Houston Behavioral Healthcare Hospital LLC

“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, record review, and interviews, the facility failed to provide a safe environment for 18 of 18 patients (Patient #1 through Patient #18) as evidenced by a mattress in the hallway on the Adult Psychiatric Unit - a prohibited practice in the hospital fire codes (NFPA 101 Chapter 19). Findings were: On 5.29.2026 at 10:25am, the surveyor reviewed video surveillance footage dated 4.3.2026 at 2:32am of the administration of an emergency medication to Patient #1. Staff A (CEO) and Staff B (Quality Director) provided commentary during the review. It was noted that a patient was lying on a mattress in the hallway on the floor. Staff B identified the patient as being either Patient #3 or Patient #4. (The patient only briefly looked up toward the camera.) They stated that sometimes a patient is afraid to sleep in her bedroom and will pull the mattress into the hallway just outside the bedroom door. They concluded by saying that the mattress should not be encroaching into the hallway creating a fire and tripping hazard, adding that the mattress can be pulled into the commons area at night for these fearful patients. In an interview with Staff E (ACNO) on 5.29.2026, 1:30pm, she stated she has seen patients sleeping in the hallway on a mattress, adding that the mattresses are returned to the patient’s bedroom in the morning after being cleaned. In an interview with Staff G (MHT on PICU) on 5.29.2026, 1:50pm, he stated that a patient will sometimes pull their mattress into the hallway to sleep.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 35028 . Based on observation, staff interviews, and record review, the facility failed to ensure the protection of the rights of 1 of 1 patients (Patient #5) to be treated in a setting in which his personal privacy (allegations he had sexually assaulted another patient) was protected by Staff G (MHT). Additionally, Staff G (MHT) accused Patient #5 of rape. Findings included: Review of Policy RI 1.01, “Patient Rights and Responsibilities: Rights and Responsibilities of the Individual,” revised 3.13.2024, showed: “Purpose: to ensure all hospital staff ... observe ... patients’ rights ... The Patient’s Bill of Rights shall include ... the patient’s right to ... Considerate, dignified, and respectful care, provided in a safe environment, free from all forms of abuse, neglect, harassment and/or exploitation ... Full consideration of privacy concerning his/her medical care ... conducted discreetly ... Confidential treatment.” Review of the Daily Nursing Assessment Note for Patient #1 written by Staff J (LVN) dated 5.15.2025 at 12:30pm, showed: MHT (Staff G) reported “witnessing patient [#1] having sex with male patient [Patient #5] in the male patient’s room.” Review of the Daily Nursing Assessment Note for Patient #5 written by Staff I (RN) dated 5.15.2025 at 12:10pm, showed: MHT (Staff G) reported Patient #5 “was found having sexual intercourse with a female patient (Patient #1).” Review of the Physician Progress Note for Patient #5 written by Staff BB (NP) dictated 5.15.2025 at 1:41pm, showed: “[Patient #5] expresses frustration. He reports one of the Mental Health Technicians accused him of raping a female patient ... He is very agitated and is yelling ... He reports this is very serious ... He is unable to discuss any other symptoms or feelings due to intense focus on recent events.” Review of Physician Orders for Patient #5 by Staff BB (NP) dated 5.15.2025 at 1:30pm, showed: Zyprexa 10 by mouth (for mood) and Ativan 1mg by mouth (for anxiety) one time NOW. In an interview with Staff G (MHT) on 3.5.2026 at 2:06pm, he stated that he had been assigned to conduct the 15-minute observation rounds on Unit B-100 on 5.15.2025. He “heard a noise” and went to the bedroom of Patient #5. When he entered the room, he found Patient #1 and Patient #5 with their pants down. Patient #5 was behind Patient #1 who was bent over. Patient #5 had an erection. He concluded by saying, “They were having sex.” In an interview with Staff T on 5.6.2026 at 10:00am, he stated that Staff G (MHT) stated: 1) Patient #1 stated the sexual act with Patient #5 was NOT consensual. 2) He announced to those in the dayroom, “They f---ing.” 3) He told Patient #5, “You’re going to get a rape case.” Staff T concluded by saying that Staff G should not have disclosed the incident to individuals in the day room and that Staff G should hot have accused Patient #5 of rape. .”

“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 the protection of the rights of 1 of 1 patients to be treated in a safe setting. Notably, the facility failed to ensure that Patient #1, an 18-year-old high school student, was kept safe from sexual assault. Following numerous instances of aggression, combativeness, paranoia, wandering into other patients’ rooms, six emergency medications, an emergency code, and engaging in sexual conduct, she was placed on one-on-one supervision - a protective measure that should have been initiated much earlier in treatment. Findings included: Review of the Policy PC 2.05, “Sexually Acting Out Precautions (SAO),” revised 3.13.2024, showed: “Patients will receive humane and compassionate psychiatric care in a safe setting ... [The facility] will protect all patients from sexual advances, intimidation, and abuse from other patients. Allegations, including reports of any sexual intimidation or abuse, will be promptly investigated and treatment will be adjusted, as necessary ... Patients are assessed for Sexually Acting Out behavior using a rating scale ... High Risk (15 or more points) - RN will obtain order from MD for SAO precautions and MD will order Q10s and at least one of the following: A blocked room or ‘no roommate status’ 1:1 Heightened observation levels beyond Q10 [minute] checks. “ Review of Policy PC 3.01d, “One to One (1:1) Observation,” reviewed 3.13.2024, showed: “The Patient can expect appropriate supervision during crisis situations ... Nursing Services provides one to one (1:1) supervision when ordered by physician ... One to One (1:1) observation is indicated in situations involving a potential clinical crisis ... Patients on 1:1 will remain within arm’s reach of assigned staff at all times.” Review of the Psychiatric Evaluation for Patient #1 by Staff O (Attending MD) dated 5.15.2025 (not timed), showed an 18-year-old high schooler admitted involuntarily for treatment of psychosis. Police intervened after she broke into “Jose’s” garage. Jose did not live in the residence. Police found her crouched in a corner of the garage, frightened, hallucinating, and delusional. Review of the Intake Assessment for Patient #1 by Staff W (RN) dated 5.14.2025 at 10:54am, showed the patient “started pushing out” as of giving birth to a baby. Review of the Nursing Admission Assessment for Patient #1 by Staff I (RN) dated 5.14.2025 at 11:55am, showed auditory hallucinations, paranoia, and impaired insight and judgment. Review of Daily Nursing Assessment Note for Patient #1 by Staff X (RN) dated 5.14.2025 at 9:00pm showed: “The patient became agitated and confused, moving from one patient room to the other.” At 10:33pm, she was given Zyprexa 10mg and Benadryl 50mg IM and placed in the seclusion room. Review of Physician Orders for Patient #1 by Staff V (NP) dated 5.14.2025 at 9:00pm, showed: Suicide Precautions, Elopement Precautions, and Unit Restrictions. Review of Daily Nursing Assessment Note for Patient #1 by Staff Y (RN) dated 5.15.2025 at 12:40am showed: The patient was “severely aggressive, combative, paranoid, and agitated. Patient kept entering other patient’s rooms and lying on their beds. Poor boundaries and not following directions. All effort to redirect with no avail.” Given Zyprexa 10mg and Benadryl 50mg IM and placed in seclusion room. Review of the Daily Nursing Assessment Note for Patient #1 written by Staff J (LVN) dated 5.15.2025 at 12:30pm, showed: MHT (Staff G) reported “witnessing patient [#1] having sex with male patient [Patient #5] in the male patient’s room.” Azithromycin and ceftriaxone prophylaxis was given for sexually transmitted infection. Patient was psychotic and confused with “bizarre behavior.” She could not follow simple commands. Review of the Daily Nursing Assessment Note for Patient #5 written by Staff I (RN) dated 5.15.2025 at 12:10pm, showed: MHT (Staff G) reported Patient #5 “was found having sexual intercourse with a female patient (Patient #1).” Patient #5 was administered 1 gram azithromycin by mouth and 500mg ceftriaxone IM prophylaxis for sexually transmitted infection. Patient #5 also placed on sexual acting out precautions (SAO). In an interview with Staff G (MHT) on 3.5.2026 at 2:06pm, he stated that he had been assigned to conduct the 15-minute observation rounds on Unit B-100 on 5.15.2025. He “heard a noise” and went to the bedroom of Patient #5. When he entered the room, he found Patient #1 and Patient #5 with their pants down. Patient #5 was behind Patient #1 who was bent over. Patient #5 had an erection. He also stated the two patients had been out of his line of sight, he did not know how long the two patients had been in the bedroom, and “they were having sex.” He also stated he had to watch Patient #1 closely because of her poor boundaries with male patients. In an interview with Staff T on 5.6.2026 at 10:00am, he stated that Staff G (MHT) stated: Patient #1 stated the sexual act with Patient #5 was NOT consensual. Review of Physician Orders for Patient #1 by Staff O (Attending MD) dated 5.15.2025 at 1:00pm showed that the patient was transferred to the female unit (C-North). Sexually Acting Out Precautions (SAO) were initiated. Review of Daily Nursing Assessment Note for Patient #1 by Staff Z (RN) dated 5.16.2025 at 8:00am, showed: Confusion, wandering the unit, in need of redirection with peer boundaries, and auditory hallucinations. Review of Physician Orders for Patient #1 by Staff K (FNP-C) dated 5.16.2025 at 10:00am, showed: Emergency room to evaluate and treat for high-risk sexual behavior. Emergency Department to administer Plan B. Review of Daily Nursing Assessment Note for Patient #1 by Staff FF (RN) dated 5.17.2025 at 1:05am, showed: When the patient returned to the unit from the Emergency Department, she refused vital signs, became aggressive and combative, and stood on a bed where a patient was sleeping. Staff unable to redirect. Zyprexa 10mg with Benadryl 50mg given IM. Prior to administration, the patient became more combative, attacking staff. Code green was called. Review of Physician Orders for Patient #1 by Staff N (PA-C) dated 5.17.2025 at 12:09pm, showed: Place patient on 1:1 supervision. .”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38015 Based on observation, interview and record review, the facility failed to meet the Condition of Participation requirements for Patient Rights. The facility failed to ensure compliance with patient’s rights to receive care in a safe setting and to be free from abuse: A) Patients on suicide precautions were exposed to a room that contained ligature risks and other patient safety hazards on the facility’s A1/A2 unit. The unit, a general adult male unit, had a dysfunctional self-locking door opening to a nutritional galley room which failed to automatically lock, remaining open for easy patient accessibility. This was not recognized by any staff. There were currently 19 patients with active suicide precautions orders residing on the unit (refer to tag A-144); B) Facility’s A1/A2 unit had a hallway leading to it with a door opening to a group activity room that also contained ligature risks and other patient safety hazards accessible to patients. This room also had a dysfunctional self-locking door which failed to automatically lock. This was also unrecognized by staff (refer to tag A-144); C) Facility was not adhering to their own Safety/Security Risk Assessment-Hospital Wide procedure for not having any plastic bags on campus; large plastic trash bags were found inside the A1/A2 unit’s galley room (refer to tag A-144); D) Facility had two bulletin board units present in the entrance to the hospital made of materials that were unsafe to be used in a behavioral health hospital. These bulletin boards were identified as an environmental risk (refer to tag A-144); E) Facility failed to ensure staff maintained patients’ food trays at a safe temperature once the trays were delivered to the unit. Staff had not been properly educated on the safe storage of food trays that had been delivered to the unit. A policy clearly outlined the timeframes and mechanisms of safe food storage in the patient care areas (refer to tag A144); F) Facility failed to ensure that a timely and thorough, objective investigation of allegations of abuse made by a patient was conducted by the Risk Manager as outlined in hospital policy. Additionally, the facility failed to ensure that the three licensed staff members that conducted a skin assessment on this patient reported to the Risk Manager the allegations of abuse made by this patient (refer to tag A-145)”

“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: 38015 Based on observation, interview and record review, the facility failed to meet the Condition of Participation requirements for Physical Environment. The facility failed to ensure the hospital was maintained to ensure compliance with patient safety: A) Patients on suicide precautions were exposed to a room that contained ligature risks and other patient hazards on the facility’s A1/A2 unit. The unit, a general adult male unit, had a dysfunctional self-locking door opening to a nutritional galley room which failed to automatically lock, remaining open for easy patient accessibility. This was not recognized by any staff. There were currently 19 patients with active suicide precautions orders residing on the unit (refer to tag A-701); B) Facility’s A1/A2 unit had a hallway leading to it which had a door opening to a group activity room that also contained ligature risks and other patient hazards which was accessible to patients. This room also had a dysfunctional self-locking door which failed to automatically lock. This was also unrecognized by staff (refer to tag A-701); C) Facility had two bulletin board units present in the entrance to the hospital made of materials that were safe to be used in a behavioral health hospital. These bulletin boards were identified as an environmental risk (refer to tag A-701).”

“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, interview and record review, the facility failed to ensure patient’s rights to receive care in a safe setting as shown by: A) Failing to prevent 19 of 29 patients on facility’s Unit A1/A2 who were on active suicide precautions (Patient #’s 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, & #30), from being exposed to a room containing hazards for self-harm. This unit, housing adult males, had a dysfunctional self-locking door opening into a patient nutrition galley room which failed to automatically lock, remaining open for easy patient accessibility. This was not recognized by any staff. The room, which connected to the unit’s common area dayroom, contained numerous ligature risks and other hazards; B) Unit A1/A2 had a hallway leading to it which had a door opening to a group activity room that was also a dysfunctional self-locking door that failed to automatically lock, and remained open. This was also unrecognized by staff. There was potential for patients passing through the hallway to enter this room which contained ligature risks and other potential safety hazards to patients; C) Facility was not adhering to their own Safety/Security Risk Assessment-Hospital Wide procedure for not having any plastic bags on campus; large plastic trash bags were found inside the A1/A2 galley room. D) The presence of 2 of 2 bulletin board units in the common entrance foyer to the hospital which were made of materials that were unsafe to be used in a behavioral health hospital. The bulletin boards were identified as an environmental risk, and; E) Staff failing to maintain 6 of 6 food trays at a safe temperature once the trays were delivered to the unit. Staff had not been properly educated on the safe storage of food trays that had been delivered to the unit. A policy clearly outlined the timeframes and mechanisms of safe food storage in the patient care areas. Findings included: A. B. and C. Review of facility policy #200.08 titled “SAFETY OF PATIENTS, VISITORS AND OTHERS. Section 02: PATIENT CARE PROCEDURES”, revised 03/31/2020 showed that to ensure a safe and secure environment of care, staff will conduct safety rounds on the physical environment every shift done by nursing staff. All safety concerns will be reported to the Charge Nurse or House Supervisor. Review of facility policy #200.29 titled “ROUNDS FOR PATIENT OBSERVATION. SECTION 02: PATIENT CARE PROCEDURES” last revised 03/31/2020 showed that staff who are performing patient rounds are to observe for and report physical plant damage and ensure that doors which are supposed to be locked, are in fact locked. Review of facility policy # LD 1.02 titled “PATIENT SAFETY PLAN. SECTION 05: LEADERSHIP”, last revised 02/11/2025 showed that the Patient Safety Plan included identifying Hazardous Conditions as part of the ongoing risk assessments, and leadership will perform rounds on a daily basis in patient care areas to ensure safe practices are occurring. In addition, the scope of the Patient Safety Plan encompasses patient safety issues with environment of care. Observation on 4/9/25 at 3:15 pm of the facility’s Unit A1/A2, an all male general adult unit showed the following: There was a large common area dayroom filled with several patients watching TV. A door was present in this room labeled “Galley”. This door was cracked open and not closed shut. When the door was pushed open and allowed to close and self-lock on its own as it was designed for, it failed to do so and remained ajar. The door was then tested several times by pushing it open and allowing it to shut on its own, but it consistently and repeatedly failed to do so. This allowed free and effortless entry by all patients on the unit. Observation inside the Galley room during the time of the door failure findings showed it was mainly being used for patient nutrition and storage. The following were found: ligature risks consisting of numerous metal cabinet door ‘loop’ type handles, a metal ‘V’-shaped door closer protruding from top of the door, a metal refrigerator handle, a 4-foot electrical cord from an ice machine, a sink faucet; large plastic trash bags-one lining a trash can and another unused bag hanging from the side of the trash can-representing suffocation/strangulation risks; a large metal-frame cup holder which could be used as a weapon; a return air vent on the ceiling that led to a space in-between ceiling and roof, large enough for a patient to crawl into and accessible by standing on two tables being stored in room. In an interview at the time of findings with Administrator (CEO) Staff #A, who was present at the time, he stated that the door should have been shut and locked, and there were numerous patient safety risks inside the room, including ligature points. Staff #A also stated that there should be no more plastic bags allowed on the campus. In an interview at the time of findings with Director of Plant Operations (DPO) Staff #G, who was also present at the time, he stated that the door to the Galley was not shutting and locking like it should have and must never remain open and unlocked due to ligature risks inside room. In an interview at the time of findings with Assistant Chief Nursing Officer (ACNO) Staff #C, she stated there were ligature risks inside the Galley room and the door must remain closed and locked. Record review of the patients clinical charts who were present on Unit A1/A2 revealed there were 19 on active suicide precautions: Patient #’s 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, & #30. Review of facility’s documents titled “Safety/Security Risk Assessment-Hospital Wide” showed the following identified hazardous items/conditions inside Unit A1/A2’s Galley: “Multiple misc. ligature points (door frame, closer, refrigerator, cabinet door pulls, vents, ice machine, faucet)”. The staff responsible for monitoring this room were listed as Nursing and Plant Ops. Further observation on 4/9/25 at 3:35 pm revealed there was a common area hallway leading into Unit A1/A2. This hall was typically used staff and also by groups of patients when being led around the facility campus by staff. There was another self-locking door identified which opened to the hallway used as a patient activity room, “A101 Activity/Group Room”. This door was also cracked open like the Galley room door and did not close shut and lock automatically as it was designed to do. Observation inside this room revealed it to have a ‘drop ceiling’, also known as a false ceiling, which had removable tiles. Behind these tiles were ligature risks consisting of plumbing pipes for the sprinkler system, electrical conduits, and light fixtures. Tables and chairs inside this room allowed a patient to stand on top of them to access the ceiling. In addition, there was also a “V”-shaped metal door closer protruding from the top of the door, window blinds, and a TV mount. There was also a portable oxygen tank present on a metal stand with an attached nasal cannula air hose. There were also large air vents present in the room. In an interview at the time of findings with DPO Staff #G, he stated that there were ligature risks inside the room and the door should have been shutting closed and locking automatically like the Galley room door. He also stated that the doors were part of the facility-wide risk assessment and should have been noticed by staff and reported to him. Further review of the facility’s risk assessment document showed the following hazards for the Activity/Group Room: “Door Frame, chairs, closer, blinds, tv and mount, cords, vents”; Under the heading “Mitigation of Risk”, it stated that patients are not allowed in this room without a staff member and the door is secured with a “store room function lock and closer”. In addition, under the heading “Mitigation of Risk”, it stated that patients are not allowed in this room without a staff member, and the door is secured with a “store room function lock and closer”. The staff responsible for monitoring this room were listed as Nursing and Plant Ops. 35028 D. Bulletin Boards. During a tour of the hospital on 4/11/2025 at 10:30 AM, two enclosed bulletin boards each with two locking sliding glass doors were observed in the vestibule or airlock (the area that acts as an antechamber between the exterior and the interior structure) at the front entrance of the hospital. In an interview with Staff A (CEO) and Staff G (DPO) during that tour, they both stated that the glass could be easily broken and then used as a means of harming self or others. They also stated the bulletin board units needed to be replaced with units made from shatter-resistant materials. Record review of the Environmental Risk Assessment showed that the assessment did not include the bulletin board units with sliding glass doors as an environmental risk. E. Safe Temperature of Food Trays. Record review of Policy # C015, “Tray Identification / Delivery / Pick-up,” revised 1/2025, showed: “All trays / food served from Food and Nutrition Services Department ... [are] marked with the patient’s identifying information. Trays are delivered to each nursing unit by Food and Nutrition Services Department.” The remainder of the policy is geared more toward medical surgical facilities and not specific to the unique needs of Houston Behavioral Healthcare Hospital’s psychiatric population. Timeframes and mechanisms for storage of food on the units are not outlined in the policy. During a tour of the adult male unit (A1-A2) on 4/10/2025 at 1:30 PM, six 3-compartment foam hinged lid containers were observed on a small table in the galley. Each container had a patient name and “11:20” [AM] written on the lid and contained chicken and sausage jambalaya, fried okra, and a dinner roll. Based on the documentation on the lid, the food had been in the containers for over two hours. In an interview with Staff J [MHT] during the tour on 4/10/2025 at 1:30 PM, he stated the six trays that were on a small table in the galley were for patients that had missed lunch because they were asleep. When asked how long the trays could be left out at room temperature, he stated, “How long do you think they can be left out.” When pressed by the surveyor to answer the question, he stated he thought the trays could be left out at room temperature for two hours. He was prompted to look at the timeframe written on the lid of the containers, noting that over two hours had passed. He discarded the food only after being prompted to do so. In an interview with Staff F [Dietary Manager] on 4/11/2025 at 10:07 AM, she stated that some patients are not allowed to come to the cafeteria for meals and that meals are taken to the unit for those patients. She also stated: “ Food is placed in Styrofoam containers by kitchen staff. “ Containers with special diets are labeled with the patient’s name and the type of diet. “ The time the containers leave the kitchen is also written on the top of each container of food. “ The containers are delivered to the units on a food cart. “ The MHT on the unit passes out the food to patients. “ The containers of food can sit on the counter for one hour. “ After one hour, the containers are placed in the refrigerator by unit staff. “ When snacks are taken to the units between meals, the containers of food that have been placed in the refrigerator are discarded by kitchen staff. She concluded by saying, “When I got here, this is the way they did it. I’m unsure of the policy.” In an interview with Staff L [Infection Control] on 4/10/2025 at 2:15 PM, he stated food could be left out for an hour if the room temperature was over 90 degrees and for two hours if the food was at room temperature. He also stated he did not know about the training that Staff C [ACNO] had provided on food storage about a year ago. Also of note, Staff L [Infection Control] had been asked if there was a policy that addressed the timeframes of food storage. The only policy that was provided was Policy # 09 IC 3.03 DRAFT, revised 1/31/2024, titled “Transmission Based Precautions.” This policy did not address the issues being discussed. In an interview with Staff C [Assistant CNO] on 4/10/2025 at 2:10 PM, she stated, “Food can be on the unit for 30 minutes, then to the refrigerator to be disposed of within 2 hours from the time it left the kitchen.” She also stated she got the material for her training from Staff F [Dietary Manager], adding that the training was conducted in August of 2024 and “about 80% of the staff got the training.” She concluded the interview by saying that additional training needed to be done for all staff handling the patient’s food.”

“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 a timely and thorough, objective investigation of allegations of abuse made by Patient #3 was conducted by the Risk Manager as outlined in hospital policy. Additionally, the facility failed to ensure that the three licensed staff members that conducted a skin assessment on Patient #3 reported to the Risk Manager the allegations of abuse made by Patient #3. Findings were: Record review of the policy RI.1.16, “Abuse, Neglect, and Exploitation Reporting, Investigation and Response to Internal Events”, revised 2/2024, showed: “As Houston Behavioral Healthcare Hospital respects and protects the rights and dignity of the individuals served, all allegations of abuse, neglect or rights violations within the facility will be investigated ... D. Investigation a. All allegations of patient abuse, neglect or exploitation will be promptly and objectively investigated by the Director of Risk Management by interviewing individuals involved or witnessing the event and conducting a thorough review of the case and situation.” Record review of the Daily Nursing Assessment Note for Patient #3 written by Staff Q [RN] on 2/23/2025 at 9:00 AM showed: “Patient reported to nursing staff stating, ‘One of the overnight male staff hit me on my shoulder and I want to be transferred to another unit’ ... patient [reported to a family member]. Family member reported to police. Police showed up at the facility to take patient’s report. Patient made statement to police ... Physician was notified ... ordered a skin assessment of patient’s upper extremities to rule out injury. Skin assessment conducted by NP [Nurse Practitioner], supervisor, and nursing staff at 12:45 PM. Assessment showed no injury, no lacerations. Patient denies all pain or injury.” Record review of the Physician Progress Note for Patient #3 written by Staff P [Nurse Practitioner] on 2/23/2025 at 1:31 PM showed: “A bald guy beat me up last night.” The patient phoned her sister who then phoned the police. “Skin assessment done by NP and 2 RNs.” Record review of the Grievance Log showed that on 3/11/2025 (not timed) Patient #3’s “mother presented to the hospital regarding report of alleged abuse that occurred while the patient was admitted. Mom felt that daughter wouldn’t just make up that someone abused her and that no one did anything about it when it took place.” Record review of the investigative note dated 3/11/2025 [not timed] written by Staff D [Patient Advocate] outlining allegations of abuse made by the mother of Patient #3 showed: “Patient mother presented to facility 3/11/25 regarding report of alleged abuse on 2/22/25 while the patient was admitted in our facility. Mom feels patient wouldn’t just make up someone abusing her and that no one did anything about it. Patient Advocate met with mother retrieving incident reports associated with patient and nursing notes. Advocate noted prior elopement attempt and false 911 call three days prior of alleged event. Disorganized thought process and skin assessment post notifying staff of alleged assault towards her which noted no findings supporting her allegation.” In an interview with Staff D [Patient Advocate] on 4/9/2025 at 12:45 PM, he stated: Patient #3 described the male staff member that allegedly assaulted her as “tall” and “wearing a beanie-style hat.” He further stated that he reviewed the surveillance video for 2/23/2025 for the following timeframes: 10:00AM - 5:00PM and 11:00PM - 2:00AM, adding “The surveillance video for 11:00PM-2:00AM showed Staff J [MHT] making rounds. He was wearing a beanie-style hat. He was seen interacting with Patient #3. At times Staff J [MHT] would be off camera in patient’s rooms as he rounded.” Staff D [Patient Advocate] concluded the interview by saying he did NOT talk with Staff J about the allegations. In an interview with Staff J [MHT] on 4/9/2025 at 4:55 PM, he was observed as being a tall - approximately 6’6” - black male. He was wearing a beanie hat. He was shown a picture of Patient #3. He stated he remembered her. He also stated he knew nothing of any allegations of abuse made by Patient #3 toward him or anyone else. He also stated he had not been questioned by Staff D [Patient Advocate] or Staff B [Risk Manager] about any allegations of abuse made by Patient #3. It was during this interview that he “first heard of the allegations.” He denied hitting Patient #3. In interviews with Staff D [Patient Advocate] and Staff B [Risk Manager] on 4/9/2025 at 4:55 PM and 5:10 PM respectively, they stated that Staff Q, the RN on duty when Patient #3 alleged abuse; the RN Supervisor; and Staff P, the Nurse Practitioner, did NOT report to them any allegations made by Patient #3 of abuse by a male staff member. Staff B [Risk Manager] went on to say that he had not been involved in the investigation of alleged abuse made by Patient #3, adding that he had read the letter composed by Staff D [Patient Advocate]. Staff B [Risk Manager] concluded by saying that allegations of patient abuse are to be investigated by him as the Risk Manager.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 35028 Based an observation, interview, and record review, the facility failed to ensure that the Director of Dietary Services was qualified in safety practices for food handling. This resulted in the facility’s failure to ensure that: 1) Staff maintained 6 of 6 food trays at a safe temperature once the trays were delivered to the unit. 2) Staff had been properly educated on the safe storage of food trays that had been delivered to the unit. 3) A policy clearly outlined the timeframes and mechanisms of safe food storage in the patient care areas. Findings were: Record review of Policy # C015, “Tray Identification / Delivery / Pick-up,” revised 1/2025, showed: “All trays / food served from Food and Nutrition Services Department ... [are] marked with the patient’s identifying information. Trays are delivered to each nursing unit by Food and Nutrition Services Department.” The remainder of the policy is geared more toward medical surgical facilities and not specific to the unique needs of Houston Behavioral Healthcare Hospital’s psychiatric population. Timeframes and mechanisms for storage of food on the units are not outlined in the policy. During a tour of the adult male unit (A1-A2) on 4/10/2025 at 1:30 PM, six 3-compartment foam hinged lid containers were observed on a small table in the galley. Each container had a patient name and “11:20” [AM] written on the lid and contained chicken and sausage jambalaya, fried okra, and a dinner roll. Based on the documentation on the lid, the food had been in the containers for over two hours. In an interview with Staff J [MHT] during the tour on 4/10/2025 at 1:30 PM, he stated the six trays that were on a small table in the galley were for patients that had missed lunch because they were asleep. When asked how long the trays could be left out at room temperature, he stated, “How long do you think they can be left out.” When pressed by the surveyor to answer the question, he stated he thought the trays could be left out at room temperature for two hours. He was prompted to look at the timeframe written on the lid of the containers, noting that over two hours had passed. He discarded the food only after being prompted to do so. In an interview with Staff F [Dietary Manager] on 4/11/2025 at 10:07 AM, she stated that some patients are not allowed to come to the cafeteria for meals and that meals are taken to the unit for those patients. She also stated: “ Food is placed in Styrofoam containers by kitchen staff. “ Containers with special diets are labeled with the patient’s name and the type of diet. “ The time the containers leave the kitchen is also written on the top of each container of food. “ The containers are delivered to the units on a food cart. “ The MHT on the unit passes out the food to patients. “ The containers of food can sit on the counter for one hour. “ After one hour, the containers are placed in the refrigerator by unit staff. “ When snacks are taken to the units between meals, the containers of food that have been placed in the refrigerator are discarded by kitchen staff. She concluded by saying, “When I got here, this is the way they did it. I’m unsure of the policy.” In an interview with Staff L [Infection Control] on 4/10/2025 at 2:15 PM, he stated food could be left out for an hour if the room temperature was over 90 degrees and for two hours if the food was at room temperature. He also stated he did not know about the training that Staff C [ACNO] had provided on food storage about a year ago. Also of note, Staff L [Infection Control] had been asked if there was a policy that addressed the timeframes of food storage. The only policy that was provided was Policy # 09 IC 3.03 DRAFT, revised 1/31/2024, titled “Transmission Based Precautions.” This policy did not address the issues being discussed. In an interview with Staff C [Assistant CNO] on 4/10/2025 at 2:10 PM, she stated, “Food can be on the unit for 30 minutes, then to the refrigerator to be disposed of within 2 hours from the time it left the kitchen.” She also stated she got the material for her training from Staff F [Dietary Manager], adding that the training was conducted in August of 2024 and “about 80% of the staff got the training.” She concluded the interview by saying that additional training needed to be done for all staff handling the patient’s food.”

“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: 38015 Based on observation, interview and record review, the facility failed to ensure the condition of the physical plant was maintained to ensure the safety and well-being of patients as shown by: A) 19 of 29 patients on facility’s Unit A1/A2 who were on active suicide precautions (Patient #’s 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, & #30, were exposed to a room containing hazards for self-harm. This unit, housing adult males, had a dysfunctional self-locking door opening into a patient nutrition galley room which failed to automatically lock, remaining open for easy patient accessibility. This was not recognized by any staff. The room, which connected the unit’s common area dayroom, exposed patients to ligature risks and other dangers; B) The same unit, A1/A2, had a hallway leading to it which had a door opening to a group activity room that was also a dysfunctional self-locking door which failed to automatically lock and remained open. This was also unrecognized by staff. There was potential for patients passing through the hallway to enter this room which also contained ligature risks and other potential hazards to patients; C) The presence of 2 of 2 bulletin board units in the entrance to the hospital which were made of materials that were safe to be used in a behavioral health hospital. The bulletin boards were identified as an environmental risk. Findings included: Review of facility policy #200.08 titled “SAFETY OF PATIENTS, VISITORS AND OTHERS. Section 02: PATIENT CARE PROCEDURES”, revised 03/31/2020 showed that to ensure a safe and secure environment of care, staff will conduct safety rounds on the physical environment every shift by nursing staff. All safety concerns will be reported to the Charge Nurse or House Supervisor. Review of facility policy #200.29 titled “ROUNDS FOR PATIENT OBSERVATION. SECTION 02: PATIENT CARE PROCEDURES” last revised 03/31/2020 showed that staff who are performing patient rounds are to observe for and report physical plant damage and ensure that door which are supposed to be locked, are in fact locked. Review of facility policy # LD 1.02 titled “PATIENT SAFETY PLAN. SECTION 05: LEADERSHIP”, last revised 02/11/2025 showed that the Patient Safety Plan included identifying Hazardous Conditions as part of the ongoing risk assessments, and leadership will perform rounds on a daily basis in patient care areas to ensure safe practices are occurring. In addition, the scope of the Patient Safety Plan encompasses patient safety issues with environment of care. Observation on 4/9/25 at 3:15 pm of the facility’s A1/A2 unit, a general adult all male unit showed the following: There was a large common area dayroom filled with several patients watching TV. A door was present in this room labeled “Galley”. This door was cracked open and not closed shut. When the door was pushed open and allowed to close and self-lock on its own as it was designed for, it failed to do so and remained ajar. The door was then tested by pushing it open and allowing it to shut on its own, but it repeatedly failed to do so. This failure could allow free and effortless entry by all patients on the unit. Observation inside the Galley room during the time of the door failure findings showed it was mainly being used for patient nutrition and storage. The following were found: ligature risks consisting of numerous metal cabinet door handles, a metal ‘V’-shaped door closer protruding from top of the door, a metal refrigerator handle, a 4-foot electrical cord from an ice machine, a sink faucet; large plastic trash bags-one lining a trash can and another unused bag hanging from the side of the trash can representing suffocation/strangulation risks; a large metal-frame cup holder which could be used as a weapon; a return air vent on the ceiling that led to a space in-between ceiling and roof, which was large enough for a patient to crawl into and accessible by standing on two tables being stored in room. In an interview at the time of findings with Administrator (CEO) Staff #A, who was present at the time, he stated that the door should have been shut and locked, and there were numerous patient safety risks inside the room, including ligature points. Staff #A also stated that there should be no more plastic bags allowed on the campus. In an interview at the time of findings with Director of Plant Operations (DPO) Staff #G, who was also present at the time, he stated that the door to the Galley was not shutting and locking like it should have and must never remain open and unlocked due to ligature risks in room. In an interview at the time of findings with Assistant Chief Nursing Officer (ACNO) Staff #C, she stated there were ligature risks inside the Galley room and the door must remain closed and locked. Record review of the patients clinical charts present on Unit A1/A2 revealed there were 19 on active suicide precautions: Patient #’s 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, & #30. Review of facility’s documents titled “Safety/Security Risk Assessment-Hospital Wide” showed the following identified hazardous items/conditions inside Unit A1/A2’s Galley (a room connected to the common area dayroom, separated by a self-locking door): “Multiple misc. ligature points (door frame, closer, refrigerator, cabinet door pulls, vents, ice machine, faucet)”. The staff responsible for monitoring this room were listed as Nursing and Plant Ops. Further observation on 4/9/25 at 3:35 pm revealed there was a common area hallway leading into Unit A1/A2. This hall was typically used staff and also by groups of patients when being led around the facility campus by staff. There was another self-locking door identified which opened to the hallway used as a patient activity room the A101; Activity/Group Room. This door was also cracked open like the Galley room door and did not close shut and lock automatically as it was designed to do. Observation inside this room revealed it to have a ‘drop ceiling’, also known as a false ceiling, which had removable tiles. Behind these tiles were ligature risks consisting of plumbing pipes for the sprinkler system, electrical conduits, and light fixtures. Tables and chairs inside this room allowed a patient to stand on top of them to access the ceiling. In addition, there was also a “V”-shaped metal door closer protruding from the top of the door, window blinds, and a TV mount. The was also a portable oxygen tank on a metal stand with an attached nasal cannula air hose. In addition, there were also large air vents present in the room. In an interview at the time of finding with DPO Staff #G he stated that there were ligature risks inside the room and the door should have been locking automatically like the Galley room door. He also stated that the doors were part of the facility-wide risk assessment and should have been noticed by staff and reported to him. Further review of the facility’s risk assessment document showed the following hazards for the units Activity/Group Room: “Door Frame, chairs, closer, blinds, tv and mount, cords, vents”. In addition, under the heading “Mitigation of Risk”, it stated that patients are not allowed in this room without a staff member and door is secured with a “store room function lock and closer”. In addition, under the heading “Mitigation of Risk”, it stated that patients are not allowed in this room without a staff member and the door is secured with a “store room function lock and closer”. The staff responsible for monitoring this room were listed as Nursing and Plant Ops.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 43549 The hospital must ensure that the exercise of patients’ rights requirements are met. Based on observation and record review and interview the facility failed to ensure that the exercise of patients’ rights requirements are met by allowing an inpatient with a reasonable opportunity to get food for 15 hours one of one patient (#F) on a 1:1 observation. During a tour of the facility on 8/27/24 at 10:30 am patient #F was observed sitting in a unit day room watching television with a Mental Health Technician (MHT) #20 standing next to her as a 1:1 monitor. Patient #F requested this surveyor speak to her. During an interview on 8/27/24 at 10:35. The patient reported to this surveyor that she was on 1:1 observation because she feels suicidal with plans to either be discharged and overdose or to “cheek” (not swallow and save for later) her pills and overdose in the facility. Patient #F stated the prior day, 8/26/24 she was hungry and had not eaten from after lunch at 11:30 on 8/25/25 until approximately 11:00 am on 8/26/24. She stated she sleeps a lot due to her depression thus missing meals. On 8/25/24 she stated she took a nap after lunch and asked MHT #20 to awaken her for dinner. She stated she was not awakened for the evening meal and did not independently awaken until about 9:00 am the next morning, 8/26/25. She explained she was very hungry when she awoke and wanted “real food” not snacks of chips. She stated she was told by MHT #20 she would have to wait until snack time at approximately 10:00 to eat a snack and that lunch was at 11:00. She reported that MHT # 20 refused to give her any food until snack time and stated “It’s not my problem you sleep. If you got up, you could eat.” Patient #F stated she became angry and acted out resulting in her receiving emergency meds and time in seclusion. She stated she was given food to eat when lunch was served at about 11:00 am on 8/26/24 approximately 23.5 hours later. Patient #F’s record contained a seclusion/ restraint form dated 8/26/24 indicating the patient was in seclusion from 09:55 am to 10:03 and had received Zyprexa 10 mg and Benadryl 50 mg IM as emergency medication for behaviors od agitation, kicking and swinging at staff. When interviewed, 8/27/24 at 10:45 MHT #20 stated she was the staff assigned as the 1:1 for patient #C on 8/26/and 8/27/24. When asked if the patient had asked her to awaken her for dinner on 8/26/24 she said “Yes.” When asked if she had awakened the patient, she said she hadn’t, that that was not her job. She stated the patient sleeps a lot and she just lets her. MHT #20 was asked if there was a reason why she did not give the patient any food when she requested it, knowing the patient had not had dinner or breakfast as she had been wit the patient during those times. She adamantly responded “We can’t give just anybody a snack when they want it. If we did that everybody would want a snack.” Review of MHT #F’s personnel information revealed she was assigned to 1:1 patient #C alone on 8/26/27 and 8/27/24 while still in training as a new hire. She had with previous MHT experience at a prior employer.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 23032 Based on observation, interview, and document review, the facility failed to meet the requirements of the Condition of Participation for Patient Rights. This failure had the potential to affect all patients receiving services in the hospital. The facility failed to protect a patient’s right to be free from abuse & neglect (Patient # 1 ). Facility staff failed to notify hospital nursing leadership and complete an Incident Report concerning an assault and an atttempted assault. This occurred on 2/21/2024 in the common day area of B-1/ B-2 Unit . This deficient practice contibuted to an unsafe room assignment of Patient # 2 that led to the assault and subsequent death of Patient # 1. Refer to Tag A-0145”

“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: 23032 Based on observation, interview, and record review, the facility failed to protect a patient’s right to be free from abuse & neglect (Patient # 1 ). Facility staff failed to notify hospital nursing leadership and complete an Incident Report concerning an assault and an attempted assault. This occurred on 2/21/2024 in the day area of Unit B-1/ B-2. This deficient practice contributed to an unsafe room assignment of Patient # 2 that led to the assault and subsequent death of Patient # 1. Findings included: Review of facility self-reported incident, dated 2/22/2024, showed : Patient # 1 was admitted on 2/21/2024 at 1:55 AM to B1/B2 unit with a diagnosis of major depressive disorder. He was assigned to room 211-A. Patient # 2 was admitted on 2/20/2024 at 7 PM to A1/A2 unit with a diagnosis of schizophrenia. On 2/21/2024 around 8:30 AM, Patient # 2 got into a physical altercation and punched a peer on the left side of his face. An order was written to transfer Patient # 2 to B1/B2 unit. Patient # 2 arrived on the B1/B2 unit about 9 AM and was assigned to room 211-B. Facility review of camera footage showed the first time Patients # 1 and # 2 were in room 211 together was on 2/21/2024 between 12:03 PM until 12:59 PM. The door was closed most all of this time period. Patient # 2 came out of the room at 12:59 PM: video showed something red on his left hand. Patient # 2 approached another Patient (# 13) and hit him unexpectedly. A tech noticed a red substance on Patient # 2’s hands that appeared to be blood; they didn’t see blood on the other patient. Staff ran into the room (211) and found Patient #1 injured. A code was called; cardiopulmonary resuscitation (CPR) initiated; and an automatic external defibrillator (AED) was placed on Patent # 1 . No shock was indicated. Patient # 1 was transported via emergency medical services (EMS) to an acute care hospital. The facility was notified that Patient # 1 was pronounced dead at 2:04 PM. ~~~~~~~~~~~~~~~~~~~~~~~~~ Record review of facility policy titled: “Patient Rights and Responsibilities, revised date 02/22/2023, showed: C. The Patient Bill of Rights shall include, but is not limited to, the patient’s right to:....3. Considerate, dignified and respectful care, provided in a safe environment, free from all forms of abuse, neglect... Record review of facility policy titled : “Incident Report”, revised 04/07/2020, showed: -An Incident Report is to be completed for every occurrence which meets the following definition: any happening not consistent with the routine care or operation of the facility. -The Incident Report must be completed immediately following an event that meets the above-mentioned definition. -Categories to be reported include: assaultive behavior to peer; assaultive behavior to staff...; -Notifications to (nursing) supervisor, as indicated. ~~~~~~~~~~~~~~~~~~~~~~~~~ Facility staff interviews conducted on 3/01/2024 on unit B1 / B2 between 10:30 AM and 12:30 PM showed the following: [*All staff interviewed verified they were present on the B1 / B2 unit the day Patient # 2 assaulted Patient ID # 1 in their shared room # 211] A. Staff -H said : -Patient # 2 was transferred from A1/A2 Unit because he tried to hit his room mate on that unit. -This patient did not go directly into to his newly assigned room (211), but spent 30 to 40 minutes slowly walking around the the day room. While he was in the day room area, Patient # 2 attempted to assault another patient near the entrance to the group room. He also hit a Tech who tried to hold him back. -Staff H verified this occurred prior to Patient # 2 entering his room (211) for the first time. B. Staff -L said: -Patient # 2 had been transferred to B1/B2 unit from a different unit because he hit another patient. He wandered around in the day room after he first got on our unit. Within less than an hour, he chased and tried to attack another patient ( identified him as Patient # 10 ). -Staff L verified this occurred prior to Patient # 2 entering his room (211) for the first time. C. Staff -F said: -He was the charge nurse on the B1 / B2 unit the day Patient # 2 assaulted Patient ID # 1 in their shared room # 211. Staff F said he was unaware of Patient # 2’s attempted assault of another patient and hitting a tech prior going into his room, # 211. ~~~~~~~~~~~~~~~~~~~~~~~~~ Record review of facility House Supervisor reports for the night shift, dated 2/20/2024 and day shift, dated 2/21/2024, failed to show documentation that the house supervisor was notified of any attempted or actual assaults by Patient # 2 after he was transferred to B1/B2 Unit and before he entered his newly assigned room # 211. Record review of all documented incident reports related to Patient # 2 : failed to show a documented variance report of the assault and attempted assault that occurred on 2/21/2024 shortly after this patient arrived in the B1/B2 unit. ~~~~~~~~~~~~~~~~~~~~~~~~~ Video Footage Review: [video date & time reviewed: 2/21/2024 8:45 AM- 10 AM ] Video camera footage review on 3/4/24 at 2:50 PM of B1/B2 Unit with Staff -A , Chief Executive Officer (CEO ) and Staff B, Chief Nursing Officer (CNO) CNO showed: A common group room was visible on left side of view. This group room had glass walls which allowed visualization into room, partially seen on video; a common area dayroom in the middle encompassing the majority of the camera view; unit double door entrance/exit on right side of view. At approximately 9:00 A.M., Patient # 2 was seen entering the unit through double doors escorted by two staff. He was wearing a black jacket and was barefoot. He then spent the next 40 minutes standing and pacing in the common area dayroom with the majority of time spent in the common area dayroom just outside the common group room. He was initially barefoot until he was offered socks by the staff at 9:15 A.M.. He temporarily sat down and allowed staff to place the socks on his feet. On three occasions after putting on the socks, the patient was seen requesting and receiving cups of water from staff at the nurse’s station. At 9:41 A.M. Patient# 2 was seen entering the common group room. Within 5 seconds he was seen running after another person, Patient # 10. Patient # 2 had both his fists held up in a fighting stance. Patient # 2 chased Patient # 10 outside the room and into the common day area. Several (at least three staff) were then seen intervening, surrounding Patient # 2 getting in between him and Patient # 10. Patient # 2 was then seen striking a mental health tech (MHT), Staff -K, with both arms simultaneously. Patient # 2 subsequently appeared to have calmed down and was allowed to pace the unit again. ~~~~~~~~~~~~~~~ During interviews conducted on 3/04/2024, immediately after video footage review , the CNO said “no one told us about this.” Both the CEO and CNO acknowledged if they had known of the attempted / and actual assault, it would have changed the room assignment decision. Patient # 2 would not have been roomed with Patient # 1. CNO later confirmed there were a total of 3 mental health techs (MHTs) seen in the video during the assaultive behavior event by Patient # 2 [ one (1) MHT stepped in between the patients; and 2 assisted during the event]. One (1) registered nurse (RN) assisted during the event. There was an additional RN and a licensed vocational nurse (LVN) viewed in the vicinity watching the event.”