Medical Behavioral Hospital of Clear Lake, LLC

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 38387 Based on record review and interview, the facility failed to ensure medications were administered as physician order in one of seven patient medical records reviewed (Patient #A). Findings include: Record review of facility policy Medication Reconciliation (Admission and Discharge Medications) (Policy ID 12197197, last approved 02/2026), showed the following information: “When the most accurate listing of medications has been completed, the nurse will compare the list to the must order each drug, dosage, etc. by written or verbal order. Those medications, which match these orders, are considered to be reconciled and a check should be placed in the “(admit) Continue” box. Medications, which do not match from the admission database to the orders, require reconciliation. Communication with the admitting provider is required to discuss those medications that were not reordered on admission. If the provider decides the medication is not to be continued during hospitalization, then a check is placed in the “(admit) Discontinue” box. 1. Time frames for medication reconciliation will vary based on the time of admission. A 24-hour medication that requires reconciliation does not need to be reconciled at 0300, while an antihypertensive medication due at 0600 will need to be reconciled. 2. Any medication that needs to be reconciled with the MD and is added should have a corresponding order written. 3. The Medication Reconciliation List is to be passed to the oncoming nurse if there are medications that need to be reconciled. When all medication orders have been reconciled, the completed form is placed on top behind the Providers order tab in the patient record.” Medical record for review for Patient #A revealed he is a 20 year old male who admitted to the facility on an EDO for SI and HI with a history of seizures. Review of his medical record revealed an order an order for clonidine 0.05 mg QAM, QPM (2 PM) on 07/12/26 at 3 PM and a discontinue order for clonidine on 07/16/26 at 4 PM. Review of provider notes from 07/12/26 at 3:18 PM it stated under Psychiatrist Assessment/Plan “abilify 10 mg QD lamotrigine 150 mg BID clonidine 0.05 mg QAM and QPM (1400)” Review of provider notes from 07/13/26 at 6:09 PM, it stated under Psychiatrist Assessment/Plan “discontinue abilify 10 mg PO daily due to patient-reported worsening aggression. Continue lamotrigine 150 mg PO BID for mood stabilization and seizure management. Continue clonidine 0.05 mg every morning and at 1400 for impulsivity, agitation, and behavioral regulation.” Review of provider notes from 07/14/26 at 4:19 PM, it stated under Psychiatrist Assessment/Plan “Continue lamotrigine 150 mg PO BID for mood stabilization and seizure management. Continue clonidine 0.05 mg every morning and at 1400 for impulsivity, agitation, and behavioral regulation.” Review of provider notes from 07/15/26 at 6:08 PM, it stated under Psychiatrist Assessment/Plan “Continue lamotrigine 150 mg PO BID for mood stabilization and seizure management. Continue clonidine 0.05 mg every morning and at 1400 for impulsivity, agitation, and behavioral regulation.” Review of provider notes from 07/16/26 at 2:39 PM, it stated under Psychiatrist Assessment/Plan “Continue lamotrigine 150 mg PO BID for mood stabilization and seizure management. Continue clonidine 0.05 mg every morning and at 1400 for impulsivity, agitation, and behavioral regulation.” Review of Patient #A’s Med-Dispense from 07/12/2026 to 07/16/2026, it revealed patient received clonidine 0.1 mg on 07/12/26 at 3:42 PM; 07/13/26 at 8:46 AM; NONE on 07/14/26; and 0.1 mg on 07/15/26. In an interview with Staff # 1 on 07/24/26 at 1:30 PM in the conference room confirmed the above findings.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 38387 Based on records reviewed and interviews, the facility failed to ensure nursing services carried out their responsibilities; and followed facility policies and procedures to ensure patient care and safety. Specifically, Nursing Services failed to: 1. Follow the patient’s physician orders and/or facility policy of wound care management and skin assessment for three of five patients reviewed (Patient #H, I, J). Refer to A0395 2. To develop and provide a nursing care plan to provide nutritional needs for one of five patients reviewed (Patient #H). Refer to A0396 As a result, the facility was not able to meet the requirements for the Condition of Participation, CFR 482.23 Nursing Services, and placed all patients in the facility at risk for the likelihood of harm.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 35028 Based on observation, interview, and record review, the facility failed to ensure a safe transition of Patient A, a 68-year-old male, from an acute inpatient psychiatric facility to a long-term treatment facility. Failure to do so resulted in an unsafe discharge. More specifically, the facility utilized Uber services to transport Patient A to a facility nearly three hours away. The patient was oriented to person only. His vision was compromised. He was on assaultive and elopement risk precautions - precautions that were not discontinued at the time of discharge. He was also at high risk for falls. Patient A had a PEG tube in place that required flushing every six hours. Additionally, Patient A had numerous physical problems including cerebrovascular accident (stroke) with left-sided weakness and dysphasia, dementia, pulmonary embolism treated with Eliquis (blood thinner), questionable metastasis of lung cancer, hypertension, and questionable A-Fib. The most dangerous risks of A Fib are stroke (from blood clots forming in pooled blood) and heart failure. The facility chose to transport the patient using an Uber. An ambulance, which would have been better equipped to provide medical care had Patient A encountered cardiovascular or pulmonary problems during the transit, was deemed too costly. Finally, during the transport to the receiving facility, Patient A pulled the hair of the Uber driver, which could have resulted in a serious automobile accident. Based on interviews and documents review, the facility does not have systems or processes in place to ensure effective and safe discharge of patients. Refer to A 802”

“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 patients’ right to receive care in a safe setting as shown by the presence of hazardous items and furnishings inside patient bedrooms. More specifically: A) There was CPAP machine tubing and electrical cord found inside Patient #M and #L’s bedroom which was unmonitored by staff, representing ligature risks; one Patient #L was actively suicidal. B) There were seven patient bedroom toilets with exposed sharp, rusty toilet bolts representing laceration risks (self-harm or accidental) and potential infection hazards. C) There was one of 22 wheelchairs had removable armrests that could be used as a weapon. D) There were 25 Medline soap dispensers in patient bathrooms that could be removed from the wall and disassembled for easy access to the coiled wire mechanics. The wire had been used by Patient N to self-harm. E) There was a towel dispenser in the seclusion room bathroom on Unit 100 that was not secured flush to the wall creating a potential tie of point for self-harm. Additionally, the handrail behind the toilet had a small gap that potentially could be used as a tie off point for self-harm. F) There was a metal playing card container on Unit 400 that could be bent in such a way as to create a sharp metal point for potential self-harm. Findings included: Review of facility policy #12197124 titled “Safety”, last revised 1/20, showed that the hospital staff would provide a safe environment for patients. It also showed that all patient belongings identified as restricted articles would be locked and only available to patients under staff supervision. Review of facility Risk Assessment documents showed a category for durable medical equipment, classifying it as “moderate risk” and stating that equipment is stored off the unit when not in use. It also showed that the suicide risk levels of patients sharing the same room with roommates using durable medical equipment will be taken into consideration to minimize ligature risk. In addition, it showed that any equipment left in a patient’s room would be moved immediately. Exposure of metal toilet bolts were not recognized as possible safety hazard risks in facility’s Risk Assessment. However, review of facility’s current Weekly Housekeeping Quality Audit showed that all toilets in all patient bathrooms were damage free under a checklist category labeled “Toilet clean, damage free, and flushes properly”. A) Observation on 1/6/26 at 9:35 am of facility’s 100 unit showed that patient bedroom #111 had an unattended CPAP machine (continuous positive airway pressure device) located on top of Patient #M’s bed. There was no one inside the bedroom. The machine had plastic airway tubing and an electric cord, both approximately six feet long. In an interview at the time of findings, CEO Staff #1 stated that it was Patient #M’s machine, who was getting ready to discharge. He added that the nurses should not have allowed the machine inside the room unattended and should have taken it away and secured it, acknowledging the machine’s tubing and cord were safety hazards. Record review of Patient #M’s medical chart showed he was suicidal when he was admitted to the facility. Review of Patient #L’s medical records showed he was still actively suicidal. He was admitted to the facility after he had been in an ER for a suicide attempt after intentionally overdosing on the drugs Oxycodone and Seroquel. Psychiatric progress notes dated 1/5/26 showed the patient “continues to endorse suicidal ideation” and indicated that he had a plan to commit suicide. Other psychiatric progress notes showed the patient had a history of multiple suicide attempts and him stating he “wanting to die for a long time”. B) Observation on 1/6/26 starting at 9:40 am showed the following rooms had sharp, rusty metal toilet bolts protruding vertically from the bathroom floor through the base of the toilet bowls, approximately ¼ to ½ inch high: Rooms 101, 102, 104, 206, 402, 408 & 411. In an interview at the time of findings, CEO Staff #1 and DPO Staff #9 acknowledged the bolts were safety hazards and they would be addressed and the hazards would be mitigated. 35028 . C) Wheelchairs. During the tour of unit 100 on January 6, 2026, Patient UU was observed sitting in a wheelchair in the commons area. The armrests of the wheelchair were removed by the surveyor with the push of a button. In an interview with Staff #1 (CEO) and Staff #9 (DPO), they stated that the wheelchair belonged to the patient. They also stated the armrest could be wielded as a weapon. D) Soap dispensers. During the tour of unit 200 on January 6, 2026, with Staff #1 (CEO) and Staff #9 (DPO), a Medline soap dispenser was observed in the bathroom of room 212. In response to the surveyor’s concern that the dispenser could be used as a tie off point for self-harm, Staff #1 (CEO) stated the soap dispensers had been installed on December 8, 2025, and that within an hour of the dispensers being installed, three had been “ripped off the wall.” Staff #9 (DPO) added, “Any force can pull them off. They’re held on with double sticky tape.” Staff #1 (CEO) went on to say that Patient N had removed the dispenser from the wall in his bathroom, disassembled it, and removed a coiled wire that he then used as a self-harm tool. Staff #9(DPO) stated the soap dispensers were in the process of being removed throughout the facility. Further observation on unit 200 confirmed this statement by Staff #9 (DPO). The tour on units 300 and 400 showed that there were 24 soap dispensers in the bathrooms. Review of the Admission Orders by Staff #14 (MD) dated January 2, 2026, 2:30pm, showed: Reason for admission - suicidal ideation, auditory hallucinations. He was placed on suicide precautions. Review of the Daily Nursing Assessment by Staff #12 (RN) dated January 3, 2026, 5:22pm, showed Patient N was “verbally aggressive.” He had a “superficial abrasion around the neck.” Patient N stated, “I took a spring from the soap dispenser in my bathroom. There are two in there. I took one and tried to slit my throat.” He was placed on “continuous 1:1” observation. Review of the Daily Nursing Assessment by Staff #13 (RN) dated January 3, 2026, 8:00pm, showed Patient N stated voices had instructed him to attempt to harm himself earlier, adding, “Voices in [my] head are so bad.” E) Towel dispenser and handrail. During the tour of unit 100 on January 6, 2026, with Staff #1 (CEO) and Staff #9 (DPO), it was observed that the towel dispenser in the seclusion room was not secured flush to the wall, allowing the left edge of the dispenser to be pulled out enough to create a tie off point. Additionally, the handrail behind the toilet had a small gap that potentially could be used as a tie off point. In an interview with Staff #9 (DPO), he stated the towel dispensers and handrails had been identified as a potential risk. The mitigation plan included screwing the left edge of the towel dispenser into the wall and caulking the top of the towel dispenser, as well as the bottom of the handrails. F) Metal playing card container. During the tour of unit 400 on January 6, 2026, with Staff #1 (CEO) and Staff #9 (DPO), it was observed that a metal playing card container was among the games in the commons area. In an interview with Staff #9 (DPO) during the tour, he agreed that the metal playing card container should not be on the unit because it could be bent in such a way as to create a sharp metal point that could be used for self-harm.”

“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: 38387 Based on review of facility policy, random record review, and confirmed in interviews, the facility’s nursing services failed to supervise and evaluate the nursing care for each patient in accordance with the patient’s physician orders and/or facility policy for three of five patients reviewed (Patient #H, I, J). Findings included: Review of the facility policy Wound Care and Treatment (Policy ID 12385988, approved 11/2025) revealed “Procedure FOR WOUND TREATMENT: treatment order will be obtained upon identification of a wound. o The order will include cleansing, the type of topical product (if indicated), the type of occlusive dressing (if indicated), the frequency of treatment application/dressing change. Standard precautions will be utilized during all contact with wounds. Treatment will be completed in accordance with the provider order and will be documented by the Wound re Nurse and/or designee. The provider will be notified immediately if there is evidence of wound regression or signs of infection. e provider will order additional interventions and/or a change in treatment as deemed necessary. charge orders will include any wound treatments that remain current.” Review of the facility policy Skin Assessment (Policy ID 12385990, approved 11/2025) revealed “the assessment process should include identification of any wounds, injuries, bruises, skin conditions, self-harm behaviors, and/or contraband” Patient #H Patient #H is an 84-year-old male with a history of Alzheimer’s who came to the facility for agitation and behavioral disturbances. On 10/20/2025 Patient #H suffered a fall as an inpatient that required him to go to the ED (emergency department). Following the ED visit, his assessment included orders: “forehead skin laceration with stitches; clean[with] NS [normal saline] tap dry, apply TAO [triple antibiotic] Bid [twice a day] for 5 days. Review of Patient #H record revealed no documentation that the wound was cleansed and assessed per orders on 10/21/2025 and 10/22/2025 for each of the nursing shift skin assessments. Patient #I Patient #I is a 48-year-old woman who admitted to the facility with suicidal ideations with a plan. Review of the patient record revealed Patient #I was involved in a behavioral incident on 08/12/2025 after slapping her 1:1 staff. She was given emergency behavioral medication. During the reassessment, the nurse documented “bruises (back, hips, buttocks) observed during 1:1 assessment.” Review of the patient record revealed no documentation that the bruising was assessed per facility policy for each shift assessment (08/13/2025; 08/14/2025; 08/15/2025; 08/16/2025). Patient #J Patient #J is a 61-year-old female admitted to the facility for altered mental status with schizophrenia. Review of Patient # J nursing notes following a patient incident on 09/06/2025 that included ‘pt [patient] has bruises on right forehead, right elbow and left fifth finger from being on the floor and self-falling on the floor.’ Review of Patient #J record revealed no documentation that the bruising sustained on 09/06/2025 were assessed per facility policy on 09/07/2025, 09/08/2025, 09/09/2025, or 09/10/2025 for each of the shift skin assessments. Review of Patient #J revealed she was transferred to the ED for further evaluation on 09/11/2025 after an unwitnessed fall. Review of the ED record from 09/11/2025 revealed patient #J came with multiple bruises in different stages of healing with very extensive hematomas affecting her left breast, left side of her torso, left hip right arm right elbow left arm and also her scalp. In an interview with staff #2 on 01/07/2026 at 2:40 PM in the conference room, she confirmed the above findings.”

“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: 38387 Based on review of the facility policy, record review, and confirmed in interview, the nursing staff failed to develop and provide a nursing care plan to provide nutritional needs for one of five patients reviewed (Patient #H). Findings included: Review of facility policy Standards of Nutrition of Care (Policy ID 12511831, effective 11/2025) it stated “based on the analysis of the objective and clinical data, nutrition problems are identified. They may include the following: Inappropriate weight status Potential for other nutrition problems Knowledge deficit of modified diets. Nutrition Intervention includes: Plan nutrition intervention. Formulate goals and determine a plan of action Implement nutrition intervention -Care is delivered and actions are carried out Documentation. Goals are developed to provide direction in solving identified nutrition problems. The goals will be realistic, understood by all caregivers, measurable, and consistent with overall medical therapy. Based on the identified nutrition problems and goals, an individualized nutrition care plan is developed in collaboration with the patient, family, nursing, speech therapy and other disciplines, as indicated for the patient. The care plan may include the following as immediate interventions: Nutrition Therapy Diet prescription Menu adjustment Nutritional supplements. Education Nutrition counseling re: modified or special diet Diagnostic Additional data needed to better identify nutrition problems Discharge Planning Interdisciplinary discharge plan Referral for additional nutrition intervention by a registered dietitian or a community agency or extended care facility. Nutrition Monitoring and Evaluation includes: Monitor progress Measure outcome indicators Evaluate outcome” Patient #H Patient #H is an 84-year-old male with a history of Alzheimer’s who came to the facility for agitation and behavioral disturbances. Review of the initial nursing assessment for Patient #H revealed no documentation of the nutritional screening. However, a regular diet was ordered for him at admission on 10/13/2025. Review of the 10/15/2025 medical progress notes revealed an assessment and plan for “GERD, diet management” Review of nursing notes on 10/18/2025 revealed ‘poor PO intake’ and ‘po fluid/food offered but refused.’ Review of nursing notes on 10/19/2025 revealed ‘refused food and liquids’ Review of provider orders on 10/20/2025 revealed an order for “encourage oral fluid intake 1800 ml/day for dehydration” Review of the 10/23/25 medical progress notes revealed “report pt poor oral intake in the past 2-3 days. Today more lethargic. Changed in condition.” Review of nursing notes from 10/23/2025 at 1:13 PM revealed “patient appetite is poor. Patient drank half cup of juice in the morning. Patient refused his tray.” Review of patient records revealed no documentation of a dietician consultation and/or nutrition intervention to promote patient nutrition goals. In an interview with staff #2 on 01/07/2026 at 2:40 PM in the conference room, she confirmed the above findings.”

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 38387 Based on review of the facility policy, record review, and confirmed in interview, the facility failed to meet individual patient nutritional needs for one of five patients reviewed (Patient #I) Findings included: Review of the facility policy Food Services and Nutritional Balance (Policy ID 12197130, approved 11/2025) it stated “special diets and altered diets are accommodated...notify physician of any problems with diet type or intake ...weights will be obtained weekly or otherwise ordered, should patient refuse, that will be documented.” Patient #I Patient #I is a 48-year-old woman who presented to the facility with suicidal ideations with a plan. Review of Patient I chart revealed there was an initial nutritional screening “appears well nourished [yes] and [regular] diet preferred” on 08/07/2025. However, the internal medicine progress notes on 08/11/2025, 08/12/25, 08/13/2025, 08/17/2025 revealed assessment/plan of ‘diet rich in iron’ for anemia. In an interview with Staff # 11 on 01/08/2026 at 2:20 PM in her office, she stated that there are no approved diets of iron rich diets. She further stated that the dietician only does a consultation as ordered. He does NOT do nutrition consultations on all patients.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 35028 . Based on observation, interview, and record review, the facility failed to ensure a safe transition of Patient A from an acute inpatient psychiatric facility to a long-term treatment facility by making necessary modifications to the discharge plan. This was evidenced by: “ The facility’s failure to ensure that Patient A, with a history of physical aggression and elopement risk, as well as dementia, was transported safely to a lower level of care. “ The facility’s failure to ensure that a mode of transportation was utilized in the transport of Patient A, a medically compromised patient, that could have provided emergency medical care if needed. “ The facility’s failure to ensure that Patient A was no longer on assault and elopement precautions when he was discharged into the care of an Uber driver. “ The facility’s failure to ensure the documentation of a safe mode of discharge for Patient A. Findings were: Review of “Patient Registration” dated June 13, 2025, 9:30pm, showed Patient A had been aggressive and assaultive toward staff at Baywind Village SNF [Skilled Nursing Facility]. Review of “Psychiatric Evaluation” by Staff #15 (PMHNP) [Psychiatric Mental Health Nurse Practitioner] dated June 14, 2025, identified Patient A as a 68-year-old male admitted on June 13, 2025. He arrived on an Emergency Detention Order from Baywind Village Skilled Nursing Facility. He was agitated, anxious, irritable, angry, and hopeless. Review of “Admission Orders” by Staff #19 (MD) dated June 13, 2025, at 9:30pm showed Patient A was placed on assault, elopement, aspiration, and fall precautions, as well as every 5-minutes observations. On June 20, 2025, observations were changed to 15 minutes by Staff #15 (PMHNP). Review of “History and Physical Examination” conducted by Staff #20 (NP) on June 14, 2025, at 11:30am and cosigned by Staff #14 (MD) on June 15, 2025, at 12:12pm, showed: Patient A’s chief complaint - “I don’t know.” Medical History included: CVA [cerebrovascular accident] with left side weakness and dysphagia, pulmonary embolism [a clot of blood] - on Eliquis [anticoagulant or blood thinner medication], right upper lung nodule, right kidney lesion, questionable metastasis of lung cancer, hypertension, prostatic cancer, PEG tube [Percutaneous Endoscopic Gastrostomy tube - a flexible feeding tube placed directly into the stomach through the abdominal wall] in place, questionable a-fib [atrial fibrillation - irregular heartbeat or arrhythmia - significantly raising stroke risk]. Review of “Provider Orders” by Staff #20 (NP) [Nurse Practitioner] dated June 14, 2025, at 12:14pm, showed: PEG flush 100cc every 6 hours. Clean PEG site every shift. Notify NP of any signs and symptoms of infection. Review of “Nursing Admission Assessment” by Staff #23 (RN) on June 13, 2025, at 9:30pm, showed: Patient A had “difficulty seeing - low vision,” PEG placement, “unsteady slow gait, wheelchair placement,” and ambulates with cane. He scored 65 on the Fall Risk Assessment, a score that is indicative of a high risk for fall (greater than 45). Review of “Provider Orders” by Staff #15 (PMHNP) dated June 26, 2025, at 6:55am, showed: 1:1 sitter while awake because of “wandering/elopement.” The 1:1 was discontinued by Staff #15 (PMHNP) later that morning - 9:00am. Every 5-minute observation started. Review of “Provider Orders” by Staff #21 (NP) dated June 28, 2025, at 12:06pm, showed wound care to top of foot. Review of “Treatment Plan Update” dated July 9, 2025 (two days prior to discharge), showed the following problems for Patient A: aggression, hypertension, fall risk, elevated HDL [High-Density Lipoprotein]. The patient’s progress (or lack of) was not documented for each problem. Review of “Daily Nursing Assessment” by Staff #22 (RN) dated July 9, 2025, at 9:00pm, showed Patient A was oriented to person only. Review of “Interdisciplinary Discharge Plan/Order” by Staff #15 (PMHNP), Staff # 16 (LMSW - Licensed Masters Social Worker), and Staff #17 (RN), dated July 10, 2025 (various times), showed Patient A had a discharge diagnosis of unspecified mood disorder and dementia. He was discharged to Wells Long Term Center in Wells, TX. Further review of the Clinical Information section showed the following items were not documented: Activities of Daily Living, Fall Precautions, Continent, Dental, Vision, Speech, Hearing. Orientation: Person [was checked]. [Place, time, and situation were NOT checked.] Discharge Patient Via: No items checked. [Options included: BLS Ambulance, ALS Ambulance, taxi, personal care, and other.] Review of the “Discharge Summary” by Staff #15 (PMHNP) dated July 11, 2025, 8:22am, documented Patient A had a diagnosis of unspecified mood disorder. Review of the “Provider Orders” for Patient A showed that the assault and elopement precautions were not discontinued at the time of discharge. Review of an online GPS service shows Wells, TX, to be 160 miles north of Clear Lake, TX - just under 3 hours. In an interview with Staff #18 (DCS) [Director of Clinical Services] on January 7, 2026, at 11:30am, he stated that initially Patient A was going to be transferred to Wells Long-Term Center by ambulance. Review of the “Physician’s Medical Necessity Certification for Non-Emergency Ambulance Transports” through City Ambulance Service, dated July 10, 2025, showed that Patient A was to be transferred from Medical Behavioral Hospital of Clear Lake to Wells, TX. The certification further states, “This patient suffers from altered mental status. The form was signed by Staff #18 (DCS). The interview with Staff #18 (DCS) was continued on January 7, 2026, at 11:30am. He stated: “ Patient A was discharged on July 10, 2025. “ An ambulance request with City Ambulance Service was created. “ The ambulance service was not used because of the expense. The facility [Medical Behavioral Hospital of Clear Lake] would have to pay additional money for that service. “ Patient A was sent to Wells Long-Term Care in Wells, TX, by Uber. “ The Nurse Practitioner would have determined if Patient A was appropriate for the long ride to Wells, TX, by Uber vs. ambulance. “ He was not aware that there were allegations that Patient A arrived at Wells LTC in soiled disposable scrubs. “ He was not aware that there were allegations that Patient A pulled the hair of the Uber driver. Staff #18 (DCS) also stated: “ There is no note by Nursing Services on July 10, 2025, adding there should be a note by Nursing Services for July 10, 2025. “ There is no documentation in the medical record by the Nurse Practitioner that Patient A was appropriate to be sent to Wells, TX, by Uber. Staff #18 (DCS) was reinterviewed telephonically on January 9, 2026, at 10:15am. He stated: “ Staff #15 (PMHNP) said that “it was not a good idea to put Patient A into an Uber” for transfer to Well LTC. “ Several days following the discharge of Patient A, his daughter informed the facility that Patient A had pulled the hair of the Uber driver. “ The Uber driver submitted a complaint about the patient. In an email dated January 9, 2026, at 1:57pm, Staff #2 (QIRM) wrote: “We were never informed about a complaint made by Uber. During the survey is when we learned of it. Staff #18 (DCS) provided an email to Staff #2 (QIRM) [Quality Improvement Risk Manager] dated January 9, 2026, at 1:53pm. The email read: I recall receiving a call from Patient A’s daughter after his discharge. I don’t recall how long this was after the discharge. She asked why we sent him via Uber and informed me that he had pulled the driver’s hair. In a telephonic interview with Staff #15 (PMHNP) on January 9, 2026, at 10:22am, he stated: “ On July 10, 2025, he spoke with Staff #18 (DCS) about the inappropriateness of using an Uber vehicle to transport Patient A to Wells LTC. “ After Staff #18 (DCS) asked him about the appropriateness of transferring Patient A via Uber, he responded in a text message that read: “Afternoon sir. Might as well quit right after you put him in an Uber.” “ When Staff #15 (PMHNP) was asked to clarify what he meant, he stated, “[I was] implying you will lose your job for doing something that wrong. So, if you put him in an Uber, that [action] will get you in a lot of trouble obviously because [of] the safety concerns here.” In a telephonic interview on January 11, 2026, at 10:00am with the administrative team, the surveyor provided a detailed summation of the physical and psychiatric condition of Patient A at the time of discharge (as outlined in the medical record). The administrative team included Staff #1 (CEO) [Chief Executive Officer], Staff #2 (QIRM), Staff #4 (Quality Coordinator), and Staff #18 (DCS). The team was asked, “Why was Patient A NOT discharged by ambulance?” Following several moments of silence, Staff #18 (DCS) stated, “The cost. The family and the receiving facility were not willing to pay for that.””

“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 ensure patients received care in a safe setting for six of six (Patient #A, B, C, D, E, H) patients reviewed. Refer to A0144-A The 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. Surveyor reviewed the updated Patient Observation Policy and confirmed re-training records confirmed IJ abated on 04/25/2025 at 1:55 PM.”

“EMERGENCY SERVICES CFR(s): 482.12(f)(2) If emergency services are not provided at the hospital, the governing body must assure that the medical staff has written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate. This Standard is not met as evidenced by: 38387 Based on record review and interview, the governing body failed to ensure the facility written policies and procedures were followed in that Memorandum of Transfer (MOT) was not completed and sent with each patient transferred in two of three (Patient #A, G) patients reviewed for hospital transfer to the emergency room. Findings included: Review of the facility policy Transfer of Patient (Policy ID 10623375, effective 11/2024) it stated “The hospital will follow the procedure outlined below when transferring / transporting a patient to another health care facility. Patient transfers will be carried out per physician order in a safe and timely manner, keeping quality patient care a focus, with consideration for patient status. Appropriate patient information will accompany the patient during transfer / transport...Arrange transportation as ordered by physician Type of transportation must be decided based on the patient’s condition: Nursing to prepare the patient for transport The reason for, including the risks and benefits of the transport, need to be explained to the patient. This is documented on the nursing assessment. The patient or personal representative shall consent to transfer. Prior to transport, and upon returning, the Nurse will document a patient assessment, condition, on the nursing assessment. The original will remain on the medical record and the copy shall accompany the patient. The following forms are required to be completed when transporting the patient: Transfer Order The following will accompany the patient during transport: A copy of all pertinent medical records pertaining to the reason for transport. Transfer Order Any additional documents requested by the receiving facility.” Patient #A Review of Patient#A medical record revealed he was a 66 year old male who had a history of Parkinson and bipolar. He was readmitted on 4/2/2025 with cellulitis on contact precautions for MRSA and on an EDO (emergency detention order) as he was a risk to himself and others. On 4/21/2025, Patient #A had an incident at an unknown time with the tech finding him in his room with a bleeding toe at 5:15 AM. After nurse assessment, patient was transported to an ER (Facility B) for continuity of care. Review of records from Facility B revealed Patient #A was transferred via ambulance without an escort. Review of the patient records revealed no information was provided to the facility as to his medical history. He was treated for hypothermia and hypotension and was admitted. In an interview with Staff #2 on 04/24/2025 at 1:23 PM in the meeting room, she stated that if a patient is transferred out, a tech would typically escort the patient when they are on an EDO. In another interview with Staff #2 on 04/25/2025 at 1:45 PM in the meeting room, she acknowledged that with Patient #A above, the staff did not assess vitals prior to transfer; they also did not escort the patient nor were patient records to include the MOT and EDO provided to Facility B per facility policy. Patient #G Review of Patient #G medical record revealed she was a 55 year old female who was an involuntary admission for psychiatric stabilization for depression with suicidal ideation with a plan. On 3/31/2025 at 7:30 AM, Patient #G had an unwitnessed fall on the unit and complained of a hip pain with pain level at 10/10. There were orders to transfer for further evaluation. Review of records available revealed no documentation of the MOT to Facility B. She was admitted for medical treatment to Facility B. In an interview with Staff #2 on 04/25/2025 at 2:50 PM in the conference room, she confirmed the above findings.”

“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 review of video and patient records, and confirmed in interview, the facility failed to promote care in a safe setting. The facility failed to monitor patients per provider’s orders and per facility policy for six of six patients (Patient #A, B, C, D, E, H) reviewed. Additionally, the facility failed to promote a safe and sanitary environment for its patients for four of four units observed. A. Patient observation B. Safe and sanitary environment Findings included: A. Review of the facility policy Patient Observation (Policy ID 12931622, effective 11/2024) stated “Observation levels can be increased or decreased by a provider’s order. Observation Levels: A frequency or intensity of observation assigned to a patient during which a health care professional, or their designee, will observe a patient. The approved observation levels assigned are: Level I - General Observation All patients on this level are on every 15-minute observation, at a minimum. This is the minimum acceptable level for all patients; for patients at a lower risk. The location of the patient should be known to staff at all times but they are not necessarily within sight. Positive engagement with the patient is integral for this level of observation. Level II - Every 5 Minutes. All patients on this level are on every 5 minute observation, at a minimum. This is an increased level of observation for patients at an increased risk. The location of the patient should be known to staff at all times but they are not necessarily within sight. Positive engagement with the patient is integral for this level of observation. Level III - 1:1 Observation The patient is to be under constant visual observation by an assigned staff member, regardless of other unit activities. Staff member must remain in close proximity to the patient, to include patient bathing and toileting activities. Under these conditions, the patient’s safety and protection outweighs his/her right to privacy. For bathing and toileting activities, staff of the same sex may be utilized. Staff will continuously monitor the patient’s behavior and immediately report any changes in conditions of circumstances to the nurse. Staff is not to engage in personal activities such as reading, eating, phone use, or similar activity that could distract or otherwise interfere with the continuous observation of the patient. Documentation: Documentation of all observations will be completed in the patient’s record per their ordered observation status. Staff will complete the patient observation record using a coding system described on the Patient Observation Monitoring Form. Staff will initial, date and/or time appropriate documentation in the designated areas for observation of a patient.” Review of patient physician orders revealed six patients (Patient #A, B, C, D, E, H) had orders for Q15, Q5, and/or 1:1 observation rounds. Review of Patient #A, B, C, E’s physician orders revealed an order for Q15 observation rounds Review of Patient #D’s physician orders revealed an order for Q5 observation rounds Review of Patient #H’s physician orders revealed an order for 1:1 observation rounds Video review of Unit 200 from 4/20/25 at midnight to 4/21/25 5:15 AM revealed the following times that a tech made rounds for the above patients. No other times were observeed. 12:20 AM 1:00 AM 1:22 AM 1:39 AM 5:15 AM In an interview with Staff #2 on 04/24/2025 at 10:50 AM in the meeting room, she awknowledged that the techs performed improper rounds at 1:22 AM and 1:39 AM.- the tech is observed to briefly open and shuts door. She also stated that the rounds performed in the video reviewed were inadequate. In an interview with Staff #3 on 4/24/25 at 1:20 PM in the meeting room, he stated that techs are trained to go into the room (at night with a flashlight) and to visualize the patient and monitor their breathing for 2 breaths. B. Safe and sanitary environment Hospital policy Cleaning Patient Rooms (Policy ID 9826636, effective 11/2024) stated in part, “ Any waste should be removed from patient rooms/bathrooms. Dust all fixtures, ledges and surfaces in the room and bathroom above shoulder height. Begin at the door and work clockwise around the room. Damp dust over bed tables, bedside tables, telephone, chairs, stools, ledges, light switches, lamps and spots on walls or cabinets with a hospital approved germicidal solution. Damp wipe the bed frame, both sides of the mattress, pillows and bed control with germicidal solution. Clean the bathroom as per procedure. Damp mop floor with a hospital approved germicidal solution. Begin at the farthest corner of room working backwards toward door including the bathroom and closet. Be sure to disinfect baseboards. Surveyor tour of the facility on 04/24/2025 at 10:10 AM revealed the following environmental concerns at random patient rooms observed in the four units: Unit 100 Dirty and rusted bath benches Dirty bath assistance chairs Full sized personal hygiene bottles Thick layers of dust on cabinets and beds Mildew in bathroom stalls Biohazard trash inside room with red plastic bag Seclusion room between Unit 100 and 200 Vulgar words scratched onto the padding on wall Unit 200, 300, and 400 Trash in rooms Bodily fluids on walls Thick layers of dust on cabinets Mildew in bathroom Dirty linens Standing water in bathroom and room In an interview with Staff #3 on 04/24/2025 at 10:40 AM during the tour, he acknowledged that the facility could do a better job of maintaining the units. He also stated that staff do safety rounds in the patient rooms at each shift, but it does not include environmental checks. In an interview with Staff #2, she stated that the above policy for patient room cleaning is for when patients are discharged or transferred. There is no other policy for monitoring for sanitary or clean patient rooms.”