, and 2 PCAs assigned to 1:1s. No Lifeguard. The RN (Staff #53) that was assigned to the overflow patients was also assigned as the lead RN for Handle with Care emergency code interventions throughout the facility. Had Staff #53 (RN) been pulled to another area of the facility for an emergency code intervention, the unit would have been left with 15 patients, 1 RN (Staff #54), 1 PCA (Staff #56), and 2 PCAs each with a within-arms-length 1:1 assignment. In an interview with Staff #1 on 4/1/26 at 10:15am, she stated that the acuity was high on 3/24/26 and “We did not have enough staff members.” Numerous patients were involved in the following two incidents. “ Review of the “Seclusion & Restraint Initiation of Intervention/Order” dated 3/24/26 at 1:15pm for Patient C showed the patient was “severely agitated” with “physical and verbal altercation with peers on the unit. She was medicated with Zyprexa and Ativan IM.” “ Review of an “interdisciplinary Progress Note” dated 3/24/26 at 1:50pm showed, Patient M was “severely agitated and had verbal altercation with peers.” She was medicated with Zyprexa and Ativan IM. “ Review of an “interdisciplinary Progress Note” dated 3/24/26 at 6:00pm showed, Patient M got into a physical altercation with a peer. Patient M hit staff. She was medicated with Zyprexa IM. She was placed in the quiet room which required monitoring by a staff member. 3/24/26 - 7PM-7AM. Willows 7PM-7AM - Census 10. 1RN and 1 PCA. Cedars 7PM-7AM - Census 15. 2 RNs, 1 PCA, and 2 PCAs assigned to 1:1s. One Lifeguard (Staff #16) was assigned to cover both the Willows and Cedars units. Policy dictates one Lifeguard per adolescent unit. The Staffing Grid dictates 2 RNs, 2 PCAs, and 1 Lifeguard for a census of 13-16. The Cedars Unit was short 1 PCA. In an interview with Staff #1 on 4/1/26 at 10:15am, she stated that the acuity continued to increase on the evening of 3/24/26, adding that there was a shortage of staff. She also stated that the census for staffing according to the grid does not consider patients on a 1:1. In other words, the census for Cedars was 15 but with 2 patients on a 1:1, the unit would be staffed for 13 patients. With 13 patients, the Cedars Unit was still short 1 PCA. Review of an Interdisciplinary Progress Note by Staff 57 (RN) on 3/24/26 at 7:15pm showed, Patient C was “agitated and physically aggressive, engaging in a fight with another patient. De-escalation attempts, including verbal redirection and offering space, were unsuccessful. Due to imminent risk of harm to self and other, code was called.” Patient C was administered Zyprexa 5mg and Benadryl 50mg IM. Further review of an Interdisciplinary Progress Note by Staff 57 (RN) on 3/24/26 at 8:50pm showed, Patient C was “still attempting to hit peers. Was placed in quiet room for about 30 minutes with the door open and staff at the door.” Review of an “Employee Safety Incident Report” dated 3/24/26 at 8:30pm showed that Staff #14 (Intake RN) responded to a code on the Cedars Unit involving a combative patient. She was hit on the forehead with a piece of sheetrock. Review of a picture of Staff #14’s injury showed a large abrasion and bump on the left side of her forehead. In an interview with Staff #1 on 4/1/26 at 10:20am, she identified the patient that had assaulted Staff #14 on 3/24/26 as Patient R3, a 15-year-old female. The video surveillance footage of the incident on 3/24/26 shortly after 8:00pm was observed with Staff #1 providing commentary. She identified the 4 girls in the video as Patient C, Patient M, Patient L3, and Patient R3. They were fighting each other with staff attempting to intervene. Staff #1 also stated that there had been 3 overflow patients that had been admitted to the Cedars Unit that day bringing the census to 15. These adolescent females were Patient B, Patient T, and Patient H. They were assigned to sleep in the day room on sleeping cots. 3/25/26 - 7AM-7PM. Willows 7AM-7PM - Census 11. 1 RN, 2 PCAs with one of the PCAs providing Line of Sight for a patient. One Lifeguard was assigned to cover both the Willows and Cedars units. Policy dictates one Lifeguard per adolescent unit. Cedars 7AM-7PM - Census 15. 2 RNs, 4 PCAs with 2 PCAs assigned to 1:1s. One of the PCAs not assigned to a 1:1 was Staff #42. As noted, there was 1 Lifeguard to cover both Willows and Cedars units. Review of the “Patient Observation Sheet” for Patient C on 3/25/26 shows Staff #42 was provided the Q-15-minute observation checks from 9:45am until 12:50pm and 1:15pm until 2:00pm. The Seclusion & Restraint Monitoring Activities” form for Patient C shows that Staff #42 provided Q-5-minute observation checks from 12:07pm until 5:17pm. This assignment would have pulled her from her Q-15-minute rounds for all the other patients. This left the short one PCA. 3/26/26 - 7AM-7PM. Willows 7AM-7PM - Census 12. 1 RN. 1 PCA (Staff #49). One Lifeguard was assigned to both Willows and Cedars units. Policy dictates one Lifeguard per adolescent unit. Staff #49 was assigned as the PCA on the unit AND the Safety Monitor/Patient Area Control for emergency code interventions throughout the facility, leaving the RN alone with a Lifeguard who was split between two units should there be a code situation. Cedars 7AM-7PM - Census - 12. 1 RN. 2 PCAs with one assigned to a 1:1. One Lifeguard was assigned to Willows and Cedars. 3/26/26 - 7PM-7AM. Video surveillance footage showed Patient #I3, a male patient, jumping over the counter of the Nurse’s Station and going from the Willows Unit (male) to the Cedars Unit (female). A door behind the Nurse’s Station separated the two units. Additionally, female patients jumped over the counter of the Nurse’s Station and went to the male unit. During this episode Patient #13 hit a police officer and was arrested. In an interview with Staff #1 on 3/31/26 at 10:45am, she stated the police officer happened to be in another area of the hospital when an emergency behavioral code was called on the adolescent unit. 3/30/26 - 7A-7P. Willows 7A - 7P. Census of 12. 1 RN. 1 PCA. One (1) Lifeguard was assigned to be split between the two units. Cedars 7A - 7P. Census of 12. 1 RN. 1 PCA. Staff #7 confirmed that one (1) Lifeguard was assigned to cover both units instead of the required one Lifeguard for each unit. In an interview with Staff #1 (QA) on 3/31/26 at 10:45am, she stated acuity is not factored into the staffing pattern. In an interview with Staff #1 (QA) on 4/1/26 at 10:15am, she was asked about the multiple codes that had been reported earlier in the week. She stated that the units feel like “PICUs” (Psychiatric Intensive Care Units), adding, “Sometimes codes are happening on multiple units at the same time all day, day after day.” In an interview with Staff #10 (Staffing Coordinator) on 3/31/26 at 2:20pm, she stated she makes the staff assignments for each unit. She concluded by saying, “Acuity doesn’t play into staffing.” When asked to describe what staff were saying about the acuity, she stated, “In the current situation, staff are fearful, unsure if they are doing the right thing. They state there’s not enough staff to go to a code.” In an interview with Staff #47 (Intake Coordinator), on 3/31/26 at 3:29pm, he stated acuity is not factored into staffing, adding that the acuity level has been very high. Lack of adequately trained staff and numerous injuries. Review of the “Handle with Care Behavior Management System - Physical Intervention Participant Manual,” © 2012, showed: Page 26 shows a patient in a prone position with one staff member across half of the patient’s back, one buttock, and one thigh. This position is identified as the “neutral position.” Page 36 shows a patient in a prone position with one staff member across the patient’s back and a second staff member across the patient’s legs. This position is identified as the “Neutral Position.” Pages 37-42 demonstrate the “HWC Two-Person Supine” hold. In an interview with Staff #11 (Physical Environment Director [PED] and Handle with Care [HWC] Instructor) on 3/30/26 at 1:40pm, he stated that Handle with Care is the behavior management program that is taught to staff, adding that he and Staff #8 are the HWC instructors. He also stated that the training is scheduled for eight (8) required hours but sometimes he does it in two (2) to four (4) hours. When questioned about the obligations of ensuring a safe, compliant, and functional facility as the PED along with the duties of the HWC instructor, he stated it was “challenging” and “hard to train the whole hospital.” Staff #11 was asked about putting a patient in a “prone position.” He replied that the prone and supine positions were contraindicated in his training. Staff #11 also described an injury when he was hit in his groin area by Patient C resulting in a bruised scrotum. He was off work for two days. In an interview with Staff #8 (HWC instructor and PCA - Patient Care Assistant) pm 3/31/26 at 2:30pm, he stated he was injured twice. In the first instance, Patient K grabbed him in his privates. Later that day Staff #8 was kicked in the groin area by Patient K3. He was off work for two (2) days with blood in his urine. Staff #8 also stated there has been “inadequate staff,” adding that some staff members are “never confrontational” and “afraid of being hurt by patients.” He said he had one PCA that had a “panic attack” when it was time to go to the unit to work. When questioned about the supine position, he stated the position was acceptable “for less than five (5) minutes only.” In an interview with Staff #1 (QA) on 3/30/26 at 3/31/26 at 10:45am, she stated there have been violent patients on the adolescent units. (Video surveillance footage of incidents on 3/24/26 and 3/26/26 was reviewed.) When questioned about staff’s response to the violence, she stated that staff complained of “not feeling safe,” adding that there were “codes [behavior management interventions] throughout the hospital.” When questioned about proper training of staff to handle behavioral issues, she stated, “Staff are not getting eight (8) hours of training - usually one (1) to five (5).” In an interview with Staff #28 (PCA) on 3/30/26 at 2:40pm, she stated she transferred from kitchen staff to a PCA, adding that she had one-hour HWC training. She also stated she had never heard of a prone position. In an interview with Staff #29 (PCA) on 3/30/26 at 2:50pm, she stated she had a four-hour refresher course in HWC “two weeks ago.” In an interview with Staff #30 (Pharmacy Technician) on 3/30/26 at 3:00pm, he stated his HWC training lasted “a couple hours.” He did not believe the training prepared him to respond to patients with out-of-control behaviors. He also stated that putting a patient in a prone position was allowed “only if trying to hurt someone.” In an interview with Staff #10 (Staffing Coordinator) on 3/31/26 at 2:20pm, she stated she had received four (4) hours of HWC, adding that four (4) hours was not enough. When asked if she had been injured when applying HWC, she stated she had hit her head on a doorway within the past two weeks, adding, “There had been a lot of codes on that day.” When asked about the impact of patients sleeping on cots because of not having enough beds, she stated, “When we have more patients than beds, that’s tough because we need more staff to monitor the patients on the cots.” In an interview with Staff #23 on 3/31/26 at 3:10pm, she stated she was hit by an apple that was thrown by Patient K. When questioned about adequate staffing, she stated, “Some days we struggle.” She also stated staff were “fearful,” adding, “People are not doing the right thing in a code.” She said her HWC training was for “a half a day.” In an interview with Staff #47 (Intake Coordinator), a large, muscular male, on 3/31/26 at 3:29pm, he stated that he had worked as a PCA in the past, adding that he gets called to codes quite often because of his size and skills at de-escalation of angry patients. “Last week was bad on the male and female adolescent units.” He also stated there was a “lack of men.” He then stated, “With the high acuity, there has not been enough staff. Staff are fearful of losing their jobs because they are not doing codes right.” He concluded by saying, “Staff don’t want to touch patients because of all the paperwork, so they let the behaviors go on instead of intervening earlier.” On 4/1/26 at 10:15am, Staff #1 (QA) provided a list of incidents that had happened during the previous two-week period. She offered commentary as the list was reviewed. “ On 3/2/26 at 8am, Patient L3, a female adolescent, jumped over the counter of the nurse’s station, went through the door to the male adolescent unit, and attacked Staff #48 (RN). “ On 3/8/26 at 1:00pm, Patient N3 assaulted Staff #39. Following the physical intervention, Staff #29 was sent for medical clearance when her ankle was injured. “ That same day, the adolescent female patient jumped over the counter and attacked Staff 38 (RN). “ On 3/23/26 at 11:15am, Patient C, an adolescent female, slapped Staff #22 (RN) during an emergency medication intervention. “ On 3/24/26 at 8:41pm, Patient C, along with three other female adolescent patients, banned together and created havoc on the unit. The staff members could not handle the crisis. Patient C pulled a piece of sheetrock from the wall and hit Staff #14 (Intake RN) on the forehead with it. Staff #14 had a large knot on her forehead. “ On 3/26/26 at 9:44pm, Patient M3, an adolescent male, jumped over the counter of the nurse’s station and went through the door to the adjacent female adolescent unit. He was eventually returned to the male unit. Shortly thereafter, five (5) female patients jumped over the counter of the nurse’s station and went through the door to the male adolescent unit. A police officer who was in the building on a call to another unit, came to the adolescent male unit. Patient M3 assaulted the police officer. Patient M3 was arrested by the police officer. “ Staff #13 was slapped by a patient; Staff #18 was kicked in the stomach, head, and chest by a patient resulting in her being sent out for medical clearance; and Staff #21 was punched in the eye while administering medications with resultant “bloody red” eye by a patient. In an interview with Staff #3 on 4/1/26 at 2:45pm, she stated that the instances of patient-on-patient physical aggression trended upward during the first quarter of 2026: January - 56, February - 49, March - 83. Additionally, patient-to-staff instances of physical aggression also trended upward: January - 5, February - 5, March - 12. Review of an “Open Job Requisition Report” presented on 3/31/26 by Staff #41 (HR) showed twelve (12) openings. These included 6 PCAs, 3 unit RNs, 2 RN House Supervisors, and an Assistant DON. In an interview with Staff #7 on 3/30/26 at 10:50am, she reported being “short” 15 PCAs and 11 RNs. . 33326 Based on record review, observations, and interviews, the facility failed to provide the necessary care when the facility’s staffs did not prevent patients from eloping from the facility and the facility assigned units; 1.) On 3/21/26, Patient #A went through 5 secured doors in 3 minutes to elope from the facility; Patient A was an adolescent and was not located following the elopement. 2.) On 3/24/26, Patient #G went through 5 secured doors in 1 minute to elope from the facility. 3.) On 3/26/26, Patient #O went through 2 secured doors before being stopped and brought back to the unit. 4.) On 4/03/26, Patient #A4 went through a secured door separating the adult inpatient unit from the adolescent female’s unit; there were three adolescent females in the dayroom’s unit that needed to be removed for safety. 5.) On 4/06/26, Patient #Z3 went through 5 secured doors to elope from the facility; he attacked a female passerby out walking her dog. Patient #Z3 put the female in a headlock; the staffs had to physically remove the female from Patient #Z3 when he started to choke her. 6.) Six additional patients eloped from the facility units within the past 4 months. (Patients C3, VV, YY, LL, PP, MM) This failure places patients and the public at risk for harm or serious injury. Findings include: 1.) Review of Patient #A’s medical records reflected a voluntary admission on 3/18/26 at 11:33 am for suicidal ideation, he was going to run in front of a vehicle with thoughts of running away from his group home; he had made ‘many attempts to vacate his RTC’ (residential treatment center). Patient #A is a 17-year-old-adolescent male with a diagnosis of IDD, Autism, conduct disorder, Depression and Prenatal alcohol and drug exposure, learning disability PTSD, ADD/ADHD, and reactive attachment disorder. Review of Patient A’s Psychiatric exam, dated 3/19/26 at 10:00 am reflected: Judgment: Poor based on patient’s behavior/ HPI Insight: Poor based on patient’s understanding severity of illness/ HPI ... Suicide Risk in the Community: High Due to Mitigating Circumstances, Suicide Risk in the Hospital: Low Level of Observations: Q15 Precautions: Suicide. The patient was not identified as an elopement risk upon admission. Review of the facility provided video 3/19/26 at 5:00 pm first incident reflected, 2:45 minutes, Patient #A is seen walking over to the door and pushing the door open with his right shoulder. He opens the door and holds it open for a few seconds, then he comes back into the room. Two unnamed adolescents are seen jumping up and down and giving him high-fives for opening the doors. Review of the nurse’s notes dated 3/19/26 at 5:35 pm reflected, “Patient started getting agitated punching holes in walls and hitting doors trying to break through ...” The facility did not identify or initiate Elopement risk precautions following Patient #A opening the security doors. The facility did not complete an incident report or report the incident to the EOC director. The door’s integrity was not checked. Review of the facility provided video dated 3/21/2026 at 9:00 pm reflected, 00:45 sec, Patient #A opens the first door and exits the adolescent male unit. 00:51 sec, a Staff member is seen walking out the door to follow Patient #A, a second staff stands at the door. 01:08 sec, a second staff member is seen leaving the unit. 1:13 minutes, Patient #A hits the second door two times and is unable to open it. The female staff is seen talking to him. Patient #A then kicks the bottom of the door six times and opens the door. 1:18 sec Patient #A kicks the metal doors 4 times and exits. 1:21 sec. Patient #A opens the Intake doors, enters the lobby and pushes the front door open and exits. The two staff are seen walking to the exit door but not following him out. During an interview, on the morning of 3/26/26, Staff #11, EOC director confirmed the five door’s integrity was not checked according to the manufacture’s recommendations following the elopements. 2.) Review of Patient #G’s medical records reflected a 49-year-old-male admitted voluntarily on 3/25/26 on 10:45 pm for suicidal ideation without a plan. Nursing note dated 3/25/26 at 10:00 pm reflected, “pt got off the Unit, he hit the double door and ran out, code brown was called Pt was brought back to the unit ...” Nursing assessment on 3/25/26 at 10:00 pm, reflected, property destruction, “broke the unit door”. Level of observation q 15 minutes, level of observation: Precautions: Suicide Precautions and Aggression Precautions. Review of the nurse note dated 3/26/26 at 2:00 pm reflected, “This pt continued yelling and screaming demanding his belongings so he could leave. Pt started kicking the exit door. Pt kicked opened the exit door and moved staff that was guarding the door out of the way and started walking out of the unit. Pt again kicked open another exit door and started walking to intake. Staff was following pt, calling codes and trying to redirect pt. Pt was redirected back on the unit.” Review of the facility provided video of the Adult mixed unit dated 3/26/26 at 2:00 pm reflected, 00:22 sec, Patient #G pushes the door open with his shoulder, ten staff members follow him out the door, and a staff in the hall, joins them. 00:30 sec, as the staffs leave the unit, two male patients jump over the nurse’s counter and a female in a wheelchair, enters the nurse’s station through non-locking swinging half-doors, one staff comes back into the room, and another is blocking the patients from exiting the nurse’s station. 1:30 sec, Patient #G exits the facility. The facility did not provide incident reports for the patients climbing over the nurse’s station and the wheelchair bound patient entering the nurse’s station. 3.) Review of Patient O’s medical records revealed a 17-year-old-male, was admitted on 3/11/26 for suicidal ideation and aggression. Review of the treatment plan dated 3/12/26 at 09:23 am, reflected, “Hit a peer. Eloped from Hospital. LOS (line of sight) 1:1 at night.” Nurses note dated 3/13/26 at 11:50 pm reflected, “Patient tried to elope from the ambulance stretcher. Review of the facility provided video dated 3/14/2026 at 9:00 pm reflected, 00:10 sec, Patient O pushes the Adult mixed unit door open, entering the shared hallway, six staff are observed following him. He then, with two shoves, pushes the second door open. 00:46 sec, the hallway is empty at this point, an unknown male patient is seen kicking open the Adult mixed unit exit door, the door opens on the far end of the hallway and the patient then goes back into the unit. 01:02 sec, Patient O is escorted back to the unit by a male staff member. 4.) Review of Patient # A4’s medical records reflected an admission assessment record dated 4/1/26 at 12:20 pm reflected, admission of a 30-year-old male, “History per intake staff: Per staff: SI, Psychosis-AH; Hx schizophrenia. Patient stated he sees demons and “the one day the devil grabbed me and I was scratching the floor” Patient is restless and pacing in hallway. Responding to internal stimuli. Based on currently available information, there is evidence of: Severe mental/physical deterioration or incompetence. Review of Patient A4’s nursing notes in the medical record dated 4/3/26 at 6:00 pm reflected, “Patient became agitated and kicked the exit door leading towards the cedar’s unit; in attempt to elope. Staff immediately intervened. The patient was redirected to his room and education was provided. The patient verbalized understanding. Dr. was notified. An order was received to put the patient on elopement and aggression precautions. Currently, the patient denies pain and no other concerns. During assessment, no injuries were found by RN or reported by the patient. The patient denies suicidal and homicidal ideations. The patient denies visual and auditory hallucinations. Prior to the incident, the patient was given hydroxyzine at 1746 for anxiety. RN and staff will continue to monitor the patient. Observations of the facility provided video dated 4/3/26 at 6:00 pm revealed Patient #A4, an approximately 250 lb. male patient is seen running into the nursing station, he then ran into the juice machine counter twice, then he ran into the exit doors leading into the Cedars, adolescent female’s unit. A view from the Cedars unit of the camera revealed 3 female patients are present in the dayroom, the nursing staff are seen directing the female patients to another room for safety. Three male MHT are seen getting in front of the female patients and staff and immediately physically restraining the patient, then walking him back to the adult unit. Review of the Nursing notes reflected on 4/3/26 q 15 checks, and on 4/4/26, 4/5/26, 4/6/26, 4/7/26, 4/8/26 aggression and elopement risks were marked. Review of Patient #A4 MHT’s level of observation sheets reflected on 4/3/26, 4/4/26, and 4/5/26 sheets there were no restrictions for the am and pm shift. On 4/6/2/, 4/7/26, and 4/8/26 the MHT’s level of observation sheets reflect Aggression and Elopement precautions; three days after the patient had eloped from the unit. 5.) Review of Patient # Z3’s admission medical record dated 4/2/2026 at 7:00 am reflected, HISTORY OF PRESENT ILLNESS:16-year-old psychotic male presents with worsening symptoms of mania and psychosis. Observations of the facility provided video dated 4/6/26 at 10:00 pm revealed Patient #Z3 quickly went through 4 security doors. When he reaches the last exit door, the patient is unable to open the doors. He repeatedly tries to slam into the door with his shoulder; the door bends, showing daylight at the bottom half of the door each time he hits the door. Three large male staff are observed attempting to de-escalate the situation; they are talking to him and motioning him to come inside the lobby. The patient then grabs Staff #58’s shirt, Staff #58 attempts to restrain him, holding him for a few seconds. Patient #Z3 pulls away and brings Staff #8 with him, hitting the front exit door. The door opens and Patient #Z3 runs out the door; the staff are not able to get a hold of him. An unidentified male nurse is seen standing in a corner of the vestible, he has not made any attempts to take contol of the patient. During a telephone interview, on the afternoon of 4/13/26, when asked about the elopement of Patient #Z3, Staff #58, Mental Health Tech stated, “We tried to talk him into coming back to his unit. He grabbed Staff #37, I tried to intervene. When I grabbed him (Patient #Z3), we both fell toward the exit door. When we hit it (the door), it opened and the patient ran out. We (Staff #58 and Staff #8) followed him in my car. We didn’t follow too close because we didn’t want to make him run out into traffic. We had to make a U-turn to get back to him, that’s when he grabbed the lady and put her in a head lock. We had to physically remove the lady. When CIT (police crisis intervention team) arrived, the patient was handcuffed and taken back to the facility.” 6.) Review of the facility provided patient Elopement Incidents in the last 4 months reflected, - Patient C3, on 6/24/2025 at 9:17 am. “Patient was in courtyard. Patient pushed open gate in courtyard and eloped from the facility”. - Patient VV, on 11/29/25 trying to elope. - Patient YY, on 12/21/25, busted two security doors - Patient L, on 3/31/26, “Patient attempted to elope form [sic] the unit - Patient PP, 11/13/25 on the adult psych unit, “Patient kicked the door that separated meadow and Cedars and got in between the unit. - Patient MM, 1/13/26 on the adult psych unit, reflected, “Patient became aggressive, jumped out of the line and burst the exit door open and ran to the cafeteria.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38387 Based on surveyor observations, review of facility incident reports and patient record review, and confirmed in interview, the facility failed to promote patient’s rights when: The facility failed to uphold the privacy and safety of five of five patients (Patient S3, I, B, T3, U3) reviewed. Refer to A0142 The facility failed to ensure two of five patients received care in a safe setting (Patient #O3). Patient #O3 and #C had multiple days of aggressive behaviors and facility failed to ensure he/she did not injure themselves or others repeatedly. Refer to A0144”

“LICENSURE OF HOSPITAL CFR(s): 482.11(b) The hospital must be - o Licensed; or o Approved as meeting standards for licensing established by the agency of the State or locality responsible for licensing hospitals. This Standard is not met as evidenced by: 38387 Review of facility records and confirmed in interview, the facility failed to be licensed and approved for the number of beds used for one of ten days reviewed (02/03/2026) Findings included: Review of the facility records revealed the facility is licensed for 96 beds with an expiration date of 09/30/2026. Review of the midnight census on 02/03/2026 revealed 96 patients. Review of the 5 AM census on 02/04/2026 revealed a census of 98, two more than their licensure. Patient #B and Patient #C were admitted overnight. In an interview with Staff #3 on 02/26/2026 at 1:15 PM in the conference room confirmed the above findings.”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 38387 Based on review of facility policy, patient records, and confirmed in interviews, the facility failed to uphold the privacy and safety of five of five patients (Patient S3, I, B, T3, U3) reviewed. Facility failed to follow its overflow capacity policy to document all the requirements the facility took to provide the patient with an inpatient bed for their treatment. Findings included: Review of facility policy Wait List and Over Capacity Admission Policy for IP, PHP and IOP (PolicyStat ID 18132637, effective 06/2025), it stated, “When patients are assessed and the Psychiatric Medical Provider determines the patient requires inpatient admission to the Hospital and there is not an inpatient bed available, the Assessment Department will begin to locate alternative placement for the patient. However, if alternative arrangements cannot be secured for the patient, the patient shall be admitted to the hospital utilizing the Over-Capacity Emergency Admissions Checklist. This process is as follows: 1. Documentation reflecting capacity status of Hospital at time of decision. 2. Documentation reflecting efforts to accommodate patient with local option. 3. Documentation reflecting the On-Call Psychiatric Medical Provider recommends or agrees that the patient’s condition warrants admission despite the limited capacity at the Hospital. 4. Documentation that the Director of Nursing or designee is notified to discuss census and acuity to determine need for additional staffing. 5. Documentation that the patient will be accommodated in a manner that will ensure safety, privacy, access to bathroom facilities and all other essentials including a comfortable, safe bed option. 6. Documentation reflecting that the AOC or designee has spoken with the patient/and or family to explain the situation and obtains their understanding and approval. This should include: a. that the arrangement states that the patient will not occupy a patient room for the night, b. the details of the patient’s accommodation, c. assurance that all patient safety and privacy rights will be in compliance throughout the accommodation time, d. both patient and or guardian/family will have access to AOC/Patient Advocate for questions or concerns. 7. Documentation that the Hospital CEO or their designee has been notified and agrees to the alternative accommodation.” Random review of patient records from March 2026 who were offered the over capacity cot beds had no documentation of the above checklist available for review for five of five records (Patient S3, I, B, T3, U3) reviewed. Patient S3 Patient S3 is a 17 year old male who was transferred via ambulance to the facility for homicidal ideation and depression. He was assessed on 03/03/2026 and admitted. Review of the bed census for 03/03/2026 and 03/04/2026 revealed Patient S3 had an overflow cot in the boys adolescent unit day room. Patient I Patient I is a 32 year old female who presented to the facility on an EDO for suidical ideation on 03/10/2026 and admitted. Review of the bed census for 03/10/2026 revealed Patient I was in an overflow cot on 03/10/2026 Patient B Patient B is a 15 year old female who presented to the facility for suicidal ideation with a plan on 03/23/2026 and admitted. Review of the bed census for 03/23/2026 revealed Patient B was in an overflow cot. Patient T3 Patient T3 is a 13 year old female who presented to the facility via ambulance for self harm and suicidal ideation and admitted on 03/23/2026. Review of the bed census for 03/23/2026 revealed Patient T3 was in an overflow cot. Patient U3 Patient U3 is a 16 year old female who presented to the facility via ambulance for suicidal ideation and admitted on 03/19/2026. Review of the bed census for 03/19/2026 revealed Patient U3 was in an overflow cot. In an interview with Staff 4 on 03/31/2026 at 12:40 PM in the conference room confirmed the above findings. She stated that the required information would be a progress note but none were found for the above patients.”

“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: 38387 Review of facility incident reports, patient charts, facility policy, and confirmed in interview, the facility failed to ensure two of five patients received care in a safe setting (Patient #O3). Patient #O3 and #C had multiple days of aggressive behaviors and facility failed to ensure he/she did not injure themselves or others repeatedly. Findings included: Review of the facility policy Management of Assaultive-Combative Patients (PolicyStat ID 18034785, approved 04/2025), it stated “ In the event a patient escalates and becomes assaultive/combative, all safety measures shall be provided to the patient, other patients, and staff with the least restrictive interventions possible based on the level of acuity and patient needs..Make every attempt to decrease the stimulus and isolate the patient from other patients. A staff member should be responsible for removing the other patients from the immediate environment, and remaining with them to decrease their anxiety.. Review of the facility policy Seclusion and Restraint (PolicyStatID19845992, approved 02/2026) it stated “RN assesses the patient upon admission for seclusion/restraint risk and identifies factors that could minimize the use of seclusion/restraint. o Identifies triggers that place the patient at risk for seclusion/restraint o Identifies preventative strategies to assist the patient to control behavior o Identifies pre-existing conditions that would place the patient at greater risk, including: physical disabilities/limitations, medical conditions, and history of sexual/ physical abuse o Assesses the patient’s behavior on a regular basis to determine any imminent risk of the patient physically harming self, staff or others. Nursing Staff o When a patient is presenting behaviors that are such that they present an imminent danger to the patient or others, staff should utilize the following less restrictive, nonphysical interventions: o Separate the patient from the group or community. o Redirect the patient’s focus. Engage in 1:1 conversation or activity to allow the patient the opportunity to safely express feelings. o Employ verbal de-escalation. o Take the patient to his/her room with staff present. o Offer the patient the opportunity to use the quiet room to decrease stimuli and regain control. o Administer medication (licensed nurse) as ordered by the Physician to help the patient more effectively function in his/her environment. o Document the alternatives attempted or the rationale for not using alternatives.” Patient #O3 Review of the facility incident reports revealed the following incidents with Patient #O3 on 02/08/2026; 02/09/2026; 02/10/2026; 2/21/2026 Review of Patient #O3 chart revealed the following nursing notes that corresponded to these incident reports: 02/08/2026 “[Patient #O3] started disturbing his roommate, yelling banging his head against the wall and hitting his nose with his fist.” 02/09/2026 “[Patient #O3] became agitated after an argument with his roommate, scratched his roommate on the face and refused redirection after separation.” 02/10/2026 “[Patient #O3] continued on 1:1 due to behavioral issues. Patient was aggressive towards roommate; [Patient #A] is on 1:1 and also the aggressor. Incident was witnessed by the sitter, no injury sustained.” 02/13/2026 “[Patient #O3] attacked and hit another patient on this back without provocation; staff intervened and separated patients..staff will continue to monitor safety measures” 02/16/2026 “[Patient #O3] scratched his left arm for self harm and he was not redirectable or listen to staff members. He was moved to the seclusion room for a time out for few minutes. Per report, ’[Patient #O3] punched his nose ‘two times’ and he started bleeding.’ Code Blue was announced to the seclusion room and patient was met on the floor with copious blood was splashed on the floor, and walls of the seclusion room. Comfort measures were provided, blood was cleaned up, while patient was stable enough to be transferred to the unit. Upon assessment blood was noted on patient’s scalp, nose was swollen, while patient was in and out of sleep.” 02/17/2026 “[Patient #O3] Patient experienced an acute psychotic episode and was observed repeatedly striking his face, nose, and neck with his fists and forcefully hitting his head against the wall. The patient was unable to be redirected despite multiple attempts and continue engaging in self injurious behavior.” 02/21/2026 “[Patient #O3]’s peer- had been picking on [Patient #O3] throughout the day, acting aggressively and attempting to punch him. Staff redirected the peer multiple limes. During this shift, [Patient #O3] was visible in the milieu, interacting with peers and playing board games. He was compliant with scheduled activities and refused meds twice, staling he was not ready. While the RN was passing medications, the [Patient #O3] ran toward peer’s room. Staff on 1:1 observed Patient #O3 strike the peer with his fist. The patient was redirected to the milieu but remained agitated and swung at staff. Staff secured [Patient #O3] and removed him from the situation.” Patient #C Review of the facility incident reports revealed the following incidents with Patient #C on 03/19/2026; 03/21/2026; 03/22/2026; 03/23/2026 Review of Patient #C chart revealed the following nursing notes that corresponded to these incident reports: 03/23/2026: [Patient #C] started hitting her head on the wall unprovoked. A code called but the patient continues to hit her head on the wall. 03/22/2026: [Patient #C] and another peer [Patient #M] got into a verbal and physical altercation. A code was called and the [Patient #C] was taken to the quiet room. While in the quiet room, [Patient #C] was banging her head. 03/21/2026: [Patient #C] became physically aggressive with other patients [Patient #M, L3], then taken to the seclusion room. In the seclusion room, the patient started hitting her head several times and when staff intervened the patient became aggressive causing bleeding to her head. 03/19/2026: [Patient #C] attacked another patient [Patient #M] in the dayroom. Review of the above records revealed no documentation of preventative strategies to assist the patient to control behavior even after repeated injuries to themselves and/or others.”

“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: 35028 . Based on observation, interview, and record review, the facility failed to provide a safe environment during a behavior management intervention for 1 of 1 patients. This was evidenced by the facility’s failure to provide: a) Proper “Handle with Care” technique - staff were not trained on how to manage patients that spit on staff members during emergency interventions. b) A staff member to maintain a continuous one-on-one patient assignment - a staff member was assigned two concurrent duties: a monitor for a one-on one patient and a member of the emergency response team. c) A staff member’s self-removal from a volatile intervention in which he was the focus of the patient’s anger - a staff member became the focus of a patient’s rage and did not remove himself from the situation. d) A reliable Code 100 response team - two staff members that were assigned as part of the Code 100 response team did not respond to the code. Additionally, these failures contributed to an emergency intervention that did not follow Handle with Care procedures and an injury to Patient #1. Findings included: Review of Policy 19933489, “Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation,” last approved March 2026, showed: “Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation. It is the policy of the Facility to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff members ... Employees shall protect patients from abuse, neglect, and exploitation ... Violation of this policy by an employee shall be grounds for dismissal of the employee ... The chief executive officer or designee shall take immediate action to prevent or stop the abuse, neglect, or exploitation and provide appropriate care ... The provider shall ... enforce appropriate sanctions for confirmed violations; including but not limited to termination of personnel with confirmed violations of client or participant physical or sexual abuse or instances of neglect that result in client or participant harm.” Review of a photograph of Patient #1 - provided by Staff B (Quality Director) - showed a scratch on the right side of his neck. Staff B stated the scratch occurred during the Code 100 on March 6, 2026, in which Patient #1 was restrained by Staff E (PCA), Staff F (PCA), Staff G (PCA) and Staff H (RN). Review of the Staffing / Assignment Sheet dated March 6, 2026, 7am-7pm, showed that specific staff members from the Willows and Meadows Units had been assigned to respond to any Code 100 (a behavioral emergency) on any one of the five units throughout the hospital. Each of these staff members had a dual role. The assignments included: 1) Staff H was the Willows Unit Charge RN. He was also assigned as the Code 100 Lead Responder and Verbal De-escalator. 2) Staff E (PCA - Patient Care Assistant) was assigned to provide a one-on-one for Patient #2 on the Willows Unit. He was also assigned the role of Code 100 Safety Monitor and Patient Area Control. 3) Staff I was a PCA on the Meadows Unit, as well as the Code 100 Handle with Care Lead. 4) Staff J was a PCA on the Meadows Unit, as well as the Code 100 Recorder. In an interview with Staff C (CNO) on March 12, 2026, at 2:00pm, she provided information about the Code 100 involving Patient #1. She stated: 1) The adolescent boys on the Willows Unit were loud and engaged in excessive horseplay upon return to the unit from the cafeteria. To regain order to the milieu, the patients were asked to go to their rooms. Patient #1 did not want to comply with the request and began to escalate. 2) A Code 100 was called around 5:40pm. 3) Patient #1 became fixated on Staff E (PCA). He hit, kicked, and spit on Staff E (PCA). Staff E (PCA) placed himself in the role of verbal de-escalator. 4) Staff E (PCA) should have removed himself from the intervention once he became the focus of Patient #1. 5) Staff E (PCA) stated he could not remove himself from the intervention because more manpower was needed. He used excessive force with Patient #1 as was evidenced by video surveillance footage. Additional information provided by Staff C (CNO) included: 1) Staff I (PCA) and J (PCA), both assigned to the Meadows Unit, did not respond to the Code 100, adding that she did not know why they did not respond. 2) Staff E (PCA) should not have had two assignments, i.e., Safety Monitor and Patient Area Control AND the one-on-one for Patient #2, adding that an individual cannot leave a patient on a one-on-one unless there is another individual to take over the assignment. 3) The hospital could have used an additional PCA on March 6, 2026 - 7am-7pm. Review of policy 19287532, “Levels of Observation and Precautions,” last approved November 2025, showed: “Purpose - to ensure there is clear differentiation between patients’ needs when different levels of risk are present ... “1-to-1 Observation at all times: “This is the most restrictive level of observation for the patient. Staff must be within arms-length to the patient at all times.” The Video Surveillance Footage and interview with Staff B (Director of Quality) and Staff C (CNO). Staff B (Director of Quality) and Staff C (CNO) cued up and offered commentary on the video surveillance footage of the Code 100 that occurred on the Willows Unit on March 6, 2026. Staff B stated that the adolescent boys are first seen arriving back to the unit into the day area around 5:30pm following dinner. The footage shows the patients becoming rowdy and staff members attempting to redirect them. Staff E (PCA) was one of those staff members identified. The patients were directed to go to their rooms so that order could be re-established. A Code 100 was called when Patient #1 became focused on Staff E (PCA) and attacked him. There was video footage (timed 5:50pm) of four members of the code team escorting Patient #1 into the seclusion room. These staff members were identified as Staff E (PCA), Staff F (PCA), Staff G (PCA) and Staff H (RN). In the seclusion room, video footage shows Staff F (PCA) with her hand in front of Patient #1’s face. It is difficult to tell if her hand contacted the patient’s skin. Staff C (CNO) stated that Staff F (PCA) reported that she was blocking the patient’s spit. Video footage also shows Staff E (PCA) with his hand on the patient’s cheek and jaw pushing his head to the side. Staff C (CNO) stated that Staff E reported he was pushing the patient’s face to the side so that the patient could not spit on the code responders. Staff B (Director of Quality) stated Staff K, the Handle with Care instructor, had reviewed the video and stated that the handling of Patient #1 through the seclusion room door was “improper,” adding that “all staff need a refresher [of the Handle with Care procedures].” Review of the “Handle with Care Behavior Management System: Verbal Intervention Manual for Participants” 2023 shows, “Physical Intervention ... When is it appropriate and timely to use physical intervention? ... Most of the time, terminating the intervention or staging a tactical retreat will be the best decision because it allows you to use a team approach and buy time. Most will agree that this makes the most sense for many reasons: safety, witnesses, etc.” Review of the “Handle with Care Behavior Management System: Physical Participant Manual” 2023 shows the Four Person Team on page 43. That system was not followed by Staff E (PCA), Staff F (PCA), Staff G (PCA) and Staff H (RN) in the take down and transport of Patient #1 on March 6, 2026. In an interview with Staff C (CNO) on March 12, 2026 at 2:00pm, she stated Staff E (PCA), Staff F (PCA), Staff G (PCA) and Staff H (RN) had been suspended pending the investigation. Documentation of the administrative interview with Staff E (PCA) dated March 11, 2026, at 8:19am. Staff E stated that Patient #1 was agitated at the beginning of dinner and remained agitated while returning to the unit. When the patients were given instructions to go to their rooms, Patient #1 refused. He told Staff E (PCA), “You don’t tell me what to do ... I run this unit ... I’ll punch y’all if y’all get close to me.” Patient #1 then balled his fists and continued threatening staff. The patient’s kicking of a door “prompted staff to initiate seclusion after verbal de-escalation effort were unsuccessful.” Staff E also stated that Patient #1 spat on him and attempted to “punch” him. Staff E reviewed the video footage and stated that he did not choke the patient or apply pressure to the patient’s neck, explaining that he placed his hand under the patient’s jaw to press the patient’s mouth closed to prevent further spitting or biting. Staff E addressed a portion of the footage in which it appeared he placed the patient in a rear choke hold. He denied placing his arm under the patient’s neck, adding that he placed his arm behind the patient’s neck to gain control of the patient’s head. Staff E concluded the interview by stated that he was unable to remove himself from the situation despite the appearance that Patient #1 was fixated on him “due to a lack of additional assistance arriving at the time [the patient was] medicated.” Documentation of the administrative interview with Staff F (PCA) dated March 11, 2026, at 9:39am. Staff F stated that Patient #1 was fixated on Staff E (PCA), directing “the majority of his anger toward him.” The patient repeatedly yelled, “I will kill you.” When asked about placing her hand over the patient’s mouth, she stated that her intention was to prevent exposure to the patient’s spit and to prevent the patient from biting staff. She also stated she was not aware of any Handle with are training techniques that specifically addressed protection from a patient’s spit. She concluded by saying that she never obstructed the patient’s airway. Documentation of the administrative interview with Staff G (PCA) dated March 10, 2026 at 8:48am. Staff G stated that Patient #1 used racial slurs toward staff members. Adding that during the escort to the seclusion room, the patient began spitting, biting, kicking, and punching staff members. He stated that Patient #1 was fixated on Staff E (PCA). Documentation of the administrative interview with Staff H (RN) dated March 10, 2026, at 9:31am. Staff H stated that Patient #1 became “increasingly vulgar and aggressive and kicked the door.” He targeted Staff E (PCA). Staff H (RN) advised that he and three other staff members escort Patient #1 to the seclusion room because his behavior continued to escalate. He also stated that during the escort, the patient became “extremely combative and began spitting, kicking, and punching staff members, particularly targeting Staff E (PCA).” Staff H restrained the patient’s hands. He concluded by stating that a code was called during the incident; however, “additional assistance did not arrive at the time the code was called,” adding, “staff were doing their best to manage and control the situation.” Documentation of a comment by Staff L (HR) during the administrative interview with Staff G (PCA) dated March 10, 2026, at 8:48am. Staff L (HR) wrote, “While it is understood that incidents of this nature can be chaotic and rapidly evolving it was communicated that proper Handle with Care techniques and facility policies and procedures must be followed at all times. Based on the review conducted, certain restraint and intervention techniques observed were not fully aligned with established policy and Handle with Care guidelines.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 35028 . Based on observation, staff interviews, and record review, the facility failed to meet the Condition of Participation requirements for Patient Rights as evidenced by failure to ensure patients were provided a safe environment. More specifically, the facility failed to ensure: A) The door to the training room had functioning self-closing hardware that closed the door properly. This failure had the potential to expose 8 of 12 patients on suicide precautions to numerous ligature risks (Patient #15, 16, 17, 18, 19, 20, 21, and Patient #22). These risks included power and computer cords that could be used to commit suicide by hanging, one of the most common suicide methods with a high mortality rate. Additionally, there was a box of rubber gloves that could be used for suffocation or strangulation. The training room had a desk and four tables in it, allowing access to numerous anchor-points in the space above the drop ceiling - anchor-points such as electrical wiring and plumbing. The 8 adult patients were from the Maples Unit, an acute psychiatric unit. The training room was on the hallway used by these patients three times a day to access the cafeteria. See A144 - Patient Rights: Care in a Safe Setting. B) Observation rounds and “lifeguard rounds” were conducted every 15 minutes. Failure to perform the lifeguard safety rounds had the potential to expose 9 of 9 patients (Patient #1, 2, 3, 9, 10, 23, 24, 25, and Patient #26) to safety risks of suicide and other sentinel events when the lifeguard (Staff G) abruptly left his post, exiting the unit for over 10 minutes. Additionally, the Charge Nurse (Staff C) failed to perform the 15-minute observation rounds when the PCA (Staff B) abruptly left his post, exiting the unit for 40 minutes. All 9 patients were on a precaution or a combination of precautions, including unit restriction, suicide, assault, elopement, and sexual acting out precautions. As a result of this negligence, two of the adolescent patients, ages 15 (Patient #1) and 17 (Patient #2), engaged in sexual activity with allegations of “rape” with anal penetration being made by the 15-year-old male patient (Patient #1). See A144 - Patient Rights: Care in a Safe Setting. C) Precautions were maintained by Staff H, assigned to perform 1:1 observation (within arm’s length) on Patient #26, a patient with a history of sexual acting out and suicidal ideation. Failure to continue the 1:1 resulted in Patient #26, being left unattended when the PCA (Patient Care Assistant) abruptly left his 1:1 post and exited the unit for over 40 minutes, leaving this patient in his room alone. See A144 - Patient Rights: Care in a Safe Setting. .”

“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: 35028 . Based on observation, staff interviews, and record review, the facility failed to ensure 17 of 21 patients received care in a safe setting (Patient #1, 2, 3, 9, 10, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, and Patient #26). This was evidenced by the facility’s failure to ensure that: 1) The self-closing door to the training room functioned properly. This failure had the potential to expose 8 of 12 adult psychiatric patients on suicide precautions to ligature risks and anchor-points for hanging, as well as items that could be used for suffocation or strangulation (Patient #15, 16, 17, 18, 19, 20, 21, and Patient #22). 2) Staff B (PCA) fulfilled his assignment to conduct 15-minute observation rounds on 8 of 9 patients for 40 minutes (Patient #1, 2, 3, 9, 10, 23, 24, and Patient #25). Additionally, Staff C (RN) did not assume the responsibility to conduct the 15-minute observation rounds. As a result of this failure, two adolescent patients (Patient #1 and Patient #2) engaged in sexual activity, with Patient #1 alleging rape and anal penetration by Patient #2. 3) 3) Staff H (PCA) provided continuous 1:1 observation for 1 of 1 patients (Patient #26), a patient on suicidal and sexual acting out precautions. 4) 4) Lifeguard duties were performed on an adjacent unit. This failure resulted in Staff G (RN Supervisor), assigned to function in the dual roles of House Supervisor and unit lifeguard, leaving his post as the lifeguard to function as the House Supervisor during the emergency code, leaving Staff C (RN) on the unit alone. 5) A medical consult ordered by Staff J (ANP) on 4/25/25 for Patient #2 for possible exposure to a sexually transmitted disease was conducted. This failure resulted in Patient #2 being discharged without medical follow-up, following an alleged sexual assault in which Patient #2 could have been exposed to blood of Patient #1. Findings were: 1) The self-closing door to the training room. Review of policy 17833451, Patient Bill of Rights, last approved 4/2025, showed: “Basic Rights for All Patients ... You have the right to a ... humane environment in which you are protected from harm.” Observation on 6/18/2025 at 9:15am showed a hallway with doors into rooms on both sides. These rooms included offices, a patient bathroom, and a training room. On 6/18 and 6/19 patients were observed in the hallway before and after lunchtime. On the morning of 6/20, the surveyor was moved from an office on this hallway to the adjacent training room. It was observed around noon that the self-closing hardware on the training room door malfunctioned - the lock latch did not fall into the strike plate after the door was manually opened and released. The handle was not needed to open the door; the door simply needed to be pushed open. Inside the room was a desk and four tables that could be used to access the crawl space above the drop ceiling. There was a wall-mounted television and a monitor/television atop the desk with several power cords. There were a dozen light weight chairs positioned at the tables. On the desk was an open container of plastic forks, a box of rubber gloves, and a container a hand sanitizer. At the back of the room in the right corner were party supplies including a container of helium. The room was lit by florescent bulbs that, if broken, could be used for self-harm. In an interview with Staff P (Quality Director) and Staff F (Environment of Care - EOC - Director) on 6/20/2025 at 12:55pm, they stated that the door should have closed on its own and locked and that failure to function properly created a safety risk. Staff P (Quality Director) stated that patients from the Maples Unit, an acute adult unit, used the hallway to and from the cafeteria. Review of the Maple Assignment Sheet showed that 8 of 12 patients were on Suicide Precautions (Patient #15, 16, 17, 18, 19, 20, 21, and Patient #22). Additionally, 3 of 12 patients were on Assault Precautions (Patient #19, 21, and Patient #27). 2) The failure to conduct 15-minute observation rounds. Review of policy 17833451, Patient Bill of Rights, last approved 4/2025, showed: “Basic Rights for All Patients ... You have the right to a ... humane environment in which you are protected from harm.” Review of policy 17787642, “Rounds for Patient Observation,” last approved 4/2025, showed: “Purpose. To ensure there is an accurate record of the whereabouts of all patients in inpatient. The record will be maintained during each shift ... Procedures ... C ... When the assigned person is off the unit for breaks, the assignment of the close observations must be given to another staff memver and this must be reflected on the assignment sheet ... E. Staff members must complete the Close Observation Sheet at least every 15 minutes by making visual contact with the patient ... G. During the nighttime ... the observation of the patient is required.” Review of policy 18040290, “Levels of Observation and Precautions,” last approved 4/2025, showed: “Purpose. To ensure there is clear differentiation between patients’ needs when different levels of risk are present. The levels of observation and precautions are identified based on the risk assessment as well as by patient behavior ... Procedures. 1. Every 15-minute observation: ... Staff members must complete the Close Observations Sheet by noting the patient behaviors and location codes, along with the initials of the staff member who is conducting the observation. Review of policy 15562536, Suicide Prevention Program Guidelines, last approved 4/2024, showed: “Purpose ... To ensure a safe patient care environment ... Policy. The Facility implements a suicide prevention program to ensure the safety of patients who are at risk for suicide ... The program includes strategies ... to ensure ... a safe environment.” During a tour of the Willows Unit with Staff A on 6/18/2025 at 11:15am, the following observations were made: The Nurse’s Station and a commons area were at one end of a hallway. At the opposite end of the hallway were double doors that exit the unit. Above the doors was a convex mirror. Other convex mirrors were positioned along the hallway. There were three alcoves evenly spaced on one side of the hallway. Each alcove was about two feet deep with two adjacent doors, each providing entrance into a patient bedroom. Each bedroom accommodated two patients, giving the unit a capacity of 12 patients. The last two bedrooms, those furthest from the Nurse’s Station were rooms 501 and 502. Staff A positioned herself in front of the Nurse’s Station. The surveyor positioned himself in room 502. He moved from room 502 to 501. Staff A stated she could not see the surveyor’s movement in the convex mirror. She also stated that the alcoves had been identified as blind spots, adding that the PCA providing observation rounds at night would need to be positioned further down the hallway to observe the alcoves. Review of the Willows Adolescent Male Unit Assignment Sheet for 4/23/2025, 7P-7A showed the following room assignments: 501A - Patient #1 501B - No patient 502A - Patient #2 502B - Patient #3 Review of the Screening Assessment by Staff Q (RN), dated 4/21/2025 at 8:17pm-8:43pm, showed Patient #1 disclosed a history of physical and sexual abuse at the age of seven “by a foster parent.” He also stated he was in CPS (Childs Protective Services) custody because of “abandonment.” He scored 10 out of 10 for depression and anxiety, making him a high risk for self-harm. Review of Inpatient Admission Orders by Staff S (MD), dated 4/21/2025 at 9:49pm, showed Patient #1 was admitted into the Adolescent Program. He was placed on Suicide Precautions and observation every 15 minutes. Review of Patient #1’s lab report showed RPR (rapid plasma regain - test for syphilis) was collected on 4/22/2025 at 7:49am. It was nonreactive. Review of the Inpatient Comprehensive Psychiatric Evaluation by Staff K (MD), dated 4/22/2025 at 7:58am, showed Patient #1 was a 15-year-old male, living in a group home. He reported prior suicide attempts, 12 previous admissions into multiple behavioral health hospitals, anger, and depression. Diagnoses: Unspecified mood disorder, Bipolar depression. Review of the Psychosocial Assessment by Staff R (LMSW), dated 4/22/2025 at 1:24pm, showed Patient #1 was no longer in his mother’s custody “due to both physical and sexual abuse.” Review of Interdisciplinary Progress Note for Patient #1 by Staff C (RN), dated 4/23/2025 at 9:45pm-10:50pm, showed: “Staff was doing rounds and alerted nurse and supervisor that patient was in another patient’s room.” [NOTE: Staff A (Quality Coordinator) clarified that the incident happened in Patient #1’s room. Patient #2 left his room and entered Patient #1’s room.] Staff reports that as he [Staff B] was opening the door, he saw the patient [#1] in bed who stated, ‘He [#2] tried to rape me,’ while peer [#2] was pulling his shorts up and running to the bathroom. RN, supervisor, and other staff went to the room and peer [Patient #2] was found standing in the patient’s restroom and when staff took off the patient’s beddings, he [#1] was completely undressed from the waist down. When peer [Patient #2] was asked what he did to the patient, he reported, ‘He [Patient #1] wanted it.’ Patient [#1] denied and stated that peer woke him up from his sleep and further reported that penetration had happened ... Patient [#1] assessed and denied pain.” Patient #1 was interviewed by a detective. Patient #1 was transferred to another unit. Review of the Staffing Sheet on 4/23/25, 7PM-7AM, showed: On the Willows Adolescent Males unit, the PCA assigned to do observation rounds was Staff B. Review of Willows Adolescent Male Unit Assignment Sheet, dated 4/23/2025, showed Staff B (PCA) was assigned to conduct the observation rounds on 8 of 9 patients (Patient #1, 2, 3, 9, 10, 23, 24, and Patient #25). All 8 patients were on a precaution or a combination of precautions, including unit restriction, suicide, assault, elopement, and sexual acting out precautions. Video Surveillance. Review of video surveillance for 4/23/2025 showed the last observation round made prior to the incident between Patients #1 and #2 was conducted by Staff B (PCA) at 10:03pm. Within a minute, Staff B (PCA) abruptly left the unit, leaving only Staff C (Charge RN) on the unit. Rounds were not conducted at 10:15pm or 10:30pm by Staff C (Charge RN). At 10:44pm, Staff B (PCA) returned to the unit, picked up the 15-minute observation rounds sheets, and resumed conducting rounds. Review of physician orders by Staff U (APRN), dated 4/24/25 at 3:30am, showed Sexually Acting Out Precaution. Review of 7PM-7AM Shift Nursing Assessment by Staff C (RN), dated 4/24/25 at 7:00am, showed, “Patient [#1] was found in an inappropriate sexual contact with peer. Patient reported contact was non-consensual ... Patient moved to Cedars unit for safety.” Review of Inpatient Progress Note by Staff U (APRN - Advanced Practice Registered Nurse), dated 4/25/25 at 7:40am, showed Patient #1 was evaluated at Memorial Hermann after an alleged sexual assault by another peer on the unit. He stated, “The last time it happened I did not consent to it.” Review of a consultation by Staff J (NP - Nurse Practitioner), dated 4/25/2025 and signed 4/26/2025 at 3:30pm, showed Patient #1 stated he had blood on toilet paper after defecation. Staff J also documented that the patient had been to an emergency room for a SANE assessment (Sexual Assault Nurse Examiner exam). Patient #1 claimed sexual assault with anal penetration by his roommate. Blood tests were completed, and he was prescribed prophylactic antiviral medication. Diagnosis: Rectal injury, status post sexual assault. Review of Inpatient Progress Note by Staff T (APRN), dated 4/26/2025 at 9:48am, showed Patient #1 complained of “rectal bleeding and diarrhea.” He stated, “I need to see the medical doctor ... It’s just blood all over.” He was “irritable and anxious” with poor impulse control. Nursing reported him was “very hyperverbal, loud, and intrusive,” needing redirection. Plan: Medical consult for the rectal bleeding and diarrhea. Review of Interdisciplinary Progress Note by Staff V (RN), dated 4/26/2025 at 4:15pm and 5:00pm, showed, Patient #1 “very irritable, intrusive ... reported diarrhea ... [and] blood ... tissue with spotted blood ... Patient had to be redirected as he kept talking about the sexual assault and the boys was [sic] using it to trigger him.” Review of a consultation by Staff J (NP), dated 4/27/2025 at 6:39pm, showed Patient #1 reported diarrhea and blood in his stools. Outer examination showed no perianal skin tear. Review of Discharge Medication Summary for Patient #1, dated 4/29/2025 (not timed), showed: bictegravir-emtricitabine-tenofovir 50mg-200mg-25mg tablet (Biktarvy) for post exposure HIV prophylaxis, 1 table every day. Review of Discharge Summary for Patient #1 by Staff K (MD), dated 4/29/2025 at 10:42am, showed: Patient admitted for “mood stabilization and safety monitoring ... He had poor boundaries.” Patient #1 and Patient #3 were “caught in the midst of sexual acts, alleged that incident was not consensual. Hospital admin and law enforcement were involved. He was transferred to the emergency room for an evaluation. Upon return to the unit, he was placed in a blocked room on another adolescent unit. He was reluctant to process the event.” Discharge diagnosis: Bipolar disorder, depressed. In an interview with Staff E (CNO) on 6/20/2025 at 12:25pm, she stated Staff C (RN) should have conducted the observation rounds while Staff B (PCA) was off the unit. She also stated that when she asked Staff C (RN) why she did not conduct the observation, the RN stated that she was “upset” talking with Staff G (RN Supervisor and Lifeguard) and “did not realize that Staff B (PCA) was not on the unit.” Staff E (CNO) concluded the interview by saying that Staff C (RN) was negligent by not conducting the observation rounds and that this negligence created an unsafe environment. In an interview with Staff G (RN Supervisor and Lifeguard) on 6/19/2025 at 10:20am, he stated Staff C (RN) was supposed to assume the observation rounds when Staff B (PCA) left the unit, adding, “The RN stayed to cover the unit. There was no other staff on the unit with her.” He did not offer an explanation as to why he as the RN Supervisor did not prompt the RN to assume the observation rounds or assist her with the rounds. In an interview with Staff I (Nurse Educator) on 20/2025 at 11:43am, she stated that the staff member assigned to conduct observation rounds is supposed to pass those duties to another staff member when a break in duties is required or needed. 3) The failure to provide continuous 1:1 observation. Review of policy 17787642, “Rounds for Patient Observation,” last approved 4/2025, showed: “Staff must make visual contact with the patient at least every 15 minutes ... 1-to-1 Observation at all times. This is the most restrictive level of observation ... Staff must be within arms-length to the patient at all times.” Review of policy 18040290, “Levels of Observation and Precautions,” last approved 4/2025, showed: “Level of Observation ... During shift change or whenever staff needs to be relieved of 1:1 duty, the patient is ‘handed off’ in [the] presence of both staff. At no time will a patient on 1:1 be without staff ... Any patient on 1:1 must have a staff member within an arm’s reach at all times.” Review of the Staffing Sheet for the Willows Adolescent Male unit showed that on 4/23/25, 7PM-7AM, Staff H (PCA) was assigned to provide the 1:1 with Patient #26. Review of the Willows Adolescent Male Unit Assignment Sheet for 4/23/25 7PM-7AM, showed that Patient #26 was in room 505. He was on a 1:1 for suicide precautions and sexually acting out precautions. Staff H (PCA) was assigned to provide 1:1. Review of video surveillance for 4/23/2025 showed Staff H (PCA), assigned to the 1:1 with Patient #26, abruptly left the unit, leaving only Staff C (Charge RN) on the unit. During the 40 minutes Staff H was off the unit, Staff C never went into room 505 to check on Patient #26. Staff H (PCA) returned to his 1:1 post with Patient #26. In an interview with Staff E (CNO) on 6/20/2025 at 12:25pm, she stated Staff H (PCA) should not have left his 1:1 assignment with Patient #26. 4) The failure to ensure that Lifeguard duties were performed. Review of policy 17919210, “Adolescent Unit - Unit Management: PCA Lifeguard and Unit Separation,” originated and last approved 4/2025, showed: “Definitions ... Patient Care Assistant (PCA) Lifeguard: A staff member that has been oriented to monitor for high-risk behaviors and continuous rounding in the adolescent units. This position functions outside of the prescribed staffing ratios and this function is the sole job of the Lifeguard ... Procedures ... 2. Lifeguard Assignment by the Registered Nurse ... a. ... assign the role of Lifeguard to a trained staff member before the shift begins ... f. Maintain accountability for: 1. Not permitting distractions that pull the Lifeguard away from Lifeguard duties. 2. Not engaging the Lifeguard in requests, needs, or emergency situations related to other units unless relieved by another appropriately trained staff member to cover Lifeguard duties on the behavioral health adolescent unit. 3. Coordinating warm handoffs of Lifeguard coverage for all breaks, meals, emergencies, and shift change activities. Lifeguard Duties ... c. Never abandon your Lifeguard assignment; only step away following a warm handoff to another designated Lifeguard. d. Continuously round throughout the unit ... e. During night shifts, verify the patients are in the correct rooms and assigned beds ... g. Document unit rounding activities on the PCA Lifeguard Rounding Form.” On 6/20/25 at 12:25pm, Staff E (CNO) stated training was done on the PCA Lifeguard policy when the policy was rolled out. The dates and times of that training were not provided. The training included: “ Lifeguards do not join in the code response unless there is coverage from another hospital staff member. “ At night, randomly doing room checks, door checks, observing for any unusual activity. “ The nurse on the unit cannot take over as a Lifeguard unless there is RN coverage in the unit. “ Lifeguards also observing to make sure other levels of observation are being met, e.g., 1:1 staff not walking out [sic] the unit. Review of the Willows Adolescent Males Unit Staffing Sheet on 4/23/25, 7PM-7AM, showed: House Supervisor: Staff G. The Lifeguard position was not assigned. On the Cedars Overflow unit (an adjacent unit), there was 1 RN and 1 PCA. The Safety Guard [Lifeguard] was “OPEN.” Review of Willows Adolescent Male Unit Assignment Sheet, dated 4/23/2025, showed: Safeguard/Lifeguard: Staff G (RN Supervisor) The Supervisor position is blank. Review of video surveillance of the Willows Unit on the night of 4/23/2025 showed the last observation round was made by Staff B (PCA) at 10:03pm. Within a minute, Staff G (RN), Lifeguard for the Willows Unit, abruptly left the unit, leaving only Staff C (Charge RN) on the unit. Staff G returned to the unit around 10:13pm, positioning himself behind the nurse’s station. Staff C (Charge RN) stood outside of the nurse’s station. Though there was no audio, Staff G and Staff C were observed talking. Neither one of them assumed the duty of making the 15-minute observation rounds or checking in on Patient #26, who was on a 1:1, for 40 minutes. In an interview with Staff E (CNO) on 6/20/2025 at 12:25pm, she stated: “ There was “no Lifeguard assigned to the Cedars Unit,” an adolescent unit, on the night of 6/23/2025. “ The RN Supervisor should not have been assigned as the Lifeguard. “ When Staff G (RN Lifeguard) was asked why he did not do the Lifeguard duties, he stated that he was “debriefing” with Staff C (RN) about the code. Staff E (CNO) challenged this response by telling him that the debriefing should be with the RN in charge of the unit where the code occurred. “ Staff G (RN Lifeguard) should have prompted Staff C (RN) to conduct observation rounds and have Staff H (PCA) return to his position as the 1:1 for Patient #26. By not doing these actions, he did not provide adequate supervision, thus creating an unsafe environment. In an interview with Staff I (Nurse Educator) on 20/2025 at 11:43am, she stated Staff G (RN), as the Lifeguard, should not have left the unit for the emergency code, but as the House Supervisor was “expected to be at the code,” adding, “The same person cannot do both [jobs]. When we first rolled out the Lifeguard program, we had one lifeguard that floated to both units.” In an interview with Staff G (RN Supervisor) on 6/19/2025 at 10:20am, he stated he left his post as Lifeguard to go to the emergency code, leaving the RN on the unit alone. He also said that Staff B (PCA), who was conducting the observation rounds, was off the unit about 10 minutes. (As noted above, review of the video showed Staff B (PCA) was off the unit 40 minutes.) 5) The failure to ensure that a medical consult was conducted. Review of policy 17781401, “Medical Staff Rules and Regulations,” last approved 3/2025, showed: “Preface. The Medical Staff Rules and Regulations are adopted for the purpose of implementing, more specifically, the general principles found within the Medical Staff Bylaws of the Hospital ... 20 ... C. Consultations shall show evidence of a review of the patients’ record by the consultant, pertinent findings on examination of the patient, and the consultant’s opinion and recommendations. This report shall be made part of the patient’s medical record ... G. Consultations should be completed within 48 hours.” The Sexual Incident. Review of Interdisciplinary Progress Note for Patient #2 by Staff C (RN), dated 4/23/2025 at 10:50pm, showed: “2245-2250: Staff was doing rounds and alerted nurse and supervisor that patent (#2) was in another patient’s room (Patient #1). Staff reports that as he (Staff B) was opening the door, he saw the patient (#2) pulling his shorts up and running to the bathroom and the other patient (#1) stated, “he tried to rape me.” RN, supervisor, and other staff went to the room and patient (#2) was found standing in other patient’s restroom and when staff took off the peer’s beddings, he (#1) was completely undressed from the waist down. When patient (#2) was asked what he did to the other patient, he reported, “He (#1) asked for it. He wanted it.” Peer (#1) denied and stated that patient (#2) woke him up from his sleep.” Medical Record for Patient #1. Review of 7PM-7AM Shift Nursing Assessment by Staff C (RN), dated 4/24/25 at 7:00am, showed, “Patient [#1] was found in an inappropriate sexual contact with peer. Patient reported contact was non-consensual. Review of a consultation for Patient #1 by Staff J (NP - Nurse Practitioner), dated 4/25/2025 and signed 4/26/2025 at 3:30pm, showed Patient #1 stated he had blood on toilet paper after defecation. Staff J also documented that the patient had been to an emergency room for a SANE assessment (Sexual Assault Nurse Examiner exam). Patient #1 claimed sexual assault with anal penetration by his roommate (Patient #2). Blood tests were completed, and he (Patient #1) was prescribed prophylactic antiviral medication. Diagnosis: Rectal injury, status post sexual assault. Review of Discharge Medication Summary for Patient #1, dated 4/29/2025 (not timed), showed: bictegravir-emtricitabine-tenofovir 50mg-200mg-25mg tablet (Biktarvy) for post exposure HIV prophylaxis, 1 table every day. Medical Record for Patient #2 and Interviews. Review of an Inpatient Progress Note by Staff U (APRN), dated 4/25/2025 at 6:53am, showed: Patient #2 stated, “I had intercourse with another peer.” Review of Ancillary Orders by Staff J (NP), dated 4/25/2025 at 1:45pm showed a medical consult was ordered for Patient #2 for “possible exposure to STDs (sexually transmitted diseases).” In an interview with Staff M (HIM Director) on 6/19/2025 at 1:50pm, she stated that there was no consult for possible exposure to sexually transmitted diseases in Patient #2’s chart. In an interview with Staff J (NP) on 6/19/2025 at 2:26pm, he was given the opportunity to review the order he wrote on 4/25/2025 at 1:45pm for a medical consult for Patient #2 for possible exposure to sexually transmitted diseases. He stated he did not remember who did the medical consult. He was not sure if the consult was done by the medical team. He concluded by saying he would have expected to see a blood test ordered. In an interview with Staff K (psychiatrist) on 6/19/2025 at 1:52pm, she stated she was “not brought into” the medical consult that was ordered for Patient #2, adding, “I feel the medical team would have done this.” .”

“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: 35028 . Based on interviews, observation, and record review, the facility failed to ensure: a) Staff E (CNO) scheduled adequate staff coverage on the night of 4/23/2025. b) Staff G (House Supervisor) aided Staff C (Charge RN) on the Willows Unit on the night of 4/23/2025 when all other staff members abruptly left the unit to attend an emergency code on an adjacent unit. c) Staff C (Charge RN) provided prudent supervision of Staff B and H (both PCAs). As a result of this failure: a) Staff E (CNO) placed Staff G (House Supervisor) in a dual role as House Supervisor and Lifeguard on the Willows Unit from 7PM to 7AM. b) Staff G (House Supervisor) did not aid Staff C (Charge Nurse) in the observation rounds on 8 of 9 patients (Patient #1, 2, 3, 9, 10, 23, 24, and Patient #25). Staff G also allowed Staff H (PCA) to abandon his 1:1 assignment with Patient #26. c) Staff C (Charge RN) neither continued the observation rounds on 8 of 9 patients (Patient #1, 2, 3, 9, 10, 23, 24, and Patient #25) nor prevented Staff H (PCA) from abandoning his 1:1 assignment with Patient #26. These failures created an unsafe environment in which Patient #2 went to Patient #1’s bedroom where they allegedly engaged in sexual activity. They were found in bed together. Patient #1 alleged rape and anal penetration by Patient #2. Findings were: Review of policy 17833451, Patient Bill of Rights, last approved 4/2025, showed: “Basic Rights for All Patients ... You have the right to a ... humane environment in which you are protected from harm.” Review of policy 17787642, “Rounds for Patient Observation,” last approved 4/2025, showed: “Purpose. To ensure there is an accurate record of the whereabouts of all patients in inpatient. The record will be maintained during each shift ... Procedures ... C ... When the assigned person is off the unit for breaks, the assignment of the close observations must be given to another staff memver and this must be reflected on the assignment sheet ... E. Staff members must complete the Close Observation Sheet at least every 15 minutes by making visual contact with the patient ... G. During the nighttime ... the observation of the patient is required.” Review of policy 18040290, “Levels of Observation and Precautions,” last approved 4/2025, showed: “Purpose. To ensure there is clear differentiation between patients’ needs when different levels of risk are present. The levels of observation and precautions are identified based on the risk assessment as well as by patient behavior ... Procedures. 1. Every 15-minute observation: ... Staff members must complete the Close Observations Sheet by noting the patient behaviors and location codes, along with the initials of the staff member who is conducting the observation. Review of Willows Adolescent Male Unit Assignment Sheet, dated 4/23/2025, 7PM-7AM, showed: a) Staff B (PCA) was assigned to conduct the observation rounds on 8 of 9 patients (Patient #1, 2, 3, 9, 10, 23, 24, and Patient #25). All 8 patients were on a precaution or a combination of precautions, including unit restriction, suicide, assault, elopement, and sexual acting out precautions. b) Staff H (PCA) was assigned to provide 1:1 on Patient #26 in room 505. The patient was on suicide and sexually acting out precautions. c) Staff G, the House Supervisor, was also assigned to be the Lifeguard. Review of video surveillance of the Willows Unit on the night of 4/23/2025 showed the last observation round made prior to the incident between Patients #1 and #2 was conducted by Staff B (PCA) at 10:03pm. Within a minute of making these rounds, Staff B (PCA), Staff H (PCA), and Staff G (House Supervisor acting as Lifeguard) abruptly left the unit, leaving only Staff C (Charge RN) on the unit. At 10:44pm, Staff B (PCA) returned to the unit, picked up the 15-minute observation rounds sheets, and resumed conducting rounds. Staff H (PCA) returned to his 1:1 post with Patient #26. During the 40 minutes Staff H was off the unit, Staff C never went into room 505 to check on Patient #26. Rounds were not conducted at 10:15pm or 10:30pm by Staff C (Charge RN) or Staff G (House Supervisor). In an interview with Staff E (CNO) on 6/20/2025 at 12:25pm, she stated she did not have staff for the second lifeguard on the Cedars Unit, an adolescent unit adjacent to the Willows Unit. She also stated that Staff C (RN) should have done the observation rounds when the PCA assigned to rounds left the unit to attend an emergency code on an adjacent unit. She further stated that Staff H (PCA), the PCA providing the 1:1 with Patient #26, should not have left the unit. She stated Staff G should not have been assigned both lifeguard and house supervisor at the same time, adding that Staff G, as the supervisor, did not fulfill his supervisory role by assisting Staff C (RN) in assuring the safety of the adolescent patients. Review of the Employee Written Warning, signed 11/25/24 (not timed) by Staff G showed Staff G (House Supervisor) “let PCA go home - left unit vulnerable and 12 patients unattended.” Review of Employee Written Warning signed 4/28/2025 (not timed) by Staff G showed: Staff G (House Supervisor) was “observed having a conversation with RN behind the nurse’s station for over 30 minutes. As a result, rounds were missed and ... an SAO (sexually acting out) incident occurred.” Review of House Supervisor Job Description for Staff G (House Supervisor) showed: “Job Description. Assists the administration staff in overseeing and assisting all staff in all functions to ensure the provision of quality general [sic] and psychiatric care to patients ... Involved in direct patient care ... Teamwork. Takes initiative to help the team, is flexible when asked to assist in other areas ... Accountability ... Acknowledges mistakes and demonstrates willingness to learn and correct them ... Signed 5/2/2023.” Review of Employee Written Warning signed 4/25/2025 (not timed) showed Staff C (RN) was “observed having a conversation with Supervisor by the nurse’s station for over 30 minutes. As a result, rounds were missed and ... an SAO (sexually acting out) incident occurred.” .”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 35028 . Based on observation, interviews, and record review, the facility failed to ensure that the treatment plan was individualized and identified the problem of sexual outing out behavior for Patient #1 and Patient #2 after they were found in bed together, with Patient #1 alleging rape by Patient #2. Findings were: Review of policy 18132731, “Treatment Planning - Philosophy and Purpose,” last approved 5/2025, showed: “Purpose. To define and provide guidance to the expectation of care and services provided with regard to treatment planning ... Procedures ... i. A Treatment Plan review/update that evaluates patient response to goals and interventions will be revised based on changes in the patient’s condition, problems, needs, and responses to care, treatment, and services.” Review of Interdisciplinary Progress Notes by Staff C (RN) for Patient #1 and Patient #2, dated 4/23/2025. 9:45pm-10:50, showed that Staff B (PCA) resumed the 15-minute observation rounds after being off the unit for 40 minutes. He found Patient #2 in the bed with Patient #1. Patient #1 alleged rape by Patient #2. Patient #2 stated that Patient #1 “wanted it.” Review of the Multidisciplinary Treatment Plans for Patient #1 and Patient #2 showed that the plan had not been updated to include the sexual acting out that occurred between these two patients on the night of 4/23/2025. In an interview with Staff L (LMSW) on 6/19/2025 at 2:04pm, she stated she worked with the adolescent girls. She also stated that following sexual acting out behavior between patients, the Treatment Plan should be updated to include the problem of sexual acting out behavior. In an interview with Staff O (LMSW) on 6/23/2025 at 3:25pm, she stated that following the sexual acting out between Patient #1 and Patient #2, the Treatment Plan should have been updated to include the problem of sexual acting out behavior with the goal to prevent re-offending being added to the plan. In an interview with Staff K (MD) on 6/19/2025 at 1:52pm, she stated she was the attending physician for Patient #1 and Patient #2, adding, the treatment plans for these two patients should have been modified following the sexual acting out incident between them on 4/23/2025. .”

“Document Therapeutic Efforts CFR(s): The treatment received by the patient must be documented in such a way to assure that all active therapeutic efforts are included. This Standard is not met as evidenced by: 35028 . Based on interviews, observation, and record review, the facility failed to ensure that 15-minute observation rounds were accurately documented on 9 of 9 patients (Patient #1, 2, 3, 9, 10, 23, 24, 25, and Patient #26) - patients that required intensive, 24-hour, specialized psychiatric intervention that could not be provided outside the psychiatric hospital. This failure resulted when Staff B (PCA) documented two observation rounds on Patient #1, 2, 3, 9, 10, 23, 24, and Patient #25 that he had not conducted. In addition, Staff H (PCA) documented two observation rounds on Patient #26 that he had not conducted. Findings were: Review of policy 17787642, “Rounds for Patient Observation,” last approved 4/2025, showed: “Purpose. To ensure there is an accurate record of the whereabouts of all patients in inpatient. The record will be maintained during each shift ... Procedures ... E. Staff members must complete the Close Observation Sheet at least every 15 minutes by making visual contact with the patient ... G. During the nighttime ... the observation of the patient is required.” Review of policy 18040290, “Levels of Observation and Precautions,” last approved 4/2025, showed: “Purpose. To ensure there is clear differentiation between patients’ needs when different levels of risk are present. The levels of observation and precautions are identified based on the risk assessment as well as by patient behavior ... Procedures. 1. Every 15-minute observation: ... Staff members must complete the Close Observations Sheet by noting the patient behaviors and location codes, along with the initials of the staff member who is conducting the observation.” Review of video surveillance of the Willows Unit on the night of 4/23/2025 showed the last observation round made prior to the incident between Patients #1 and #2 was conducted by Staff B (PCA) at 10:03pm. Within a minute of making these rounds, Staff B (PCA), Staff H (PCA), and Staff G (House Supervisor acting as Lifeguard) abruptly left the unit, leaving only Staff C (Charge RN) on the unit. At 10:44pm, Staff B (PCA) returned to the unit, picked up the 15-minute observation rounds sheets, and resumed conducting rounds. Staff H (PCA) returned to his 1:1 post with Patient #26. During the 40 minutes Staff H was off the unit, Staff C never went into room 505 to check on Patient #26. Rounds were not conducted at 10:15pm or 10:30pm by Staff C (Charge RN) or Staff G (House Supervisor). Review of the Patient Observation Sheets - Night Shift, dated 4/23/2025 showed that the observation rounds for 8 or 8 patients (Patient #1, 2, 3, 9, 10, 23, 24, and Patient #25), were documented as having been done at 10:15pm and 10:30pm by Staff B (PCA). Review of the Patient Observation Sheets - Night Shift, dated 4/23/2025 showed that the observation rounds for Patient #26, were documented as having been done at 10:15pm and 10:30pm by Staff H (PCA). Review of Interdisciplinary Progress Notes by Staff C (RN) for Patient #1 and Patient #2, dated 4/23/2025. 9:45pm-10:50, showed that Staff B (PCA) resumed the 15-minute observation rounds after being off the unit for 40 minutes. He found Patient #2 in the bed with Patient #1. Patient #1 alleged rape by Patient #2. Patient #2 stated that Patient #1 “wanted it.” In an interview with Staff A on 6/18/2025 at 11:15am, she stated that Staff B and Staff H, both PCAs, documented rounds that they clearly had not conducted, thus “falsifying the medical record.” [As noted in the review of the video surveillance, both PCAs were off the unit at 10:15pm and 10:30pm.] .”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 35028 . Based on observation, staff interviews, and record review, the facility failed to meet the Condition of Participation requirements for Patient Rights as evidenced by the facility’s failure to ensure that an adolescent female patient was free from physical abuse by a staff member. Refer to A-0145. Additionally, the facility failed to ensure that patients were provided with a safe environment. More specifically, the facility failed to ensure: A. Three doors with self-closing hardware closed properly. This failure had the potential to expose 12 suicidal patients on the Sunrise Unit to multiple tie-off ligature points in two conference rooms (rooms 416 and 417). Inside these two rooms were numerous ligature risks including electrical and computer cords. There was a desk with drawer handles that could be used as tie-off points. Both rooms had drop ceilings with removable ceiling tiles. The desk and a table could be used to reach the drop ceiling, allowing patients access to ligature risk points in the space above the drop ceiling such as electrical wiring and plumbing that could be used to hang oneself. Additionally, this failure had the potential to expose 18 suicidal patients on the Maples Unit to multiple tie-off ligature points found on the massive locking system on the seclusion room door (room 715). Refer to A-0144. B. Seclusion room 418 was safe. A segment of the FRP trim in the seclusion room had been bent outward, creating a very sharp edge that could be used for self-mutilation (scratching or cutting self). Refer to A-0144. C. Seclusion rooms were free of items that could be used as weapons. An ottoman that could be used as a weapon was found in two seclusion suites (418 and 718). The ottoman in seclusion suite 418 had been used as a weapon less than a week earlier by a patient in an attempt to assault a staff member. Refer to A-0144. D. Cabinets and drawers were locked and/or the locking mechanisms were not compromised. On all five units, various cabinets and drawers were either unlocked or the locks were broken giving patients access to plastic markers with conical tips, plastic wrap, and removable heavy wooden shelves. This exposure exposed 54 suicidal patients and/or 15 assaultive patients to items that could be used to harm self or others. Refer to A-0144. E. Items that could be used for strangulation or suffocation were out of reach of the patients. Rubber gloves and plastic sleeves to Styrofoam cups were unattended and within the reach of 20 suicidal patients. Refer to A-0144. F. A commercial trash can was always monitored. A 45-gallon black round commercial trash can on wheels was left unattended in the hallway by a housekeeper when she entered a group room to collect trash, allowing the door to close behind her. The receptacle was lined with a large plastic bag and an unused plastic bag was draped over the edge of the container. There were two spray bottles of cleaning chemicals hung on the edge of the container. The receptacle was over three quarters full of trash. There were 7 suicidal patients and 1 assaultive patient that had potential access to these items. Refer to A-0144. G. Housekeepers were properly trained on housekeeping duties and equipment. A housekeeper didn’t know the cleaning cart locked. Refer to A-0144. H. Heat and air units were free of dust and debris. A random check of the heat and air units in the 18 patient bedrooms on the Sunrise and Willows units showed a very substantial accumulation of dust and debris. Exposure to dust can have adverse health outcomes, such as respiratory problems, asthma, and allergic reactions. Refer to A-0144. I. An environmental risk assessment with mitigation strategies had been completed. The one and one-half page facility wide Lifepoint Risk Assessment, initiated by Staff F (EOC Director), did not encapsulate the entire facility. For example, it did not include all ligature risks (seclusion room door lock, computer cords), unattended items such as housekeeping carts that contain hazardous items (mops, brooms, cleaning agents, etc.), or unsafe items brought by visitors to patients in locked units). Additionally, the assessment did not outline environmental risk assessment strategies. Refer to A-0144. J. Some form of identification was worn by all employees working with patients. Two employees, providing direct patient care, were not wearing any form of identification. Refer to A-0144.”

“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: 35028 . Based on observation, staff interviews, and record review, the facility failed to ensure that patients received care in a setting - a setting that protected emotional and physical health and safety of behavioral health patients. Namely, the facility failed to ensure that: A. Three doors with self-closing hardware closed properly. This failure had the potential to expose 30 suicidal patients to multiple ligature risks. B. The seclusion room was free of sharp features that could be used to scratch or cut self. The FRP (Fiberglass Reinforced Panels) trim in the seclusion room (room 418) had been bent outward, creating a very sharp edge that could be used for self-mutilation (scratching or cutting). C. Two seclusion rooms had been cleared of objects that could be used as weapons to harm others. An ottoman that could be used as a weapon was found in 2 of 5 seclusion rooms (418 and 718). D. Various cabinets and drawers on all five units were locked or the locks were not compromised. This failure had the potential to expose 54 suicidal patients and 15 assaultive patients to multiple items found in the cabinets and drawers that could be used for self-harm or to harm others. E. Items that could be used for suffocation and strangulation (rubber gloves and plastic sleeves) were out of reach of suicidal patients. This failure had the potential to expose 29 suicidal patients and 10 assaultive patients to these items. F. A 45-gallon black round commercial trash can on wheels filled with trash, bottles of chemicals, and plastic bags was always monitored on the Cedars Unit, an adult unit. This failure potentially placed 8 suicidal patients at risk. G. 1 of 1 housekeepers (Staff I) was properly trained on the safety features of the commercial housekeeping cart. H. The heat and air units in the patients’ bedrooms were dust-free. This failure had the potential to expose 23 patients to compromised ventilation. I. A comprehensive assessment of environmental risk strategies had been completed. J. Staff were provided with an identification badge while performing patient care. Findings were: A. Three doors with self-closing hardware did not close properly. Review of policy 17833451, Patient Bill of Rights, last approved 4/2025, showed: “Basic Rights for All Patients ... You have the right to a ... humane environment in which you are protected from harm.” Review of policy 15562536, Suicide Prevention Program Guidelines, last approved 4/2024, showed: “Unit Safety ... Group rooms and unoccupied office doors are locked.” Review of the Lifepoint Risk Assessment, initiated by the EOC Director, created 1/27/25, revised 4/8/25, showed: “Risk Reduction Feature - Doors on patient units: Hardware safe and doors are self-closing and self-latching.” Review of the Unit Census dated 5/20/2025 provided by Staff B (Compliance) and Staff C (CNO) showed 12 patients on the Sunrise Unit (Patients #15 through #26) and 18 patients on the Maples Unit (Patients #32 through #49) on suicide precautions. During a tour of the adolescent units on 5/20/2025, 10:00am - 10:45am, it was observed that the self-closing hardware on the doors of two conference rooms (rooms 416 and 417) located adjacent to the commons area on the Sunrise Unit did not work properly. The lock latch did not fall into the strike plate after the door was manually opened and released. There was a desk and a table in each room, along with two computer screens, a keyboard, a surge protector, and numerous electrical and computer cords. The desks had two metal bar drawer handles. Both rooms had drop ceilings with removable ceiling tiles. Further observation on the Maples Unit at 12:15pm showed that the self-closing hardware on seclusion room door (room 715) did not work properly. The lock latch did not fall into the strike plate after the door was manually opened and released. The seclusion room door had a massive locking system with numerous tie-off points a patient could use for hanging oneself. In an interview with Staff B (Compliance) and Staff F (EOC - Environment of Care Director) during the tour, they both stated that the doors to the two conference rooms and the seclusion room should have automatically closed. Staff B stated that the table and desk in the conference rooms could provide the necessary height for a patient to reach the drop ceiling. Staff F (EOC) stated that in the space above the drop ceiling houses electrical wires and possibly plumbing. Staff B stated that these items could provide tie-off points, thus becoming ligature risks for hanging oneself. She also stated the draw handles on the desks provided tie-off points and that the electrical and computer cords could be used to hang oneself. The computer screens and keyboards could be used as weapons. B. The seclusion room FRP trim had sharp edges that could be used to scratch or cut self. Review of policy 17833451, Patient Bill of Rights, last approved 4/2025, showed: “Basic Rights for All Patients ... You have the right to a ... humane environment in which you are protected from harm.” During a tour of the adolescent units on 5/20/2025, 10:00am - 10:45am, it was observed that 4 feet by 8 feet sheets of FRP paneling had been vertically applied to the walls of the seclusion room (room 418). A thin FRP trim ran horizontally around the room where the two panels butted together. A 2-3-inch stretch of the trim had been bent outward, exposing a very sharp edge. In an interview with Staff B (Compliance) and Staff F (EOC) during the tour, Staff F (EOC) was aware of this issue, adding that a patient had damaged the trim by trying to pull it off. Staff B (Compliance) stated that a patient could harm self with the area of the trim that had been compromised. C. Two seclusion rooms had not been cleared an ottoman that could be used as weapons to harm others. Review of policy 17833451, Patient Bill of Rights, last approved 4/2025, showed: “Basic Rights for All Patients ... You have the right to a ... humane environment in which you are protected from harm.” During a tour of the Sunrise Unit on 5/20/2025, 10:00am - 10:45am, and the Maples Unit, 12:15pm - 1:30pm, an ottoman was observed in the anteroom / seclusion room suite. In an interview with Staff B (Compliance) and Staff C (Chief Nursing Officer - CNO) during the tour, they both stated that the ottoman in the seclusion suite 418 had been used as a weapon less than a week earlier by Patient #1, a 17-year-old adolescent female, toward a staff member. They also stated the ottomans were not supposed to be in this area. In an interview with Staff H (Unit RN) on the Sunrise Unit on 5/20/2025 at 10:35am she stated that the ottoman “should never have been in the seclusion area.” In an interview with Staff G (Patient Care Assistant - PCA) on 5/20/2025 at 10:15am, she stated the ottoman can be in the seclusion room if the patient is in the Quiet Room, “but not if [the patient is] locked in seclusion.” She also stated that the ottoman should not have been in this area with Patient #1, an acknowledged “killing machine like my dad.” D. Various cabinets and drawers on all five units were not locked or the locks were not compromised. Review of policy 17833451, Patient Bill of Rights, last approved 4/2025, showed: “Basic Rights for All Patients ... You have the right to a ... humane environment in which you are protected from harm.” Review of the Unit Census dated 5/20/2025 provided by Staff B (Compliance) and Staff C (CNO) showed: “ 7 suicidal patients on the Cedars Unit (Patients #8 through #14), “ 12 suicidal patients on the Sunrise Unit (Patients #15 through #26), “ 5 suicidal patients on the Willows Unit (Patients #27 through #31), “ 18 suicidal patients on the Maples Unit (Patients #32 through #49), and “ 12 suicidal patients on the Meadows Unit (Patients #50 through #61). Additionally, this failure had the potential to provide 15 patients throughout the facility on assaultive precautions (Patients #16, 28, 30, 31, 40, 42, 59, 62, 63, 64, 65, 66, 67, 68, and #69) with the means to harm other. During a tour of the five inpatient units on 5/20/2025, 10:00am - 12:30pm, it was observed that numerous cabinets and drawers throughout the facility were either unlocked or the locks were broken giving patients access to numerous items that could be used for self-harm or as weapons. Items included plastic markers with conical tips, plastic wrap, and removable heavy wooden shelves. In an interview with Staff B (Compliance) she stated that the plastic markers with conical tips and the wooden shelves could be used as a weapon or to self-harm. She also stated that the plastic wrap could be used to suffocate oneself. E. Items that could be used for suffocation and strangulation (rubber gloves and plastic sleeves) were out of reach of suicidal patients. Review of policy 17833451, Patient Bill of Rights, last approved 4/2025, showed: “Basic Rights for All Patients ... You have the right to a ... humane environment in which you are protected from harm.” Review of the Review of policy 15562536, Suicide Prevention Program Guidelines, last approved 4/2024, showed: “No plastic wrap on linens in patient areas.” Review of the Lifepoint Risk Assessment, initiated by the EOC Director, created 1/27/25, revised 4/8/25, showed that rubber gloves or sleeves found on Styrofoam cups were not addressed. Review of the Lifepoint Risk Assessment, initiated by the EOC Director, created 1/27/25, revised 4/8/25, showed: “Nurse Stations ... The nurse stations are monitored 24/7 by a staff member. Patients will not have access to the nurse station.” Review of the Unit Census dated 5/20/2025 provided by Staff B (Compliance) and Staff C (CNO) showed: “ 12 suicidal patients (Patients #15 through #26) and 2 assaultive patients (Patient #16 and Patient #63) on the Sunrise Unit, “ 5 suicidal patients (Patients #27 through #31) and 4 assaultive patients (Patients #28, 30, 31, and Patient #64) on the Willows Unit, and “ 12 suicidal patients (Patients #50 through #61) and 4 assaultive patients (Patient #59, 67, 68, and Patient #69) on the Meadows Unit. During a tour of the five inpatient units on 5/20/2025, 10:00am - 12:30pm, the Nurse’s Station on the Sunrise Unit was observed. The workstation faced out onto the common areas. Two nurses were seated at the station. Behind them against the wall on a ledge was two unattended boxes of rubber gloves. They were within reach of patients. A plastic sleeve of Styrofoam cups was observed on the Willows Unit and the Meadows Unit. On the Meadows Unit, bath clothes wrapped in plastic wrap were stored in one of the unlocked cabinets adjacent to the common area. In an interview with Staff B (Compliance) she stated that the rubber gloves were within reach of patients, adding that the gloves should have been stored in a more secure place. She also stated the plastic sleeves and plastic wrap should not have been accessible to patients on the unit. F. 45-gallon black round commercial trash can on wheels unattended. Observation of Staff I (Housekeeper) on 5/20/2025 at 11:25am on the Cedars Unit showed Staff I had left the trash receptacle unattended in the hallway. She was observed in a group room performing duties. The group room had a self-closing door that closed and locked behind her when she entered the room. The receptacle was lined with a large black plastic bag. An unused large black plastic bag was draped over the edge of the container. There were two spray bottles of cleaning chemicals hung on the edge of the container. The receptacle was over three quarters full of trash. Review of the Cedars Unit Census dated 5/20/2025 provided by Staff B (Compliance) and Staff C (CNO) showed 7 patients (Patients #8 through #14 and Patient #62) on Suicide Precautions and 1 patient (Patient #62) on Assaultive Precautions. During an interview with Staff I on 5/20/2025 at 11:20am, Staff C (CNO) translated into Spanish the questions posed by the surveyor. According to Staff C, Staff I did not know that the trash receptacle needed continuous monitored while on the units. G. Housekeepers was not properly trained on the safety features of the commercial housekeeping cart. In an interview with Staff I on 5/21/2025 at 9:55am, Staff C (CNO) translated into Spanish the questions posed by the surveyor. According to Staff C, Staff I did not know that housekeeping cart had a lock, a safety feature. Observation of the housekeeping cart on 5/21/2025 at 9:55am showed that the housekeeper did not know how to lock the top of the cart when instructed to do so by Staff C (CNO). Further interview with Staff C (CNO) on 5/21/2025 at 9:55am, she stated that the housekeeping cart needed to be locked when on the unit. H. The heat and air units in the patients’ bedrooms were not dust-free. Review of “Guidelines for Environmental Infection Control in Health-Care Facilities,” prepared by L. Sehulster, Ph.D. and R. Chinn, MD, June 6, 2003, showed the following recommendation: “Ensure that heating, ventilation, air conditioning (HVAC) filters are properly ... maintained to prevent ... dust overloads.” Additionally, The Joint Commission standards for dust in hospitals focus on ensuring proper ventilation, maintenance of HVAC systems, and preventing dust accumulation to minimize the risk of infection. Review of policy 17833451, “Patient Bill of Rights,” last approved 4/2025, showed: “Basic Rights for All Patients ... You have the right to a clean ... environment in which you are protected from harm.” Review of the policy 17332679, “General Cleaning Policy,” last approved 3/2025, showed: “Monthly: Vertical surfaces, corners, vents, grates, etc., should be cleaned using a vacuum cleaner with crevice tool and upholstery brush attachments.” Review of the Unit Census dated 5/20/2025 provided by Staff B (Compliance) and Staff C (CNO) showed 15 patients (Patients #15 through 26, 63, 70, and #71) were on the Sunrise Unit and 8 patients (Patients #27 through 31, 64, 72, and #73) were on the Willows Unit. Random checks of the heat and air units in the 18 patient bedrooms during the tour of the Sunrise and Willows units on 5/20/2025, 10:00am - 12:30am, showed a very substantial accumulation of dust and debris. This had the potential to affect patients on the Sunrise and Willows Units. In an interview with Staff L (RN - Infection Control Coordinator - ICC) on 5/21/2025 at 11:21am, she stated the dust should not have been in the heat and air units. She also stated General Cleaning Policy states that all vents and grates are to be cleaned with a vacuum cleaner monthly. I. Comprehensive assessment of environmental risk strategies. Review of the Lifepoint Risk Assessment, initiated by the EOC Director, created 1/27/25, revised 4/8/25, showed: The drop ceilings throughout the facility had not been assessed with mitigation strategies. (See item A.) There was no reference to the FRP trim in the seclusion room (room 418). (See item B.) The cabinets and drawers adjacent to the common areas on the five behavioral health units were not included in the assessment with mitigation strategies. (See item D.) Unsupervised access to rubber gloves and plastic sleeves for Styrofoam cups were not included in the assessment with mitigation strategies. (See item E.) The trash receptacles and commercial cleaning carts were not included in the assessment with mitigation strategies. (See item F and G.) In an interview with Staff F (EOC) on 5/21/2025 at 10:30am, he stated the environmental issues found the previous day during the tour on the facility needed to be on the Lifepoint Risk Assessment to minimize environmental risks. Staff F and Staff B (Compliance) stated that a team would be created to develop a more comprehensive environmental risk assessment. They also stated that based on the risk assessment findings, education and training would be needed. J. Staff were not wearing an identification badge while performing patient care. Review of policy 15183000, “Identification Badges, Keys, Personal Safety Devices, last approved 3/2024, showed: “Identification badges are to be worn at all times while on work premises and while conducting facility business. Badges will state the employee’s name, position, and/or department. The identification badge should be attached to the outermost garment and should be worn at all times while on duty. The employee’s picture and name should be visible at all times ... Human Resources has the responsibility of ensuring that orienting employees have been issued a badge. Damaged and lost badges will be replaced by Human Resources.” Observation of Staff G (PCA) on 5/20/2025 at 10:15am showed that she was not wearing any type of identification. In an interview with Staff G, she stated she was providing direct patient care. She also stated her badge had “cracked” the previous day and she had not had it replaced. She had not identified an alternative method of staff identification. Observation of Staff K (PCA) on 5/21/2025 at 9:55am showed that he was not wearing any type of identification. In an interview with Staff K, he stated he was providing direct patient care. He also stated he was a new employee and had not had a badge for two weeks. He had not identified an alternative method of staff identification. In an interview with Staff C (CNO) on 5/21/2025 at 10:00am, she stated all staff were required to wear an identification badge.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 35028 . Based on observation, interview, and record review, the facility failed to ensure that 1 of 1 patients, Patient #1, a 17- year-old adolescent was free from physical assault by Staff E, a Patient Care Assistant (PCA). Staff E did not follow the behavioral management training by disengaging and “punting” the intervention to another staff member when her personal feelings interfered with her ability to effectively respond to the patient. Additionally, other staff members did not intervene by encouraging Staff E to disengage and punt the intervention to them. Findings were: Review of policy 17833451, “Patient Bill of Rights,” last approved 4/2025, showed: “Basic Rights for All Patients ... You have the right to be free from mistreatment, abuse, neglect, and exploitation.” Review of “Handle with Care Behavior Management System - Verbal Intervention Manual for Participants,” copyright 2012, showed: “Be aware of your body language - nonverbal communication (facial expressions, hand gestures, pointing, etc.) reveals your true affect. If your own feelings about the client are interfering with your ability to do good work with him, recollect yourself or punt the intervention to someone else.” Review of Psychosocial Assessment by Staff S (LMSW) dated 5/9/2025 at 4:41pm, showed “unprovoked” anger, self-harm - cutting, and history of suicide attempt by overdose. She resided in a group home. Review of Seclusion and Restraint documentation dated 5/15/2025 at 10:33am, showed that Patient #1 was given Haldol 5mg IM [antipsychotic given Intramuscularly], Ativan [used for anxiety] 2 mg IM, and Cogentin [counters side effects of antipsychotic] 1 mg IM by Staff R (RN) after the patient “threw things in the nurse’s station and broke the exit doors” because she was “upset about discharge.” The patient went to the seclusion room suite. Review of video surveillance dated 5/15/2025 at 10:30am, showed Patient #1 and Staff E and Staff K, both PCA’s, in the anteroom of seclusion suite 418. Though there was no audio, Staff E and Patient #1 were in what appeared to be a highly charged, emotional exchange. There were a lot of hand gestures made by Staff E. The patient picked up an ottoman and hurled it at Staff E. Staff K blocked the ottoman from hitting Staff E. The confrontation then moved to the hallway, just outside of the anteroom. More staff members arrived. Staff E continued to be engaged in an argument with the patient. Patient #1 quickly moved toward Staff E, striking Staff E. Immediately Staff E charged the patient and began hitting the patient with her fists, landing several blows to the patient’s head. Other staff members intervened to protect the patient. In an interview with Staff B (Compliance Director) on 5/20/2025 at 3:00pm during the review of the video surveillance, she stated Staff E (PCA) hit Patient #1 with a closed fist on 5/15/2025 at approximately 10:30am. She identified the following staff members as those that intervened to protect the patient from Staff E’s punches: Staff J (HR), Staff K (PCA), Staff N (RN), Staff O (Patient Advocate), and Staff P (PCA). Staff E immediately went to the parking lot. Staff B (Compliance) was notified of the incident. Staff E was brought to Staff B’s office to review the video. Staff E stated, ‘I just lost it.’ Staff E was sent home after relinquishing her keys and identification badge. She was terminated the following day. Staff B concluded by saying, “The police were called on behalf of the patient.” In an interview with Staff J (HR) on 5/20/2025 at 2:45pm, he stated that Staff E (PCA) had been “verbally inappropriate” with Patient #1. Review of The State of Texas Fort Bend County police documentation (not dated or timed) showed that Staff M (Deputy) opened an investigation - Case #25-19375. In an interview with Staff N (Nurse Supervisor) on 5/22/2025 at 9:34am, she stated Staff E should not have gotten into a power struggle with Patient #1. Further interview with Staff B (Compliance Director) on 5/21/2025 at 1:30pm, she stated that Staff E (PCA) did not follow the Handle with Care behavioral management training. “She should have ‘tapped out’ and allowed another staff member to engage the patient. She also stated other staff members did not get Staff E to disengage and “tap out.” Review of the Employee Action Form showed “termination 5/16/2025.” Staff E (PCA) “was struck by an adolescent patient and she [Staff E] responded by hitting the patient many times with her fists. Staff members had to restrain her [Staff E] from continuing the assault. Employee was suspended pending investigation immediately. This incident was reviewed and confirmed by camera footage. Due to this, they [sic] will be terminated.””

“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: 35028 . Based on observation, interview, and record review, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care of patients on an ongoing basis. More specifically, the facility failed to ensure that 1 of 1 patients (Patient #1), a 17-year-old female adolescent, was protected from physical assault by Staff E, a Patient Care Assistant (PCA). Staff E did not follow the behavioral management training by disengaging and “punting” the intervention to another staff member when her personal feelings interfered with her ability to effectively respond to the patient. Instead, Staff E hit Patient #1 repeatedly with her fists. Additionally, the registered nurse did not intervene by removing Staff E from the highly charged situation before it escalated to the point of a physical altercation between the PCA and the patient. Findings were: Review of “Handle with Care Behavior Management System - Verbal Intervention Manual for Participants,” copyright 2012, showed: “Be aware of your body language - nonverbal communication (facial expressions, hand gestures, pointing, etc.) reveals your true affect. If your own feelings about the client are interfering with your ability to do good work with him, recollect yourself or punt the intervention to someone else.” Review of Psychosocial Assessment by Staff S (LMSW) dated 5/9/2025 at 4:41pm, showed “unprovoked” anger, self-harm - cutting, and history of suicide attempt by overdose. She resided in a group home. Review of Seclusion and Restraint documentation dated 5/15/2025 at 10:33am, showed that Patient #1 was given Haldol 5mg IM [antipsychotic given Intramuscularly], Ativan [used for anxiety] 2 mg IM, and Cogentin [counters side effects of antipsychotic] 1 mg IM by Staff R (RN) after the patient “threw things in the nurse’s station and broke the exit doors” because she was “upset about discharge.” The patient went to the seclusion room suite. Review of video surveillance dated 5/15/2025 at 10:30am, showed Patient #1 and Staff E and Staff K, both PCA’s, in the anteroom of seclusion suite 418. Though there was no audio, Staff E and Patient #1 were in what appeared to be a highly charged, emotional exchange. There were a lot of hand gestures made by Staff E. These three individuals were in the room arguing for several minutes. The patient picked up an ottoman and hurled it at Staff E. Staff K blocked the ottoman from hitting Staff E. The confrontation then moved to the hallway, just outside of the anteroom. More staff members arrived. Staff E continued to be engaged in an argument with the patient. Patient #1 quickly moved toward Staff E, striking Staff E. Immediately Staff E charged the patient and began hitting the patient with her fists, landing several blows to the patient’s head. Other staff members intervened to protect the patient. The charge RNs for the unit (Staff T and Staff U) were not identified in the video. In an interview with Staff B (Compliance Director) on 5/20/2025 at 3:00pm during the review of the video surveillance, she stated Staff E (PCA) hit Patient #1 with a closed fist on 5/15/2025 at approximately 10:30am. She identified the following staff members as those that intervened to protect the patient from Staff E’s punches: Staff J (HR), Staff K (PCA), Staff N (RN), Staff O (Patient Advocate), and Staff P (PCA). Staff E immediately went to the parking lot. Staff B (Compliance) was notified of the incident. Staff E was brought to Staff B’s office to review the video. Staff E stated, ‘I just lost it.’ Staff E was sent home after relinquishing her keys and identification badge. She was terminated the following day. Staff B concluded by saying, “The police were called on behalf of the patient.” In an interview with Staff J (HR) on 5/20/2025 at 2:45pm, he stated that Staff E (PCA) had been “verbally inappropriate” with Patient #1. Review of The State of Texas Fort Bend County police documentation (not dated or timed) showed that Staff M (Deputy) opened an investigation - Case #25-19375. Review of documentation of the meeting dated 5/15/2025 (not timed) with Staff E (PSA) showed that surveillance footage of the assault was viewed by Staff B (Compliance Director), Staff C (CNO), Staff J (HR Director), and Staff E. In an interview with Staff C (CNO) on 5/21/2025 at 10:00am, she stated that Staff E (PCA) should have removed herself from the altercation with Patient #1. Evidence of a thorough investigation of the incident could not be provided. In an interview with Staff N (RN) on 5/22/2025 at 9:34am, she stated Staff E should not have gotten into a power struggle with Patient #1, adding, “Don’t have a power struggle. Let know before you lose it. It’s okay. Let me switch out with you.” Further interview with Staff B (Compliance Director) on 5/21/2025 at 1:30pm, she stated that Staff E (PCA) did not follow the Handle with Care behavioral management training. “She should have ‘tapped out’ and allowed another staff member to engage the patient. She also stated other staff members did not get Staff E to disengage and “tap out.” Review of the Employee Action Form showed “termination 5/16/2025.” Staff E (PCA) “was struck by an adolescent patient and she [Staff E] responded by hitting the patient many times with her fists. Staff members had to restrain her [Staff E] from continuing the assault. Employee was suspended pending investigation immediately. This incident was reviewed and confirmed by camera footage. Due to this, they [sic] will be terminated.””

“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: 38015 Based on observation and interview, the facility failed to ensure care in a safe setting on a unit with 22 patients, 16 of which were on suicide precautions, as shown by the presence of four sharpened ‘golf’ pencils left unattended on a table in the common dayroom. Findings included: Review of facility policy ID #15183010 titled “Safe & Functional Environment”, last reviewed 7/2020, showed the facility will ensure that areas used by patients are maintained to promote patient safety. Observation on 10/29/24 at 12:10 pm of facility’s Maples unit revealed there were four ‘golf’ type of pencils left unattended on one of the tables patients use on the unit’s common area dayroom. These wooden pencils had sharpened tips capable of inflicting self-harm including puncturing, cutting, and swallowing. They also posed a risk for patients to use as a weapon to injure others. Record review of facility’s current census on the Maples unit for the day showed there were a total of 22 patients presently residing on the unit. Of these, 16 patients were currently on suicide precautions and one was on assault precautions. During this observation time, the following staff were present and also observed the pencils present on the table: DQS-Staff #A, QC-Staff #C, RN-Staff #D. In an interview at the time of these findings, Staff #A acknowledged the pencils were a safety hazard and subsequently removed them from the table, then informed other staff to ensure they monitored the area for sharp objects.”

“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: 38387 Based on surveyor observations, record review and confirmed in interview, the facility failed to implement their policies and procedures that promoted care in a safe setting. The facility failed to ensure staff observed patients per doctor’s orders as line of sight (LOS) for two of ten patients reviewed (Patient # 3 and 4). The findings include: In review of facility policy Levels of Observation and Precautions (Policy Stat ID 14807112, effective 03/2024), it stated “To ensure there is clear differentiation between patients’ needs when different levels of risk are present. The levels of observation and precautions are identified based on the risk assessment as well as by patient behavior. The nursing staff and medical providers will assess patients for risk level and make level of observation and precaution recommendations based on the risk level assessment findings and patient behavior. It is critical that patient observation level and precautions are documented on the Close Observation Sheet and communicated to team members... 2. Line of sight observation: This level of observation is very restrictive and involves continuous visual monitoring at all times. Documentation should reflect the need for continued line of sight or improvement in behaviors. Staff must be within visual contact of the patient at all times. A staff member may observe more than one patient on line of sight observation only while those patients remain in an area for scheduled activity (i.e. group therapy, dining, outside break or activity). If a staff member is observing more than one patient and one or more of the patients go to separate areas, the staff must transfer responsibility for line of sight to other staff members) so that there is continuous observation of all patients on line of sight precautions. Staff shall maintain a continuous log which indicates the patient’s location and behavior every 15 minutes and document throughout each shift.” Review of Patient #3’s chart revealed he was admitted on 06/19/2024 for Major Depressive Disorder for mood stabilization and safety monitoring with a level of observation ordered as a line of sight at admission. Review of patient #4’s chart revealed she was admitted on 06/19/2024 for Major Depressive Disorder for mood stabilization and safety monitoring with a level of observation ordered as a line of sight after her history and physical assessment. Surveyor review of video recording in the Willows unit on 08/27/24 revealed Patients #3 and 4 in the hallway of their unit down the hall from the nursing station on 07/09/2024 at approximately 5:33 PM. For two minutes, Patient #3 and #4 had privacy to engage in inappropriate touching. Video review showed a tech entering the unit onto the hallway at 5:35 PM who subsequently separated the two patients. No staff had line of sight visualization for either Patient #3 and Patient #4 for two minutes on 07/09/2024. An interview with Staff # 1 on 08/27/2024 at 2:20 PM in the conference room confirmed the above findings.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 43549 Based on record review and interview, the hospital failed to prove the patient/grievant with a writtan notice containing the steps taken to investigate the grievance, the results of the grievance process and the da te of completion for one patient (ID #B) of one grievance letter reviewed regarding the assault of the patient. Findings Include: Record review of the facility policy “General Grievances and Patient Advocacy” #14962780 dated 01/2024 stated: Purpose: To establish a mechanism by which to impartially receive, investigate, review and process patient complaints, patient grievances, and/or in the issue regarding patient rights. Patient Grievance: The formal or informal written or verbal complaint that is made by a patient, or the patients representative, regarding the patient’s care (when a verbal complaint about patient care is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the facilities’ compliance with the CMS Hospital Conditions of Participation, or a Medicare beneficiary billing complaint related to rights and limitations. A complaint is considered the patient grievance when: If if it is a complaint that cannot be resolved at the time by staff present, was postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further action or resolution. If the patient complaint cannot be resolved promptly by staff present, information regarding the concern will be provided to the patient advocate to be handled in investigated as a patient grievance. If the patient advocate is not on site, patient advocate designee will initiate the investigative process. The Patient Advocate or Patient Advocate Designee 1. Most of acknowledge receipt of the patient grievance within 24 business hours of becoming aware of the same. 2. Provides the patient, patient representative and/or family member an opportunity to voice their concerns. 3. Investigates the identified patient grievance and determines the resolution within seven (7) business days, the patient, family member, or patient representative will be notified, in writing by the patient advocate and/or patient advocate designee that the investigation is ongoing, will furnishing a time frame for the expected completion. 4. The patient advocate will modify the patient, family member location representative of the results in writing. Record review of the grievance letter sent by the Director of Quality (staff ID #1) to patient (ID#B) on 02/25/2024 stated the facility “re-educated the leadership team and staff on the importance of overall communication in addressing families concerns as well as communicating the role they have in providing care”. Record review of the grievance letter sent by the Director of Quality (staff ID #3) to the parent of patient (ID#B) dated 02/25/2024 (1 day after the incident) stated “We our continuing to meet for progressive and actions ensuring lasting change and compliance. Some of these decisions have included, but are not limited to staff trainings an adding new staff... We will continue to share the issues you raised in your complaint with our staff in order to improve our processes and ensure a better experience for all of our patients. Interview on 03/01/2024 between 3:15 pm and 3:30 pm with both staff (ID#2, and 3) revealed there were no training records regarding assaultive behaviors, their prevention, or a debriefing on what occurred. During an interview 03/04/2024 the Director of Quality (staff ID#2) stated she does the grievance investigations and has 30 days to complete them per policy. She stated she had asked the nursing supervisor what happened and had not investigated further. During observation of film on 03-04-2024 at 1:00 p.m. with staff #2 Director of Quality and Staff #3 Chief Nursing Officer of an adolescent unit attack on 02/24/2024 showed patient #B being quickly approached and kicked and punched by patients #s C, D, E and F as patient #B sat on the floor, both staff #2 and #3 stated they had not seen the film and did not know which patients were which in the attack without a floor staff identifying the patients during the review.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 43549 Based on observation, interview, and record review, the facility failed to ensure 5 of 17 sampled patients were free from all forms of abuse or harassment (Patient ID#s B, C, D, E, F and G). The facility failed to ensure: 1. Patients were placed on appropriate safety precaution levels based on current observation and documented patient history (Patient # C, D, E, F); and 2. Staff understanding of precaution levels was consistent with facility policy. Findings include: Review of facility policy #13048351 titled “ Levels of Observation and Precautions” last revised 02/2023, read: Purpose: To ensure there is a clear differentiation between patients’ needs when different levels of risk are present. The levels of observation and precautions are identified based on the risk assessment as well as by patient behavior. Policy: Nursing staff and medical providers will assess patients for risk level and make level of observation and precaution recommendations based on the risk level process and findings and patient behavior. It is critical that patient observation level and precautions are documented as on the Close Observation Sheet and communicated to to members. Aggression Precautions: All patients scoring 3 or higher on the Broset Violence Checklist (BVC) or nursing identifies to be at high risk or aggression/violence must be placed on Aggression Precautions. Immediately initiate an order for Aggression Precautions, including required interventions and additional patient specific individualized interventions. Required interventions below: 1. Continue BVC Assessment the times daily 2. Monitor behavior signs of aggression closely so there is a lower threshold to offer medication or intervene. 3. If aggression is focused on the selected patient or staff member, separate by wing or unit 4. Often use of empty room, group room, or calm/empty room to assist in reducing additional stimuli in patient escalates or becomes agitated. 5. Room easily visible from lounge area for nurses station. 6. Consider use of exercise equipment as an outlet for aggression. 7. Engage patient in treatment planned development or focusing on precipitating factors, coping skills, and anger management. 8. Private room if not on an increased level of observation, as clinically indicated. 9. Consider creating an individually specific behavior plan to mitigate potential violence. Review of a physician order, dated 10-16-18 (1600) for Patient # 3 read: “suicide precautions...” Observation of film on 03-04-2024 at 1:00 p.m. with staff #2 Director of Quality and Staff #3 Chief Nursing Officer of an adolescent unit attack on 02/24/2024 showed patient #B being quickly approached and kicked and punched by patients #s C, D, E and F as patient #B sat on the floor. Patient C was the instigator. The attack stopped before staff were able to intervene. Patient B was immediately moved to another unit and discharged Against Medical Advice (AMA) with her parent that same day. Record review 03/01/2024 revealed patients C, D, and E were not on Aggression precautions. When interviewed 03/04/2024 at 12:20 pm Staff #9, patient C’s psychiatrist confirmed they had not been placed on Aggression Precautions after the attack. He stated he had not been made aware the attack occurred. He stated Patient C had voiced homicidal ideations on 03/04/24 during their visit. The patient expressed wanting to get a gun and shoot his social worker for “Snitching” on him and since he did not have a gun in the hospital he would “Kick the @*!!” of patients that made him mad. Patient C informed the psychiatrist he had coerced the other patients to participate and plan the attack. When interviewed 03/04/2024 at 3:40 pm staff #1 CEO stated patients # C, D, and F had attacked a different adolescent over the weekend (exact date not provided) to and police were called deescalate the aggressors. He stated they required the use of handcuffs. There was no evidence of any interventions taken for the aggressors after the first attack by patient #C on 02/24/2024 to possibly prevent a second attack that occurred on the weekend of 03/03/2024.”