Voyages Behavioral Health of Sugar Land

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 23032 Based on observation, interview, and record review, the Governing Body failed to effectively discharge its oversight responsibilities in the total operation of the hospital. The hospital failed to meet the requirements of the Conditions of Participation for : Patient Rights; Food & Dietetic Services; and Physical Environment. Findings included: Patient Rights:. The facility failed to meet the requirements of the Condition of Participation for Patient Rights: The facility failed to ensure : a) the fire safety plan included safety measure protecting staff, patients and the public from harm when the fire alarm is activated in all patient care areas; b) seclusion room badge access for exiting and door latching mechanism was in working order for 1 of 3 seclusion rooms (A); c) Prohibited items (Contraband) were not accessible to patients on 2 of 3 units (100 and 200 hallways); d) patients’ right to receive care in a safe setting as shown by the presence of 18 non-weighted plastic chairs located in two outside facility courtyards, which had the potential to be used as weapons. e) patient’s right to personal privacy as shown by the absence of bathroom door curtains and shower curtains ; and also during a Group Therapy session. [Cross refer to Tags A-0143 and A-144] Food & Dietetic Services: The facility failed to meet the requirements of the Condition of Participation for Food & Dietetic Services: a) The facility’s walk-in freezer was not in a safe working order, allowing ice build-up on the freezer floor, shelves, and the food products and the facility did not secure foods stored outside the kitchen, placing patients at nutritional risk from degraded foods, and food borne illness from spoiled or tampered food products. b) The kitchen’s hot food production area had copious amounts of a black, fuzzy, substance attached to the overhead ceiling tiles and frames, placing patients at risk of cross-contamination and gastrointestinal illness from biological contaminants. c) The facility’s high temperature sanitizing dishware washer was not being monitored according to the manufacturer’s instructions for adequate temperatures, placing patients at risk of food borne illness from uncleaned dishware. d) The facility’s kitchen had copious amounts of food debris and dust on the shelves and floors throughout the kitchen, and the exterior door had daylight gaps, providing and entrance for pests, placing patients at risk of food borne illness from environmental contaminates. e) The facility’s Registered Dietitian, did not provide individualized diet plans for persons on Therapeutic diets, placing patients at risk of inadequate nutritional intake and hypo/hyperglycemia. [Cross refer: A0620, and A0621] Physical Environment : The facility failed to meet the requirements of the Condition of Participation for Physical Environment a) The facility failed to maintain the overall environment inside patient bathrooms, as shown by the abundance of holes and paint peeling on the walls of 15 of 33 patient showers [ refer to TAG A-701 ]. b) The facility failed to comply with Life Safety Code [ National Fire Protection Association] and the Texas Adminstrative Code related to fire protection.The facility failed to develop a current Life Safety Plan that included: clear identification of all smoke compartments and identification of all “fire-rated” walls.[ refer to TAG A-710 ]. c) The facility failed to develop a safe and valid Fire Evacuation Plan for patients, staff, and visitors in case of fire [Refer to Tag A-0714]”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 37490 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 to ensure fire safety plan included safety measure protecting staff, patients and the public from harm when the fire alarm is activated in all patient care areas. The facility failed to ensure seclusion room badge access for exiting and door latching mechanism was in working order for 1 of 3 seclusion rooms (A). The facility failed to ensure prohibited items (Contraband) were on 2 of 3 units (100 and 200 hallways). The facility failed to ensure the patients’ right to receive care in a safe setting as shown by the presence of 18 non-weighted plastic chairs located in two outside facility courtyards, which had the potential to be used as weapons. The facility failed ensure the patient’s right to personal privacy as shown by the absence of bathroom door curtains and shower curtains. The facility failed to ensure the patient’s right to personal privacy during a Group Therapy session. Refer to Tags A-0143 and A-144”

“FOOD AND DIETETIC SERVICES CFR(s): 482.28 The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company may be found to meet this Condition of Participation if the company has a dietitian who serves the hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment. This Condition is not met as evidenced by: 33326 Based on observation, interview, and record review, the facility failed to meet the conditions of participation for Dietary when, o The facility’s walk-in freezer was not in a safe working order, allowing ice build-up on the freezer floor, shelves, and the food products and the facility did not secure foods stored outside the kitchen, placing patients at nutritional risk from degraded foods, and food borne illness from spoiled or tampered food products. o The kitchen’s hot food production area had copious amounts of a black, fuzzy, substance attached to the overhead ceiling tiles and frames, placing patients at risk of cross-contamination and gastrointestinal illness from biological contaminants. o The facility’s high temperature sanitizing dishware washer was not being monitored according to the manufacturer’s instructions for adequate temperatures, placing patients at risk of food borne illness from uncleaned dishware. o The facility’s kitchen had copious amounts of food debris and dust on the shelves and floors throughout the kitchen, and the exterior door had daylight gaps, providing and entrance for pests, placing patients at risk of food borne illness from environmental contaminates. o The facility’s Registered Dietitian, did not provide individualized diet plans for persons on Theraputic diets, placing patients at risk of inadequate nutritional intake and hypo/hyperglycemia. Cross refer: A0620, and A0621”

“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: 23032 Based on observation, interview, and document review, the facility failed to meet the requirements of the Condition of Participation for Physical Environment. This failure had the potential to affect all patients receiving services in the hospital ; and staff and visitors. a) The facility failed to maintain the overall environment inside patient bathrooms, as shown by the abundance of holes and paint peeling on the walls of 15 of 33 patient showers [ refer to TAG A-701 ]. b) The facility failed to comply with Life Safety Code [ National Fire Protection Association (NFPA] and the Texas Admintsratve Code related to fire protection. The facility failed to develop a current Life Safety Plan that included: clear identification of all smoke compartments and identification of all “fire-rated” walls. [ refer to TAG A-710 ]. c) The facility failed to develop a safe and valid Fire Evacuation Plan for patients, staff, and visitors in case of fire. [Refer to Tag A-0714]”

“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: 38015 Based on observation, interview, and reccord review, the facility failed to: 1. Ensure the patient’s right to personal privacy as shown by the absence of bathroom door curtains and shower curtains in 6 of 33 patient rooms (Rooms 111, 117, 120, 213, 216 &316) affecting 11 patients (Patient #’s 16, 21, 23, 27, 32, 33, 34, 35, 36, 37 & 38); 2. Ensure the patient’s right to personal privacy during a Group Therapy session, as shown by the Group therapist asking personal, private psychiatric questions to 8 of 8 patients in the presence of other group members. Findings included: 1. Lack of privacy curtains: Review of facility policy titled “Daily Room Cleaning”, #VIC.1.15 effective 8/1/22, showed that the Environmental Services technician will inspect the privacy curtains in the patient bathrooms and replace them if damaged, clean them when soiled, replace them if unable to clean and/or replace them every 6 months. Observation on 5/7/24 at 9:15 am-11:00 am of facility’s 200 and 300 units showed the following: Rooms 213, 216, and 316 did not have bathroom door curtains for patient privacy. Room 310 did not have a shower door curtain for patient privacy and comfort. Further observation revealed that it was possible for others to visualize a patient inside their bathroom when walking in the unit hallways as well as while walking inside the patient room. In an interview at the time of findings, Corporate Clinical Director-Staff #F, who was present during observation, acknowledged that the curtains were missing and should have been present in these rooms. Observation the following day on 5/8/24 at 9:30 am of facility’s 100 unit showed that Room 112 did not have a bathroom door curtain for privacy. In an interview on 5/8/24 at 9:35 am, Patient #32, who was housed in Room 112, stated she had been in the facility since 5/3/24 and never had a bathroom curtain. She also stated that she had asked “the people at the desk” (staff at the unit’s nursing station) to please provide a curtain door, but they had not done so yet. Patient #32 then stated that whenever she used the toilet, she would move her roommate’s wheelchair to barricade the room’s main entrance door because she was embarrassed that people saw her on her toilet while walking in the hallway. She also stated that she had been embarrassed that her roommate could see her too but did not know what to do to prevent this. In an interview immediately after the patient interview, Regional Corporate Clinical Director-Staff #G, who was present in the unit hallway, acknowledged there was no curtain and was asked to please provide this for the two patients in Room 112. Further observation of unit 100 showed there were no shower curtains present in Rooms 111 and 129. *Note: this same issue was previously cited during a survey on 10/10/23-10/11/23. 2. Group Therapy confidentiality: Review of facility policy titled “Privacy & Security”, # VIM.1.01, effective 8/1/22 showed that the policy of Voyages Behavioral Health is to protect the privacy of patient information. In addition, review of facility policy titled “Patient Rights”, #VR1.1.01, effective 8/1/22, showed that the facility shall respect, protect and follow the Patient Bill of Rights outlined in 25 TAC 404.154, which includes treatment in an environment that ensures the protection of privacy. Observation of a Group Therapy session on 5/8/24 at 9:50 am on facility’s unit 100 led by SW-Staff #GG revealed the following: There were 8 patients present sitting in the unit’s ‘quiet room’, which was used for the therapy session that day, called a Process Group. The patients were all sitting in a semi-circle and all were participating. During the session, Staff #GG was holding and filling out 8 pages of paper; one for each patient, asking patients questions one at a time in front of the entire group. Many of these questions consisted of personal and confidential health information, including “Are you suicidal today? If yes, how much on a scale of 1-10?” Also, “Are you depressed today? If so, how much on a scale of 1-10?” Another question was “Are you anxious today? If so, how much on a scale of 1-10?” Review of clinical records for the patients who had participated in the Group Therapy session showed most patients had history of depression, anxiety, and/or suicidal ideation.”

“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: 37490 Based on observation, interview, and record review, the facility failed to provide an environment that protected patients, staff and the public from harm (safe setting) by: a) Failing to ensure fire safety plan included safety measure protecting staff, patients and the public from harm when the fire alarm is activated in all patient care areas. b) Failing to ensure seclusion room badge access for exiting and door latching mechanism was in working order for 1 of 3 seclusion rooms (A). c) Failing to ensure prohibited items (Contraband) were on 2 of 3 units (100 and 200 hallways) Findings included: a) Fire Safety Plan Observation on the 300 Hallway on 5/7/2024 at 1:45 PM showed the far end exit doors to be locked. Interview with DON (D) at the time of observation when asked if the door become demagnetized and unlocked during activation of the fire alarm, she stated “yes.” She was asked if this was just specific to the hallway where the alarm was activated or do all doors become demagnetized/unlocked and she stated that the are all connected and all will unlock throughout the facility. Record review of facility document title” Fire Safety Management Plan,” dated 1/2/22 showed the following information: I. Scope. The Fire Safety Management Plan describes the methods for minimizing the potential for a fire through the use of building systems, equipment, and training. The fire safety management plan is designed to assure appropriate, effective response to fire emergency situations that could affect the safety of patients, staff, and visitors, or the environment, and protect building occupants from fire and the products of combustion. The plan is also designed to assure compliance with applicable codes and regulations, as applied to the buildings and services provided. The Fire Safety Management Plan does not address the safety measures to protect patients, staff or public during the demagnetization/unlocking of doors within the facility or exit doors to exterior unsecure areas. b.) Seclusion Room Door Observation on 5/7/2024 at 12:30 pm the survey team entered seclusion room B via facility provided security badge. Once inside the seclusion door closed behind the surveyors. Upon attempting to exit the seclusion room via the same badge access, the badge reader did not work allowing exit. Upon calling administration to have someone come let us out, the DON arrived and opened the door. In attempt to reenact to demonstrate what had happened, the door then did not close and latch automatically two times without being manually pushed to engage latching mechanism. Interview with DON (D) at the time of observation confirmed the findings and acknowledged that the door and badge reader was not working correctly. c.) Contraband Record review of facility policy titled “Contraband and restricted Articles,” dated 8/1/22 showed the following information: POLICY Contraband is prohibited in order to protect the therapeutic milieu of the hospital and to clearly establish for patients the behavioral requirements of their continued treatment. PROCEDURE Contraband is any item that is deemed a potential threat to client, staff, and visitor safety and/or privacy, or is illegal. Examples include drugs, unidentified substance or powder, liquids containing alcohol, knives, guns, mirrors, jewelry with sharp edges, mobile telephones, clothing items such as belts or shoelaces, or metal objects designed as weapons or potential weapons. Patients are informed in writing on admission that the use or possession of contraband is not allowed. Contraband is removed when identified by staff. Observation on 5/7/ 24 at 1:00 PM and again on 5/8/24 at 10:30 am on the 100 and 200 hallways, in the day rooms, Styrofoam cups with plastic bag sheaths were observed. Interview with staff RN (W) on 5/8/2024 at 11:30 AM acknowledged that the plastic bag sheaths should not be allowed on the unit and could cause harm to patients. 38015 Based on observation, interview, and record review, the facility failed to ensure the patients’ right to receive care in a safe setting as shown by the presence of 18 non-weighted plastic chairs located in two outside facility courtyards, which had the potential to be used as weapons. Findings included: Review of facility policy titled “Patient Rights”, #VR1.1.01, effective 8/1/22, showed that the facility shall respect, protect and follow the Patient Bill of Rights outlined in 25 TAC 404.154, which included treatment in a safe environment that ensured protection from harm. Observation on 5/7/24 at 9:30 am of facility’s outside patient courtyard showed the presence of 11 solid plastic chairs for patient use. These chairs, which were all identical, were able to be lifted by the average person and had the potential to cause injury to patients if used in physical altercations. In an interview at the time of findings, Corporate Clinical Director-Staff #F who was present during observation, acknowledged that the chairs could be used to hurt others if thrown or swung, and were not weighted-down as they should be in psychiatric facilities. Observation on 5/8/24 at 9:35 am revealed there were 7 more of these same plastic chairs for patient use, located in another courtyard outside the facility cafeteria.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 23032 Based on observation, interview, and record review, the facility : Failed to initiate several important first-steps of an investigation related to a recent serious “near-miss” event. Patient # 13 obtained a fire extinguisher and sprayed several staff with fire extinguisher expellent; then pulled a fire alarm on the nursing unit. He was then able to exit through 2 sets of double doors into the front hospital lobby before he was detained. -None of the hospital leadership or Director of Plant Operations had viewed the camera surveillance of the incident or begun interviews with staff present during the incident. On Day 1 of survey, 5/07/2024 , the cabinet of the fire extinguisher used in the near-miss incident was observed unlocked and accessible to all patients. Findings Included: Record review of facility policy titled “Incident Reports,” dated 8/01/2022, showed the process for completing incident reports, as well as established timeframes for reporting. Incident reports must include: a brief description of event, any witnesses to the event, and notifications to hospital leadership. Incident investigation includes the following steps: 1. secure and review all available surveillance video of footage of the incident and leading up the incident. 2. Review medical record for information pertaining to the incident.. 3. Interview staff members, patients, and witnesses ,as applicable. 4. Report investigatory findings to immediately to CEO. The facility policy on Incident Reports did not include a timeframe for the completion of the investigation. Joint Commission (JC) definition of a “near- miss” is “any event that could have had adverse consequences but did not and was indistinguishable from fully fledged adverse events in all but outcome.” [This facility is accredited by JC.] ~~~~~~~~~~~~~~~~~~~~~~ Record review of the medical record of Patient # 13 showed the following: Nursing progress note dated 5/4/2024 (6:18 PM) read :”patient heard shouting and agitated to have the phone to make calls while another patient was using the phone. He was advised to wait for the other patient to finish making the call but he refused. He became infuriated, all attempts for de-escalation failed. Patient broke out through the door into the nursing station threatening to hurt the staff and overpowering everybody. The patient activated the fire alarm system which was going off. He grabbed the fire extinguisher the entrance of the 100 hall and started spraying it at the faces of all the staff and all over the nursing station. The patient went trough the main entrance . Dr- II was informed and emergency medication was ordered... and given in the presence of the police officers. Seclusion order was made and patient placed in seclusion.” Observation by two surveyors in the Nursing Station area on 05/07/2024 at 11:45 AM, showed the fire extinguisher cabinet outside the 100 hallway was unlocked. The fire extinguisher was accessible to the Life Safely surveyor on-site who opened the cabinet and acessible to all of the current patients. It is unknown how long this fire extinguisher cabinet had been unlocked. Interview : Staff -E, Director of Plant Operations (DPO) During an interview on 05/09/2024 at 1:20 PM with Staff E, DPO, he was asked if he was aware of an incident that occurred on Saturday, 5/4/2024. He said between 6 and 8 PM that evening he got a call that a patient had gotten ahold of a fire extinguisher and pulled the fire alarm. Staff -E called the fire alarm company to notify it was a false alarm. He called his environmental staff to clean up the unit as the patient had sprayed the fire extinguisher all around the unit. Staff-E said he was was responsible for the surveillance camera footage. Staff -E said he had not viewed the footage from that night. Surveyor and Staff E review of the camera footage for 5/4/2024 from 5:15 PM to 5:48 PM [timestamps on video monitor] showed the following (not all inclusive) : Between video timestamps of 5:33 PM and 5:46 PM, the following was observed : - Patient # 13 exited the 300 hallway doors and began walking around the area in front of the nursing station. - the patient opened the fire extinguisher cabinet outside the 100 hallway and obtained the extinguisher. He continued walking around, appeared to be attempting to operate the fire extinguisher. Several staff were seen following him, at a distance. - ( 5:37 PM) patient began spraying the extinguisher directly at several staff members and all around the nursing unit. The video showed a dense “greenish” fog. Some staff were observed to have masks on; some not. - ( 5:39 PM) Patient # 13 rounded the corner by the nursing unit and pulled the fire alarm; strobe lights were visible in the video through the fog. - patient walked past the cafeteria to the left and walked down the hall. He was seen trying to open the first set of double-doors out of the unit. He turned around and walked back toward the nursing station. - patient is seen again near the cafeteria doors; he began walking very rapidly down the hall. He was seen exiting through the first set of double doors (right side). He quickly moved toward the 2nd set of double- doors and was seen exiting these doors and into the main lobby of the hospital. Camera review of lobby area showed he did not make it through the front door exit to the outside. During continued interview with Staff -E, he said any time the fire alarm was pulled, all of the exit doors in the hospital were de-magnetized. He said he was always reminding staff of this safety issue. He was unsure if this was officially in the fire plan or staff training. Staff-E acknowledged that Patient #13 could have completely exited the building through the main doors had he not been stopped. ~~~~~~~~ Interview with Staff-A, Chief Executive Officer (CEO) During an interview on 05/09/2024 at 2:15 PM with Staff A, CEO, he said he first got a report on Saturday (5/4/2024) that a patient had grabbed a fire extinguisher and sprayed the staff. He had not watched the video yet. The CEO was unsure if the exterior hall exits on the 3 patient units were covered by staff when the doors became de-magnetized during the fire alarm activation. The CEO said he knew that Staff -P, Chief Nursing Officer (CNO ) had started looking into this incident. Interview with with Staff-D, CNO: During a telephone interview on 05/09/2024 at 2:35 PM with Staff D, CNO, she stated she had made some notes; started notes on timestamps (video). The CNO had not viewed the entire video as yet. She said that maintenance had contacted the locksmith company to come out and inspect / repair the magnetic lock on the 300 hallway. ~~~~~~~~~~ Record review of facility incident report , dated 5/4/2024 ( incident time 6:30 PM) , showed the description of the incident was consistent with the nursing progress note at time of incident. [The only discrepancy noted was the review of the video showed the patient sprayed the fire extinguisher before he pulled the fire alarm.]”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 37490 Based on observation, interview and record review, the facility failed to ensure that a Registered Nurse (RN) was physically on the unit available to provide patient care at all times in 1 of 3 patient care units (100 Hallway). Findings include: Record review of facility’s 2024 Nurse staffing plan showed the following information: The nursing services department have voyages behavioral health hospital of Sugarland supports the provision of patient care in a safe, cost-effective manner by appropriately using qualified and skilled personnel. The staffing plan is determined by the budgetary process based on historical data; projections for future program development and expansion; analysis of clinical practice patterns; and staff input into the needs of patients, unit, and staff. The hospital shall adopt, implement, and enforce a written staffing plan as outlined Texas Administrative Code Title 25, Part 1, Chapter 133, Subchapter C, Rule 133.4 (o) ... *Licensed Nurse-physically present on each hallway 24/7. Observation and interview on May 8, 2024, at 11:09 am staff nurse (S) was seen exiting the 100 Hallway unit. 8 patients were in the day room attending group, the remaining patients were in other areas of the hallway or in their rooms. Surveyors unsuccessfully tried to identify another RN on the unit. At 11:14 am the Director of Nursing (D) arrived on the unit. She was asked at that time who the RNs assigned to the unit were and if she was aware that there was no RN currently on the unit. She stated that she was not aware they were not on the unit. She went on to say that a nurse is supposed to be on the unit at all times.”

“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: 23032 Based on record review and interview, the facility failed to ensure a registered nurse supervised and evaluated the care of 2 of 2 sampled patients (Patients # 9, 31): -Two (2) patients were not placed on assault precautions following a significant patient to patient altercation (Patients # 9, 31) - One (1) patient failed to have multiple “patient observation forms” completed (Patient # 31). Findings included: a) Failure to place patients on assault precautions following a patient/patient assault: Record review of facility policy titled “Patient Safety Peculations,” dated 8/01/2022, showed: To promotes a safe environment and decrease the possibility of harm, facility precaution levels include: homicide/assault (not all inclusive). Precautions are documented in the observation record with on-going assessments necessary during hospitalization. RN may initiate precautions; however a physician must be notified and write an order for the precaution. Record review was conducted with Staff -W, RN on 5/9/2024 at 11:45 AM. Review of Patient # 9’’s clinical record record showed a NP progress note, dated 1/30/2024 that showed: “ Patient got into a physical altercation with another patient overnight... Patient stated another patient jumped her and clawed her face...” The other patient was identified in the record as Patient # 31. Continued review of Patients’ # 9 and 31 medical records failed to show that either patient had been placed on assault precautions following the altercation. During an interview at the time of review, Staff-W said all patients are required to be placed on assault precautions following a physical altercation. It is nursing responsibility to inform the provider and obtain the order. b) Incomplete patient observation forms: Record review of facility policy titled “Patient Observation,” dated 8/01/2022, showed: Policy: to establish levels of observation and monitoring that provides a safe patient environment and decrease the possibility of harm to self or others All patients will be monitored via time intervals as identified though assessments and presenting behaviors. Levels of observation will be ordered by the patent’s practitioner and implemented by nursing staff with subsequent documentation. Review of Patient #31’s “Patient Observation Forms” with Staff -W, RN showed: a) no observation levels or precautions documented : January 20, 21, 23 , 24 b) no dates , no observation levels, or precautions were documented : 6 shifts . The above information was verified by Staff-W, RN who said the forms should be documented completely. It is nursing responsibiliy to provide oversight of Mental HealthTech’s (MHT) documented work .”

“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: 33326 Based on observation, interview, and record review, the facility failed to provide an organized Dietary Service when the Director of Food Service did not establish, maintain, supervise work performance, and ensure appropriate Policy and Procedures were available for the Dietary Services. - Unsecured chemicals were being stored in the facility’s main dining room which is not kept locked and the locking kitchen door was observed propped open, allowing access into the kitchen where knives are stored. - The kitchen’s SDS (Safety Data Sheet) manual did not include items used in the department. - The kitchen floors, shelving, and equipment had food debris on its surfaces and a mold like substance was noted on the ceiling tiles and vents above the food production areas. - The facility’s dish washer was not being monitored to ensure an appropriate high temperature was reached to verify items being washed had been sanitized. - The exterior kitchen door had several gaps where daylight shone through, enabling pests access to the kitchen. - An unattended dirty mop was sitting in a bucket of gray water, creating an environment for bacterial growth. - The facility’s walk-in freezer had three different temperature gauges showing three different temperatures with a large variance; one exterior temperature read 0 degrees Fahrenheit and an interior thermometer showed the walk-in freezer was at 40 degrees Fahrenheit, and there was water dripping from the ceiling onto the food product and floor. The food had been thawing, freezing, and thawing, and freezing. - The temporary freezer truck, located outside the facility, was observed to be unlocked, and accessible to anyone wanting to tamper with the food items. These failures places all patients receiving meals at the facility, at risk of gastrointestinal pain, diarrhea, and possible death from cross-contamination from, environmental, bacterial, and chemical contaminates. Findings include: Observations made on the morning of 05/07/24, while accompanied by Staff #H, Director of Food Service, revealed the entrance door to the patient dining room was not locked. When asked why it is not secured, Staff #H stated, “The administration decided to leave them unlocked, there is no way for the patients to get into the kitchen and there isn’t anything out here that can hurt them.” Further observation on 05/07/24, of the dining room revealed, a bottle of Ecolab Lime-away (used to remove calcium build-up), Pine Sol disinfectant, and Awesome Window cleaner located under the hand sinks located behind the hot food tables. Staff #H removed the chemicals. Review of the facility provided “SDS”Safety Data Sheet, used to identify and instructions for use and safety risks, for all chemicals used in the departments, revealed the facility did have a SDS for the Lime-A-Way or the Pine Sol disinfectant. Review of the facility provided material safety data sheet reflected the following: Lime-A-way: Potential Health Effects Eyes : Causes serious eye damage. Skin : Causes severe skin burns. Ingestion: Causes digestive tract burns. Inhalation: May cause nose, throat, and lung irritation. An observation on the morning of 05/08/24, in the facility’s dining room, revealed approximately 25 patients and family in the dining room, the facility’s locking kitchen door was propped open with a door jam. The surveyor was able to enter the kitchen without intervention; there was no one watching the door. An observation, on 05/07/24, inside the facility’s kitchen revealed, copious amounts of food debris, dust, unidentified debris, a dirty food apron on the kitchen’s floor, and shelves. (3) Three food baking sheets had a greasy feel and had baked on food residue, a large plastic bin had multiple green/brown fuzzy debris on the exposed bottom and on the sink pipes in the clean dish storage area. The food exhaust hood, directly above the stove top, had signs of where a dark liquid had dripped, pooled, and dried. The exhaust hood had condensed water, which was running down the inside, down to the stove, where food was on the burners. The steamtable, (where the hot food is held for service) had two wells with dirty water and food debris from the previous meal. An observation on 05/07/24, of the facility’s walk-in freezer at 10:01 am revealed an outside thermometer temperature of 0 degrees. The internal freezer revealed a temperature of 42 degrees Fahrenheit. An observation of the facility’s walk-in freezer at 2:21 pm revealed an outside thermometer temperature of -1.2 degrees Fahrenheit, the facility provided, infrared thermometer reading revealed 13.9 degrees Fahrenheit. Staff #HH, Regional Facilities Manager, operated the infrared thermometer and confirmed the differing temperatures. An observation, on the morning of 05/07/24, in the kitchen’s dishwashing room, revealed an automatic dishwasher. A sanitizing solution record log was located on the wall next to the dish machine. The days 1 through 5 had been marked through, with the note, “was instructed by my corporate person to add this temp log back.” The sanitation log did not reflect any dishwashing temperatures had been recorded on the record. The facility was unable to provide the temperature logs for the dish machine. During an interview, on the morning of 05/07/24, in the kitchen’s dishwashing room, when asked if the dish machine was a chemical or high temperature sanitizing machine, Staff #H stated, “It’s a chemical sanitizer,” Review of the facility provided manufacturers operation manual, and the dish machine’s manufacturer installed date plate reflected it was a DynaStar®VER, Door-type machine; electrically heated, high-temp, hot-water sanitizing, with booster heater and VER heat recovery system. The instruction manual reflected the following instructions, “Water temperature is an important factor in ensuring the machine functions properly. The machine’s data plate details what the minimum temperatures must be for the incoming water supply, the wash tank, and the rinse tank. If minimum requirements are not met, it’s possible that dishes will not be clean or sanitized. Instruct operators to observe the required temperatures and to report when they fall below the minimum allowed. A loss of temperature can indicate a larger problem.” The surveyor requested all work orders placed for the facility’s walk-in freezer; the facility provided the following outside contractor, walk-in freezer repairs, not the Facility’s requisition log: 8/4/23, WIF (Walk-in freezer) is not maintaining temp, temp is staying at 32°. Located in the kitchen. Brand: US Cooler Found both evaporator fan motors shorted out. Went to supply house picked up 2 motors. Replaced both motors.” 2/27/24, “Called about the walk-in freezer in the kitchen is icing up and not going into defrost and the display on the evap (evaporator) is not coming on (not displayed) and the heat strip around the door is not hot. Evaporators#E202101001. Found Emerson temperature controller is shorted out. Found water inside control box. Checked incoming power for controller getting 208v. Also found door heater has a short. Right side door frame has ice buildup and left side.” 3/5/24: Went to kitchen and removed temperature controller and replaced with new temperature controller. Wired in and ran probe. Adjusted set point to -5. Controller checked out ok. Shut off power and removed door trim, heaters, and gasket. Ran new heater around door frame. Wired it into lights for box. Also installed new door gasket. The door trims and defrost timer didn’t use. Timer is still good. Also spoke with Staff #E, Director of Plant Operations about his door closure, wasn’t closing door all the way. He will have to wait to fix that. Freezer box coming down to temp ok. During an interview on the morning of 05//9/24, Staff #A, CEO (Chief Executive Officer) stated the facility was aware the freezer required multiple repairs. The CEO ordered a freezer truck to be placed next to the kitchen for use until the walk-in freezer could be fixed. An observation, on the morning of 05/09/24, revealed the temporary freezer truck had three doors to access the food truck, all three door had locks that were in the open position. The freezer truck was parked behind the kitchen and is not within view of the dietary staffs. Staff #HH, was informed, and stated, “Those are not our locks, we didn’t close them because we don’t have the keys.”

“QUALIFIED DIETITIAN CFR(s): 482.28(a)(2) There must be a qualified dietitian, full-time, part-time, or on a consultant basis. This Standard is not met as evidenced by: 33326 Based on record review, and interview, the facility’s dietitian failed to ensure the nutritional needs of 2 out of 4 patients requiring a theraputic diet when the facility’s menus required a specialized menu but did not recieve one, this failure places any patient being admitted on a specialized diet at risk of malnutrition, worsening cardiac disease, and hypo/hyperglycemia. (Patients #24, and #25) Findings include: Review of Patient #24’s diet order listing for 05/08/24 revealed Regular, Note: Diabetic diet. Review of Patient #25’s diet order listing for 05/08/24 reflected, Cardiac Diet. Review of the facility provided eat right Nutrition Care Manual, (dated 12/22/22) reflected, “Consistent Carbohydrate Diet Definition: A consistent carbohydrate diet provides the same amount of total carbohydrate daily, distributed evenly across all meals and snacks. A consistent amount of carbohydrate at each daily meal is the goal. The exact amount and type of carbohydrate served is individualized by the registered dietitian nutritionist (RDN). Indication: A consistent carbohydrate diet is indicated for individuals diagnosed with diabetes, prediabetes, or obesity. This diet may also be ordered to accommodate those who choose to follow a controlled or lower-carbohydrate meal pattern or for people who experience temporary elevated blood glucose levels related to acute medical conditions. Heart-Healthy (Cardiac) Diet Definition: The heart -healthy diet limits the amount of saturated fat (5% to 6% of total energy), cholesterol (<200 mg per day), and sodium (2000-3000 mg per day) and encourages foods containing unsaturated fats and unprocessed foods low in added sugars (AHA, 2021; EAL, 2017,Jacobson, 2015). The registered dietitian nutritionist (RDN) should individualize the sodium intake (EAL, 2017). Foods with trans fats are eliminated or limited as much as possible (USDA, 2020). A heart-healthy diet encourages vegetables, fruits, legumes, nuts, whole grains, low-fat or fat-free dairy, and fish (Lichtenstein, 2021; Arnett, 2019; Jacobson, 2015). A heart-healthy diet includes 22- 38 g total fiber per day and 5-10 g viscous fiber per day (USDA, 2020; Jacobson, 2015). Indication: The heart-healthy diet is indicated for individuals with cardiovascular disease such as coronary artery disease, coronary artery bypass graft, myocardial infarction, stroke, dyslipidemia, and heart failure. This diet should be individualized by the RDN.” During a telephone interview, on the afternoon of 05/08/24, when asked if patients with Constant Carbohydrate and Cardiac diets had an individualized diet plan, Staff #L, RDN, stated in part, No, Staff #H was to be coordinating the menus with the company that provides the menus.””

“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 and interview, the facility failed to maintain the overall environment inside patient bathrooms, as shown by the abundance of holes and paint peeling on the walls of 15 of 33 patient showers (Rooms 109, 111, 112, 114, 115, 118, 214, 216, 218, 309, 312, 316, 314, 317 and 319). Findings included: Review of facility policy titled “Daily Room Cleaning”, #VIC.1.15 effective 8/1/22, showed that after a housekeeper is done cleaning the patient’s room, they will note any damage and report it to the Director of Plant Operations. Observation on 5/7/24 at 9:15 am-11:00 am of facility’s 200 and 300 units’ patient showers showed the following: Rooms 214, 216, 218, 309, 312, 316, 314, 317 and 319 all had varying degrees of paint peeling and chipping on the walls of the showers, along with numerous holes in the sheetrock. Most of the showers also had the presence of air pockets under the paint on the sheetrock walls which protruded out and were saturated with water, allowing the paint to be easily peeled away. The dried areas of the paint that were peeling could easily be further peeled away from the walls as well as from the numerous holes in the sheetrock. The largest hole observed was in room 312 and was approximately 8” x 6”. These findings posed safety hazards for patients who might engage in self-harm by swallowing the paint, and, were also infection control issues due to mold and bacteria accumulation. In addition, they were unsightly and undignified for patients housed in these rooms. In an interview at the time of findings, Corporate Clinical Director-Staff #F, who was present during observation, acknowledged that the showers had paint peeling and numerous holes in the walls and should not have been present. Observation the following day on 5/8/24 at 9:30 am of facility’s 100 unit showed that Rooms 109, 111, 112, 114, 115 and 118 had the same issues as the 200 and 300 units; all had varying degrees of paint peeling and chipping on the walls of the showers along with numerous holes in the sheetrock.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b)(1)(2)(3) (b) Standard: Life safety from fire. (1) Except as otherwise provided in this section— (i) The hospital must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) Outpatient surgical departments must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. (ii) Notwithstanding paragraph (b)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. (2) In consideration of a recommendation by the State survey agency or Accrediting Organization or at the discretion of the Secretary, may waive, for periods deemed appropriate, specific provisions of the Life Safety Code, which would result in unreasonable hardship upon a hospital, but only if the waiver will not adversely affect the health and safety of the patients. (3) The provisions of the Life Safety Code do not apply in a State where CMS finds that a fire and safety code imposed by State law adequately protects patients in hospitals. This Standard is not met as evidenced by: 23032 Based on observation, interview and record review , the facility failed to comply with Life Safety Code [ National Fire Protection Association (NFPA) Codes and the Texas Adminstrative Code {TAC] related to fire protection. The facility failed to develop a current Life Safety Plan that included: a. identification of all smoke compartments; b. identification of all “fire-rated” walls and barriers . Findings included : Record review of NFPA Codes showed : NFPA 5000, Building Construction and Safety Code (2024): Wall Marking and Identification. For other than existing assemblies, where there is an accessible concealed floor, floor/ceiling, or attic space, fire walls, fire barriers, smoke barriers, and smoke partitions shall be permanently identified with signs or stenciling in the concealed space and shall comply with all of the following: (1) Be located in accessible concealed floor, floor/ceiling, or attic spaces (2) Be located within 15 ft (4572 mm) of the end of each wall and at intervals not exceeding 30 ft (9144 mm) measured horizontally along the wall or partition (3) Include lettering not less than 3 in. (76 mm) in height with a minimum 3 ?8 in. (9.5 mm) stroke in a contrasting color (4) Identify the wall type and its fire resistive rating as applicable NFPA 101 [ 2003, 8.3.5.1] : a ) Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. Review of TAC 133.162 [Physical Plant & Constriction Reqquiments] showed: §133.162(d)(1)(A) Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each hospital. The physical premises of the hospital and those areas of the hospital’s physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and Subchapters H and I of this chapter. _____________ Review of facility policy titled : “Fire Safety Management Plan,” dated 1/02/2022, showed : “The hospital is maintained in compliancee with Life Safety Code ( NFPA 101, 2012 edition).” Review of facility’s current LIfe Safety (LS) Plan, dated 5/27/2020 showed the required LEGENDS: colored line markings for smoke partitons; 1 hour smoke barriers; 1 hour fire barriers ; 1 hour bearing walls. _______ Observations made on 5/072024 by Life Safety surveyor, accompanied by Staff-E, Director of Plant Operations (DPO), showed : None of the 1 hr. smoke barrier and 1hr. fire barrier walls as indicated on Life Safety Plans were stenciled on site. It was very difficult to track the delineation of the noted smoke compartments and plan noted rated walls. Per NFPA, it is expected for the facility to track and stencil the smoke compartment walls as well as all other rated walls in the facility. While performing this task, seal and caulk any wall penetrations that are non-compliant. During an interview with Life Safety Surveyor on 5/7/2024 at 2 PM, he stated he was unable to verify the facility’s current Life Safety Plan; this included smoke compartments and ratings of fire-walls and barriers. These findings were discussed with Staff-A, CEO during the exit conference held on 5/10/2023”

“FIRE CONTROL PLANS CFR(s): 482.41(b)(7) (5) The hospital must have written fire control plans that contain provisions for prompt reporting of fires; extinguishing fires; protection of patients, personnel and guests; evacuation; and cooperation with fire fighting authorities. This Standard is not met as evidenced by: 23032 Based on record review and interview, the facility failed to develop a safe and valid Fire Evacuation Plan for patients, staff, and visitors in case of fire. The current fire evacuation plan is based upon a Life Safety Plan that was not accurate / verifiable during survey ( refer to TAG- A-0710 ). Findings included: Review of facility policy tilted “Fire Evacuation,” dated 8/1/2022, showed: 4 “....The hospital is designed to confine fire / smoke within various areas in order to reduce the need for immediate evacuation of the entire hospital because of fire and / or smoke. 5. Fire/smoke barriers wish 1 hour fire resistive construction are provided at no more than 150 foot intervals and can be identified in the fire safety drawings....”. ~~~~~~~~~~~ During an interview on 5/7/2024 at 2 PM, with Life Safety Surveyor on-site, he stated he was unable to verify smoke compartments and ratings of fire-walls as indicated on the facility Life Safety Plan architectural drawings. He went on to say that a facility’s evacuation plan is based upon the Life Safety Plan drawings. (Cross refer : TAG A-0710)”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 37490 Based on observation, interview, and record review the facility failed to provide a sanitary environment to avoid sources and transmission for infections and communicable diseases in 1 of 3 seclusion rooms (A). Findings include: Observation on 5/7/24 at 12:12 pm in seclusion room A showed brown blood-like smear from unknown source on the door. Review of facility policy titles “Housekeeping Cleaning Procedure,” dated 8/1/22 showed the following: PRUPOSE AND SCOPE The housekeeping department shall provide the facility with safe and sanitary cleaning services in the interest of promoting an effective infection prevention program. POLICY Sanitation within the hospital environment depends upon cleaning thoroughness and frequency. There are procedures for cleaning walls, floors, windows, beds, furniture, draperies, carpet, waste containers, bathrooms, equipment, and other non-patient care areas. 5. Seclusion Rooms a. Wipe and sanitize daily-or as needed due to patient use. b. Dust and wet mop: floor. Observation on 5/7/24 at 12:04 pm in seclusion room A showed large amounts of a black “splotchy “ substance noted on the ceiling on all four sides of a sky light opening. The black splotchy areas looked to be mold. In addition, there were multiple drops of moisture noted on the air vent and ceiling; some water was observed on floor directly under the vent. Interview with CNO (D) at the time of observations, acknowledged the above findings. Both were cited previously on 7/24/23.”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 37490 Based on a review of medical records, documentation, and interview, the facility failed to conduct appropriate discharge planning for patients per facility policies in 3 of 7 patients (IDs 25, 28 and 29). Findings included: Record review of facility policy titled “Discharge Planning,” dated 8/1/22 showed the following information: PURPOSE AND SCOPE To provide clear guidelines and expectations concerning discharge planning and process. POLICY Discharge planning begins on admission and should include involvement of staff, patient, and legally authorized representative, when applicable, and planning activities and following the aftercare plan once the patient is discharged from the hospital ... PROCEDURE Component of the assessment and treatment planning process, aftercare treatment recommendations are formulated and should include members of the interdisciplinary treatment team, including the patient and their legally authorized representative, when appropriate. These recommendations include the various levels of care indicated to ensure that patients are treated at the appropriate level of care. I. Discharge planning should include, at a minimum, the following activities ... A. The patient’s interdisciplinary team (IDT) recommending services and supports needed by the patient after discharge, including the placement after discharge. B. staff will assist patient in arranging for these services supports recommended by the patients IDT as appropriate. C. Discharge planning staff will provide counseling to the patient, the patient’s legally authorized representative (LAR), and the patient’s caregivers, as appropriate, to prepare them for post discharge care ... II. The discharge plan should consist of: A. a description of the individual’s living arrangement after discharge that reflects the individual’s preferences, choices, and available community resources ... Interview with Director of Clinical services (X) on 5/9/24 at 0930, she explained the initial process for when discharge planning begins. She stated that the Collateral Contact Call is when we gather information from the patient’s family or legally authorized representative (LAR) to see where the patient is going to be discharged to and formulate a plan. This process is to be completed within the first 72 hour of admission. The discharge notes/ safety plan from the therapist will state what the plan is for the patient for discharge. Medical record review for patients (IDs 25, 28 and 29) on 5/9/24 failed to show evidence of this procedure. Interview with VP of Clinical Services (Y) on 5/9/24 at 10:00, she confirmed process outlined by staff (X) and verified findings for patients (IDs 25, 28 and 29).”

“A life safety code (LSC) survey (Full) was conducted on site on 05/07/2024 and 05/08/2024. An entrance conference was held for the Director of Plant Operations on 05/07/2024 to discuss the purpose of the LSC survey, and the survey process was explained. Instructions were provided on writing plans of correction. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital’s compliance. An LSC exit conference was conducted on 05/08/2024 in the hospital. In attendance were the Director of Plant Operations. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“General Requirements - Other CFR(s): NFPA 101 General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 36250 The inspector observed, while accompanied by clinical surveyors and the director of nursing on 05/07/2024 that the door to the seclusion room 105E was not latching properly. Also control access badge was not functional and we were involuntary locked inside seclusion room. (C) Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each facility. The physical premises of the facility and those areas of the facility’s physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and subchapters F and G of this chapter. §134.122 (d)(1)(C)”

“Roofing Systems Involving Combustibles CFR(s): NFPA 101 Roofing Systems Involving Combustibles 2012 NEW Buildings of Type I (442), Type I (332), Type II (222), Type II (111) having roof systems employing combustible roofing supports, decking or roofing meet the following: 1. roof covering meets Class A requirements. 2. roof is separated from occupied building portions with two hour fire resistive noncombustible floor assembly using not less than 2-1/2 inches concrete or gypsum fill. 3. the structural elements supporting the rated floor assembly meet the required fire resistance rating of the building. 18.1.6.2, ASTM E108, ANSI/UL 790 This Standard is not met as evidenced by: 36250 The inspector observed, while accompanied by the Director of Plant Operations on 05/08/2024 that verification of the existing roofing system is needed to ensure it meets the requirement for building Type II (111).”

“Suite Separation, Hazardous Content, and Subd CFR(s): NFPA 101 Suite Separation, Hazardous Content, and Subdivision All suites are separated from the remainder of the building (including from other suites) by construction meeting the separation provisions for corridor construction (18.3.6.2-18.3.6.5 or 19.3.6.2-19.3.6.5). Existing approved barriers shall be allowed to continue to be used provided they limit the transfer of smoke. Intervening rooms have no hazardous areas and hazardous areas within suites comply with 18/19.2.5.7.1.3. Subdivision of suites shall be by noncombustible or limited-combustible construction. 18.2.5.7.1.2 through 18.2.5.7.1.4, 19.2.5.7.1.2, 19.2.5.7.1.3, 19.2.5.7.1.4 This Standard is not met as evidenced by: 36250 The inspector observed, while accompanied by the Director of Plant Operations 05/07/2024 suite separation noted on LS plan were not physically noted on existing walls.”

“Protection - Other CFR(s): NFPA 101 Protection - Other List in the REMARKS section any LSC Section 18.3 and 19.3 Protection requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 36250 The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 the access door from Lab TLT 132E to Lab 133E, penetrates a 1 Hr. wall. The panel did not bear an UL listing label. (Lab 133E needs not to be rated) “Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.” - NFPA 101, 2003, 8.3.5.1. The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that none of the 1 hr. smoke barrier and 1hr. fire barrier walls as indicated on life safety plans not stenciled on site. It was very difficult to track the delineation of the noted smoke compartments and plan noted rated walls. It is expected for the facility to track and stencil the smoke compartment walls as well as all other rated walls in the facility. While performing this task, seal and caulk any wall penetrations that are non-compliant. All fire walls, fire barriers, fire partitions, smoke barriers, and smoke partitions shall be effectively and permanently identified with signs or stenciling per IBC 2012 section 703.7. The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that the facility failed to provide a legible Life Safety Plan. Facility shall keep a large scale (24” x 36” min.) LS plan. §133.167 (f)(2)(B) Fire safety plans. These drawings shall be provided for all newly constructed buildings, conversions of existing buildings for facilities, additions to existing licensed facilities, and remodeled portions of existing buildings containing licensed facilities. Fire safety plans shall be of a sufficiently large-scale to clearly illustrate the proposed design but not less than one-sixteenth inch equals one foot and shall include the following information: (i) separate fire safety plans (preferably one floor plan per sheet) shall indicate location of fire protection rated walls and partitions, location and fire resistance rating of each fire damper, and the required means of egress (corridors, stairs, exits, exit passageways); (I) when a new building is to contain a proposed facility, when an existing building is converted to a facility, or when an addition is made to an existing facility building, plans of each floor and roof shall be provided. (II) when a portion of a building is remodeled or when a new service is added, only the plan of the floor where the remodeling will take place or new service will be introduced and the plan of the floor of discharge shall be provided. (ii) designated smoke compartments with floor areas of each compartment, location and fire resistance rating (one or two hour) of each smoke partition, location, type and fire resistance rating of each smoke damper. (iii) location of all required fire alarm devices, including all fire alarm control panels, manual pull stations, audible and visual fire alarm signaling devices, smoke detectors (ceiling and duct-mounted), fire alarm annunciators, fire alarm transmission devices, fire sprinkler flow switches and control valve supervisory switches on each of the floor plans; and (iv) areas protected with fire sprinkler systems (pendant, sidewall or upright, normal or quick response, and temperature rating shall be indicated), standpipe system risers and sizes with valves and inside and outside fire department connections, fire sprinkler risers and sizes, location and type of portable fire extinguishers.”

“Subdivision of Building Spaces - Smoke Compar CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Compartments 2012 NEW Smoke barriers shall be provided to form at least two smoke compartments on every floor used by inpatients for sleeping or treatment, and on every floor with an occupant load of 50 or more persons, regardless of use. Size of compartments cannot exceed 22,500 square feet or a 200 foot travel distance from any point in the compartment to a door in the smoke barrier. Smoke subdivision requirements do not apply to any of the stories or areas described in 18.3.7.2. 18.3.7.1, 18.3.7.2 Detail in REMARKS zone dimensions including length of zones and dead-end corridors. This Standard is not met as evidenced by: 36250 The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that the facility failed properly to discern in the field where the subdivision for the required smoke compartments occurred.”

“Building Services - Other CFR(s): NFPA 101 Building Services - Other List in the REMARKS section any LSC Section 18.5 and 19.5 Building Services requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 36250 The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that the facility failed to provide proper elevation location for the outside air intakes located at the roof AHU’s. (IV) Low air intake location limit. The bottom of outside air intakes serving central systems shall be located as high as practical but at least six feet above ground level, or if installed above the roof, three feet above the roof level (facility to verify all roof top units outside air intake locations). §134.122 (d)(2)(B)(IV) The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 and 05/08/2024 while inspecting the AHU located on the roof and while checking documents, that the units did not provide required smoke duct detectors. NFPA 90A, 6.4.2.1 Smoke detectors listed for use in air distribution systems shall be located as follows: (1) Downstream of the air filters and ahead of any branch connections in air supply systems having a capacity greater than 944 L/sec (2000 ft3/min) , (2) At each story prior to the connection to a common return and prior to any recirculation or fresh air inlet connection in air return systems having a capacity greater than 7080 L/sec (15,000 ft3/min) and serving more than one story Smoke detectors shall be installed in return air systems with a design capacity greater than 2,000 cfm (0.9 m3/s), in the return air duct or plenum upstream of any filters, exhaust air connections, outdoor air connections, or decontamination equipment and appliances. IBC 2015 606.2.1 The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that all the patient care showers failed to provide proper moisture resistant finish as required. §134.122 (d)(2)(B)(iv) (iv) Wall finishes. Wall finishes shall be smooth, washable, moisture resistant, and cleanable by standard housekeeping practices. Wall finishes shall comply with requirements contained in Table 2 of §134.131(b) of this title, and NFPA 101, §18-3.3. (I) Wall finishes shall be water resistant in the immediate area of plumbing fixtures. (II) Wall finishes in areas subject to frequent wet cleaning methods shall be impervious to water, tightly sealed and without voids. The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that a patient’s room shower stall had two towels laying on the shower floor. At time of inspection this condition did not provide a safe environment for the patient. (C) Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each facility. The physical premises of the facility and those areas of the facility’s physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and subchapters F and G of this chapter. §134.122 (d)(1)(C) The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that the electrical room was also being used for storage. “Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage.” - NFPA 70, 2012, 110.26(E) The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that the sprinkler heads inside the kitchen freezer were not protected against mechanical injury. NFPA 13 2010 - 6.2.8? Guards. Sprinklers subject to mechanical injury shall be protected with listed guards. The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that ceiling requirements were not met for the following rooms: NFPA 13 2010 - 6.2.8? Guards. Sprinklers subject to mechanical injury shall be protected with listed guards. The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that ceiling requirements were not met for the following rooms: (v) The ceiling in the food storage room and soiled and clean ware cleaning area shall be of the monolithic type as required by §134.122(d)(2)(B)(vi)(III). (B) Ceilings in soiled workrooms and secure holding rooms shall be of the monolithic type as required by §134.122(d)(2)(B)(vi)(III) of this title. The inspector observed, while accompanied by the Director of Plant Operations, clinical surveyor, and director of nursing on 05/07/2024 that ceiling requirements were not met. Portions of the ceiling grid in certain areas of kitchen had what looked like black blotches. Facility should have those tested to determine if mold is present within kitchen ceiling. (iv) The ceiling in food preparation and food assembly areas shall be washable as required by §134.122(d)(2)(B)(vi)(II). (C) Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each facility. The physical premises of the facility and those areas of the facility’s physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and subchapters F and G of this chapter. §134.122 (d)(1)(C) The inspector observed, while accompanied by the Director of Plant Operations, 05/08/2024 that the facility failed to provide Logs for each air handler showing dates when final filters, filter bed no. 2, have been replaced with the pressure differential across the filter before and after filter replacement where differential pressure monitors are required. (ASHRAE 170, Informative Appendix A, Operations and Maintenance Procedures.) The inspector observed, while accompanied by the Director of Plant Operations, 05/07/2024 that there was accumulated moisture in the ceilining of the isolation rooms. Determine if humidifiers needed and comply with below. (IX) Humidifier location. When duct humidifiers are located upstream of the final filters, they shall be located at least 15 feet from the filters. Ductwork with duct-mounted humidifiers shall be provided with a means of removing water accumulation. An adjustable high-limit humidistat shall be located downstream of the humidifier to reduce the potential of condensation inside the duct. All duct take-offs should be sufficiently downstream of the humidifier to ensure complete moisture absorption. Reservoir-type water spray or evaporative pan humidifiers shall not be used. 134.122 (d)(3)(E)(IX)”

“Health Care Facilities Code - Other CFR(s): NFPA 101 Health Care Facilities Code - Other List in the REMARKS section any NFPA 99 requirements (excluding Chapter 7, 8, 12, and 13) that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Health Care Facilities Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 36250 The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that the facility failed properly maintain low voltage wires of the existing ceiling grid. Support wires and associated fittings that provide secure support and that are installed in addition to the ceiling grid support wires shall be permitted as the sole support. Where independent support wires are used, they shall be secured at both ends. Cables and raceways shall not be supported by ceiling grids.” - NFPA 70, 2011, 300.11”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to one month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 36250 The inspector observed, while accompanied by the Director of Plant Operations on 05/08/2024 that the facility failed to provide documented performance data forboth hospital and non-hospital receptacles. A.16. Receptacles shall be tested for: 1) The physical integrity of each receptacle shall be confirmed by visual inspection. 2) The continuity of the grounding circuit in each electrical receptacle shall be verified. 3) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 4) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). (NFPA 99, 6.3.3.2)”

“Electrical Equipment - Other CFR(s): NFPA 101 Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 10 (NFPA 99) This Standard is not met as evidenced by: 36250 The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that the facility failed properly to identify required life safety branch requirements at the generator site. 6.4.2.2.3.2 “The life safety branch shall supply power for lighting, receptacles, and equipment as follows: (1) Illumination of means of egress in accordance with 101, Life Safety Code, (2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code, (3) Hospital communications systems, where used for issuing instruction during emergency conditions, (4) Generator set locations as follows: (a) Task illumination, (b) Battery charger for emergency battery-powered lighting unit(s), (c) Select receptacles at the generator set location and essential electrical system transfer switch locations,”

“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 record review and interview, the facility failed to meet the requirements for the Condition of Participation of Patient Rights. The facility failed to: A. Monitor and assess a patient placed in seclusion (see tag A-175); B. Ensure seclusion orders were not written as PRN for 1 of 2 patients (see tag A-169); C. Ensure Restraint/Seclusion orders were renewed after four hours (tag A-171); D. Obtain orders for seclusion for 1 of 2 patients (tag A-168); and E. Develop and implement a policy that fully addressed required regulatory requirements for monitoring and assessing patients placed in seclusion (see tag A-175).”

“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: 23032 Based on observation, interview, and document review, the facility failed to meet the requirements of the Condition of Participation for Nursing Services. This failure had the potential to affect all patients receiving services in the hospital. RN nursing staff failed to : a. Perform & accurately document patient assessments : infection control screening and skin / wound assessments; b. Accurately document post-fall information; c. Develop and implement a hydration policy for high-risk geriatric patients on the 100 hallway. [refer to Tag A-0395] Based on record revew and interview, nursing staff failed to provide patient care as ordered for 2 of 2 patients ( Patient IDs # 7, 9); diagnostic studies were not perfomed or were not completed in a timely manner. [refer to Tag A-0392]”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to obtain an order for seclusion for 1 of 2 patients who were placed in seclusion (Patient #10). Findings included: Review of facility policy titled “Restraint Management”, #011, last revised 7/12/23 revealed that restraints were initiated only upon the order of a physician but it did not include any information about orders for seclusion. In an interview on 2/15/24 at 1:30 pm, DQM-Staff #D stated that there were no other polices besides #011 that addressed patients in seclusion. Record review on 2/15/24 at 11:30 of all orders for Patient #10 was conducted with Staff #D. This included all electronic orders and handwritten seclusion orders. In addition, record review of the facility forms titled “Patient Observation Form Q15, which documented Patient #10’s location inside the seclusion room was compared and contrasted to all orders. It revealed the following: On 2/4/24, the patient was secluded for 10 hours inside seclusion room per Patient Observation Form Q15. It showed the patient was in seclusion from 7:00 am to 11:45 am, then again at 1:30 pm to 6:30 pm. Review of all orders in the patient’s records failed to show any evidence of corresponding seclusion orders. On 2/9/24, the patient was secluded for 11.5 hours inside seclusion room per Patient Observation Form Q15. It showed the patient was in seclusion from 7:00 pm to 6:30 am the following day. Review of all orders in the patient’s records failed to show any evidence of corresponding seclusion orders. On 2/12/24, the patient was secluded from 7:45 am to 10:15 am per Patient Observation Form Q15. Review of all orders in the patient’s records failed to show any evidence of corresponding seclusion orders. In an interview on 2/15/24 at 12:00 pm, Staff #D stated that all orders reviewed and received were complete.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to ensure seclusion orders were not written as PRN for 1 of 2 patients (Patient #10). Findings included: Review of facility policy titled “Restraint Management”, #011, last revised 7/12/23 showed under the section titled “General Provisions For Restraint And Seclusion”, that orders would not be accepted as a standing order or on an as-needed basis -PRN. Record review on 2/15/24 at 11:30 of all orders for Patient #10 was conducted with DQM-Staff #10, which included all electronic orders. An order on 2/13/24 at 10:04 pm from Dr-Staff #U showed “Seclusion/Restrain-Adult Every Four Hours PRN, ...”. Another order on 2/14/24 at 2:04 pm from Dr.-Staff #U showed “Seclusion/Restraint-Adult Not to Exceed 4 Hours PRN, ...”. In an interview on 2/16/24 at 5:15 pm, RN-Staff #(Anonymous) stated that all restraint and seclusion orders should never be written as PRN and this was wrong to do.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to ensure orders for seclusion were renewed after the 4-hour time limit for adults for 1 of 2 patients (Patient #10). Findings included: Review of facility policy titled “Restraint Management”, #011, last revised 7/12/23 revealed that it failed to include procedures for duration of seclusion orders per federal and state regulations. In an interview on the morning of 2/15/24, DQM-Staff #D stated that there were no other polices besides #011 that addressed patients in seclusion. Record review on 2/15/24 at 11:30 of orders for Patient #10 was conducted with Staff #D. This included all electronic restraint/seclusion orders as well as all handwritten restraint/seclusion orders. In addition, record review of the facility forms titled “Patient Observation Form Q15, which documented Patient #10’s location inside the seclusion room was compared and contrasted to all orders. It revealed the following: On 2/8/24, the patient was secluded for 13 of 24 hours inside seclusion room per Patient Observation Form Q15. However, there was only one order to seclude patient at 6:00 pm. On 2/13/24, the patient was secluded 15 of 24 hours per Patient Observation Form Q15 with only one order written at 9:45 pm. On 2/14/24, the patient was secluded 23.4 of 24 hours per Patient Observation Form Q15 with only one corresponding order written at 2:04 pm. In an interview on 2/15/24 at 12:00 pm, Staff #D stated that all orders reviewed and received were complete.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to: A. Continually monitor and assess a patient in seclusion for 1 of 2 patients (Patient # 10), and; B. Develop and implement a policy and procedure for the monitoring and assessment of patients in seclusion (cross reference tags A-168, A-169 & A-171). Findings included: A. Failed to continually monitor and assess a patient in seclusion: Review of facility policy titled “Restraint Management”, #011, last revised 7/12/23 revealed that seclusion shall be discontinued when the behaviors or situations that prompted the use of restraint are no longer evident. However, the policy failed to include procedures for monitoring and assessing patients who were secluded and determining the criteria for releasing them at the earliest possible time. In an interview on 2/15/24 at the time policy was obtained, DQM-Staff #D stated that there were no other policies besides #011 that addressed patients in seclusion. Record review on 2/15/24 at 11:30 am of orders for Patient #10 was conducted with Staff #D, which included all electronic restraint/seclusion orders as well as all handwritten restraint/seclusion orders from date of admission on 1/30/24 up to time of survey, 2/15/24. Review of videotape footage of seclusion room was also conducted on 2/15/24 at 2:30 pm. Numerous random times for when Patient #10 was secluded inside the room were observed from 1 to 3 hours apart. Each of the reviews of video footage showed that the door was constantly shut. Direct observation on 2/15/24 at 4:00 pm of the facility’s seclusion rooms with Staff #D present showed that when the doors were closed, they locked automatically. Record review at the time of survey of two types of medical record forms was conducted to determine when and how long Patient #10 was in seclusion and any type of monitoring and assessing that was done during that time: One form was titled “Restraint Observation Flowsheet”. This form was specifically used for patients who were restrained and secluded. The form had entries for monitoring Vital Signs, Fluid Offered, Readiness to Discontinue Restraint, Neurocgnitive status, Cardiac/Circulation status, Respiratory status, Range of Motion and Repositioning, and Physical and Comfort Status. The other facility form reviewed used to determine when patient was secluded was titled “Patient Observation Form Q15”. This form documented the location of the patient and the patient’s behavior (This form was also used for every patient to routinely monitor them every 15 minutes-aka Q15 minutes obs’). It only documented the patients’ location with a brief description of behavior. It did not include all the other types of monitoring used for patients in seclusion like the Restraint Observation Flowsheet did. The following are times Patient #10 was in seclusion: 2/6/24 starting at 8:05 pm: Restraint Observation Flowsheet showed the patient was monitored from 7:05 pm to 11:05 pm (4 hours). However, Patient Observation Form Q15 showed the patient was in seclusion for 8 more hours, with no Restraint/Seclusion monitoring/assessing. 2/8/24 starting at 5:41 pm: Restraint Observation Flowsheet showed the patient being monitored from 5:56 pm to 6:44 pm (approximately 45 minutes). However, Patient Observation Form Q15 showed the patient was in seclusion for 12.5 more hours, with no Restraint/Seclusion monitoring/assessing. 2/9/24 starting at 12:05 pm: Restraint Observation Flowsheet showed the patient being monitored from 12:05 pm to 3:50 pm (approximately 3 hours, 45 minutes). However, Patient Observation Form Q15 showed the patient was in seclusion for 11.5 more hours, with no Restraint/Seclusion monitoring/assessing. 2/11/24 starting at 10:56 pm: Restraint Observation Flowsheet showed the patient being monitored from 10:30 pm-12:20 am (approximately 1 hour, 50 minutes). However, Patient Observation Form Q15 showed the patient was in seclusion for 11.5 more hours, with no Restraint/Seclusion monitoring/assessing. 2/12/24 starting at 8:53 pm: Restraint Observation Flowsheet showed the patient being monitored from 9:45 pm to 1:30 am (approximately 3 hours, 45 minutes). However, Patient Observation Form Q15 showed the patient was in seclusion for 6.5 more hours, with no Restraint/Seclusion monitoring/assessing. 2/13/24 starting at 7:00 am: Patient Observation Form Q15 showed the patient was in seclusion from 11:30 pm on 2/13/24 up until 11:00 pm 2/14/24, the following day (23.5 hours in seclusion) with no Restraint/Seclusion monitoring/assessing. 2/14/24 at 11:45 pm: Patient Observation Form Q15 showed the patient was in seclusion from 11:45 pm until 7:00 am 2/14/24, the following day with no Restraint/Seclusion monitoring/assessing. In an interview on 2/21/24 at 11:15 am, RN Supervisor-Staff #T was asked how a patient was monitored and assessed while in seclusion. She stated that a “1-hour face-to-face” [post restraint assessment] was done. She was further questioned how a patient would be monitored in any other ways as well as being assessed to determine readiness for release after the 1-hour face-to-face assessment. Staff #T stated the patient would be monitored every 15 minutes on the facility’s rounding sheets (“Patient Observation Form Q15”, aka ‘Q15 minute rounds’-the form that is used to routinely monitor all patients in the facility, every 15 minutes). Record review of these forms showed they did not contain documentation of criteria for monitoring and assessing patients in seclusion. ------------------------------------------------- B. Failed to develop and implement a policy and procedure for the monitoring and assessment of patients in seclusion : Further review of facility policy titled “Restraint Management”, #011, last revised 7/12/23 revealed that it failed to fully address required regulatory requirements for monitoring and assessing patients placed in seclusion. In an interview on the morning of 2/15/24, DQM-Staff #D stated that there were no other polices besides #011 that addressed patients in seclusion.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 23032 Based on interview and record review , the facility failed to initiate an investigation in a timely manner or fully investigate adverse incidents for 2 of 2 patients [Patent ID # 7, 1] Findings included : TX00490857 Review of facility policy titled” Incident Reporting,” effective date 8/1/2022, 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, or the desired routine care of the patient and/or operation of the facility, which places the Company at an increased risk for liability. -All hospital employees, contractors and providers are obligated to escalate any concern they have over the safety and well-being of any patient, visitor, or staff through the chain of command. Guidelines: 1. The Incident Report must be completed by the employee(s) who witnessed or discovered the event as soon as possible following an event which meets the above-mentioned reporting definition. Occurrences must be reported within 24 hours of the occurrence, preferably by end of shift. 2. Escalation of critical concerns should occur immediately ( within 15 minutes ) 3. The following categories, not limited to, are reported on the incident form:....patient injury...falls... B. Incident Investigation: 2. When conducting event investigation, the following steps are to be taken:...c. Interview staff members, patients, and witnesses as applicable. ~~~~~~~~~~~~~~~~~~~~ Patient ID# 7: Delay in initiating an investigation : Record review of the medical record of Patient ID # 7 with Staff ID# B, CNO, showed he was transferred to an acute care hospital on 2/5/2024. The CNO said he had fallen. Patient ID # 7 was transported to a local hospital ER and from there to a hospital in the medical center. The CNO said that she heard from the nurses that Patient ID # 7 had fractured ribs and developed a pneumothorax that required chest tubes. CNO said she learned of this two days after the transfer ( on 2/7/24). The CNO said she did not complete an incident report or inform Staff-D, Director of Quality Management (DQM) of the extent of Patient ID #7’s injuries. During an interview on 2/15/2024 at 2:15 PM with Staff -D, DQM, she stated she did not learn of Patient ID #7’s fractured ribs, pneumothorax, and death until the Medical Examiner requested the medical records on 2/13/2024. Incomplete; inaccurate investigation: Patient ID # 7 [fall] Review of facility fall report and “post-fall huddle,” dated 2/4/2024 [2300 hrs] read: Patient # 7 showed the following: - “reported or found by: MHT ID-S” - “witnessed fall” - “staff assisted to bed, pt. swung at staff, lost balance & fell.” During a telephone interview conducted on 2/20/2024 at 9:08 AM with Staff ID-S, MHT, she stated she was the tech making rounds on 2/5/2024. She said while making rounds, she saw Patient ID # 7 on the floor by the bed; he had taken off his clothes. She wanted to help him back to bed so that he would not get up and fall. He was unsteady. MHT went on to say Patient # 7 attempted to hit her when she tried to help him up. He did not fall then; he was already sitting on the floor with his back to the bed. MHT stated she was certain she did not witness this patient fall. She also said that no one from the facility had talked with her about Patient ID’s 7’s fall. Patient ID # 1 [injury of unknown origin] Observation during unit tour on 2/15/2024 at 9:45 AM showed Patient ID-1 lying in a bed low to the floor. Patient ID # 1 was on 1: 1 monitoring by staff. During an interview at time of observation with Staff-ID-F, Mental Health Tech (MHT), was asked if this patient had any wounds? She said he had a wound to his left great toe. Observation on 2/15/24 of Patient ID# 1’s left great toe showed: the toe appeared very swollen & red. Dried and fresh blood was noted on the nail bed, surface, and in between the great toe and 2nd toe. Record review of facility policy titled “ Wound Care Policy & Procedure,” undated, showed:”...As part of the admission process the RN will perform an initial head-to-toe assessment to include wound photographs and documentation of the wound to include the size, depth...and appearance of the wound to include any drainage...” Review of Patient # 1’s admission ‘Skin and Wound Assessment’, dated 2/11/2024, showed : “ bruises on face..unable to do a complete assessment to pt due to his aggressive and violent behavior.” Area for notation of wounds showed “none.” Record review of Patient# 1’s nursing skin assessments by shift [dates 2/12/2024 though 2/18/2024 ] showed inconsistencies in the nursing skin assessments . --February 18, 2024 (1108) : was the first nursing skin assessment notation of abnormal findings :” laceration on toe with redness.” [surveyor observed this wound on 2/15/2024] Review of NP progress notes, dated 2-14-2024 showed :” psych NP reported pt’s great left toe has new wound noted- bruising and some open skin to the toes.” An X-ray performed on 2/14/2023 showed a fracture of acute great toe. During record review on 2/16/2024 with Staff ID -ED, Quality Director acknowledged the skin assessment findings and that they were not consistent and accurate. She went on to say that because this wound was not documented on admission-it was considered an” injury of unknown origin” and should be investigated. It had not been investigated at time of interview.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 23032 Based on record revew and interview, nursing staff failed to provide patient care as ordered for 2 of 2 patients ( Patient IDs # 7, 9) Diagnostic studies were not perfomed or were not completed in a timely manner. Fingings included: TX00490857: During an interview with Staff -B, Chief Nursing Officer (CNO), on 2/15/2024 at 1:30 PM, she said it is the responsibility of nursing to ensure all lab and x-ray orders are completed and results received in a timely manner. Nursing is also responsible for reporting critical labs or other diagnostic results to the provider as soon as received. Record review of facility’s current “Registered Nurse-Position Description” showed: i. Patient Care Essential Job Functions:”...Performs all scheduled assessments and physician orders in a timely manner...” Record review of professional guidelines established by the American Nurses Association (ANA) titled : “ Principals of Nursing Documentation: Guidance for Registered Nurses,” 2010, showed: -Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice; -The uses of Nursing Documentation include: Communication within the healthcare team. Timely documentation of the following types of information should be maintained in the patient’s health record : assessments; order acknowledgement, implementation, and management [*not all inclusive ]. Record review of the clincial records or Patient ID # 7 and #9 showed the following: Patient ID # 9: a. Nurse Practitioner (NP) provider order dated 2/2/2024 ( 1548): “STAT chest x-ray “ - Date chest x-ray exam performed : 2/6/2024 (12:24) b. NP provider order dated 2/2/2024 ( 1742 ) : “Please do COVID and flu test: please document results.” - These tests were not completed ; no results were located by Staff-V, Health Information Management (HIM) director. During an interview with Staff -B, Chief Nursing Officer (CNO), on 2/15/2024 at 2:45 PM, she said she was unable to determine the reason these tests were not done. Patient ID # 7: c. NP provider order dated 1/31/2024 (1548) : “STAT Urinalysis (UA) with culture and sensitivity C & S) “” - Lab result showed date urine specimen collected for “UA-no micro” was 2/4/2024 ; results 2/5/2024 During an email exchange on 2/28/2024 at 2:30 PM with Staff -D, Director of Quaity Management, she stated there was no facility policy regarding STAT lab orders. She went on to say the established timeframe expectation for a STAT order was 1 hour.”

“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: 23032 Based on observation, interview, and record review, the facility failed to ensure an RN accurately evaluated and supervised the care for 8 of 17 sampled patients (IDs 1,2,3,5,7,15,16, 17) . RN nursing staff failed to : a. Perform & accurately document patient assessments : infection control screening and skin / wound assessments. b. Accurately document post-fall information. c. Develop and implement a hydration policy for the high-risk geriatric patients on the 100 hallway. Findings include: TX00490857 Record review of professional guidelines established by the American Nurses Association (ANA) titled : “ Principals of Nursing Documentation: Guidance for Registered Nurses,” 2010, showed: -Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice; -The uses of Nursing Documentation include: Communication within the healthcare team. Timely documentation of the following types of information should be maintained in the patient’s health record : assessments; order acknowledgement, implementation, and management [*not all inclusive ]. a. Inconsistent infection control screening and wound/skin assessments: Patent ID # 2: inaccurate RN infection control screening assessment : Observation during 100 hallway tour on 2/15/2024 at 9:30 AM , showed Patient # 2 sitting in her room, maskless. Staff ID-E, RN reported this patient was admitted positive for COVID. Continued observation on the 100 hallway showed housekeeping staff with a cleaning cart - two doors down from Patient ID # 2’s room. Interview at this same time with Staff ID-G, environmental services tech (EST), she stated there were no current patients on the 100 hallway who were positive for COVID. Surveyor informed Staff G that the patient in room 113 was positive for COVID. Surveyor requested that she don a mask prior to entering that room. Record review of facility admission form titled “ Infection Screening” for Patient ID # 2, dated 2/11/24 at 11:20 PM, showed:” Is there a history of MRSA, VRE, E-coli, C-Diff, COVID ? box for “NO” was checked by Staff ID -Q, registered nurse (RN). Record review of Patient ID #2’s admission orders, dated 2/11/24: “ contact and droplet isolation, Patient is COVID positive.” Review of Staff ID-J, nurse practitioner (NP), progress note, dated 2/15/24 read : “patient remains on COVID isolation.” Patient ID # 1: inconsistent wound/ skin assessments: Observation during unit tour on 2/15/2024 at 9:45 AM showed Patient ID-1 lying in a bed low to the floor. Patient ID # 1 was on 1: 1 monitoring by staff. During an interview at time of observation with Staff-ID-F, Mental Health Tech (MHT), she said this patient was on 1:1 monitoring because he was very high risk for falls. Staff ID-F was asked if this patient had any wounds? She said he had a wound to his left great toe. Observation on 2/15/24 of Patient ID# 1’s left great toe showed: the toe appeared very swollen & red. Dried and fresh blood was noted on the nail bed, surface, and in between the great toe and 2nd toe. Record review of facility policy titled “ Wound Care Policy & Procedure,” undated, showed:”...As part of the admission process the RN will perform an initial head-to-toe assessment to include wound photographs and documentation of the wound to include the size, depth... and appearance of the wound to include any drainage...” Review of Patient # 1’s admission “Skin and Wound Assessment,” dated 2/11/2024, showed “bruises on face..unable to do a complete assessment to pt due to his aggressive and violent behavior.” Area for notation of wounds showed “none.” Record review of Patient# 1’s nursing skin assessments by shift [dates 2/12/2024 though 2/18/2024 ] showed the following: - February 12 & 13, 2024: box not checked to indicate normal; section tabled “abnormal findings “ left blank. - February 14, 15, 16, 17 , 2024 : box checked to indicate: “integumentary warm to touch, dry, color good. No new bruises,lacerations or abrasions.” --February 18, 2024 (1108) : first nursing skin assessment notation of abnormal findings :” laceration on toe with redness.” [surveyor observed this wound on 2/15/2024] Review of NP progress notes, dated 2-14-2024 showed : “ psych NP reported pt’s great left toe has new wound noted- bruising and some open skin to the toes.” An X-ray performed on 2/14/2023 showed a fracture of acute great toe. During record review on 2/16/2024 with Staff ID -D, Quality Director acknowledged the skin assessment findings and that they were not consistent and accurate. She went on to say that because this wound was not documented on admission, it was considered an” injury of unknown origin” and should be investigated. It had not been investigated at time of interview. b. Patient ID #7 : Inconsistent documentation of patient fall : Record review of Patient ID # 7’s medical record showed RN progress note & NP progress note regarding a patient fall were not consistent with MHT staff description of her actual observation of finding this patient on the floor. RN nursing progress note [ Staff ID-R, RN] , “electonically signed “ 2/3/2024 (05:51) , read: “ staff was trying to assist patient to bed when he tried to physical (sic) hit her. When pt swung his arm at MHT he ended up having a fall. Noted skin tear to left and right arm. No head injury noted..” NP progress note , dated 2/5/2024 (untimed), read: “nurse report (pt.) had a witnessed fall last night..found right flank area crustaceous emphysema ... sent to ER for further evaluation..” During a telephone interview conducted on 2/20/2024 at 9:08 AM with Staff ID-S, MHT, she stated she was the tech making rounds on 2/5/2024. She recalled Patient # 7 and said that when she made rounds past his door she saw him on the floor by the bed; he had taken off his clothes. She wanted to help him back to bed so that he would not get up and fall. He was unsteady. MHT went on to say Patient # 7 attempted to hit her when she tried to help him up. He did not fall then; he was already sitting on the floor with his back to the bed. She said she called for some assistance to get him back into bed. MHT re-stated she did not witness this patient fall. During a telephone interview on 2/20/2024 at 9:45 AM with with Staff ID -D, Quality Director, she stated the nursing progress note (dated 2/3/2024 ) was not consistent with the MHT ID-S account of finding the patient on the floor. Unknown if patient fell ; should have been described as unwitnessed fall. Patient ID # 7 was was transferred to a local acute care hospital on 2/5/2024 and from there to a hospital in the medical center. Record review of both acute care hospital records revealed Patient ID # 7 had four (4) fractured ribs and developed a pneumothorax that required chest tubes. He expired on 2/13/2024. Preliminary cause of death: acute pneumothorax; respiratory failure. c. Failure to develop and implement a hydration policy / process for high-risk geriatric patients on the 100 hallway: Review of patient census dated 2/15/2024 for the 100 hallway showed 18 patients. Seven (7) of the 18 patients were between the ages of 64- 89 years. Observations and interview conducted on the 100 hallway on 2/15/2024 and 2/16/2024 showed the following: - Patient # 3: age 76 years ; observed sitting in wheelchair while speaking with surveyor. She repeatedly tried to get up and walk unsteadily over to her roommate [age 87 years] who was lying in bed. Patent ID # 3 said “she keeps asking for water; she needs water.” [ 2/15/24 at 9:45 AM] - Patient # 17: age 76, observed sitting in his wheelchair in his room. Surveyor was given permission by patient for staff to remove his socks in order to observe his feet. During observation, Patient ID# 17 stated in a raspy voice” I need water!” Staff brought him a small paper cup of water ( approx. 3 ounce size). [ 2/16/24 at 2:40 PM] - Patient ID # 5 : During an interview on 2/16/2024 at 3:00 PM she stated staff never offers water to patients on the 100 hallway. - Anonymous Staff RN:-interview 2/15/2024 at 9:15 AM, she stated :”it is common for the geriatric patients to be transferred out due to dehydration.” Record review of January 2024 “Acute Transfer Log” showed: - Patient ID # 16, 73 years old: :[ transferred to acute hospital on 1/16/24] “not drinking well; altered mental status.” NP progress note , dated 1/16/24 read: “sent to ER for higher level of care: altered mental status...possible dehydration” - Patient ID # 15 , 80 years old :[ transferred to acute hospital on 1/19/24] critical labs ( “critical levels” sodium & blood urea nitrogen)--[suggestive markers of dehydration]. During an interview with Staff -B, Chief Nursing Officer (CNO), on 2/15/2024 at 1:15 PM, she said the facility did not have a hydration policy or process established for the geriatric patients. She stated “patients are offered fluids at meal times and when they tell us they are thirsty.” ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Reference : Nursing Times Magazine : “Hydration in Older People with Mental Health Problems”, 17 January 2002, Vol.: 98, Issue: 03, Page no,: 3 Josef Brown, BSc, RMN, RGN ; Glenn Marland, BEd, Dehydration: Dehydration is caused by an inadequate intake or excessive loss of fluid. Adults can become dehydrated in as little as 48 hours, depending on the individual and environmental factors. As humans age, the thirst response naturally decreases; the individual becomes accustomed to a lower fluid intake and the body adapts quickly, resulting in a reduced urge to quench the thirst (Watt, 1991). People with an organic brain disease, such as Alzheimer’s, may have damaged osmoreceptors, which are situated in the hypothalamus region of the brain and are thought to regulate the body ’ s thirst mechanism (Watson, 1996). They may also have a degree of cognitive impairment which prevents them from satisfying their thirst or letting others know that they are thirsty. Illness-dehydration cycle: Mental illnesses such as depression, psychosis, confused states, anxiety, disability and suicidal intent can all diminish fluid intake. The resulting dehydration may, in turn, lead to medical and mental health problems such as hypovolemia, tachycardia, renal failure, disorientation and hallucinations, which can exacerbate the original dehydration. If there is a concurrent increase of fluid output through vomiting, diarrhea, polyuria, excessive perspiration or blood loss, the consequences can be severe and even fatal (Alexander et al, 2000; Sansevero, 1997).”

“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: 23032 Based on interview and record review, the facility failed to ensure care of patients in a safe setting. The facility implemented an inconsistent policy and practice related to patient observation levels. a. The facility “Precaution Level” policy was not fully developed. b. The current “Patient Observation Form Q 15 “ was not consistent with the precaution policy. c. Facility staff understanding of patient precaution levels was inconsistent. Findings included: a. Precaution level policy not filly developed: Record review of facility policy titled “Precautions,” dated 8/1/2022 , showed the following: * Voyages Behavioral Health (VBH) utilizes the following safety precautions: -Danger to Self (DTS) -Danger to Others (DTO) -Sexually Acting Out ( SAO ) -Vulnerability ( VP) -Elopement (EP) -Fall ( FP) -Seizure (SP) -Detoxification ( DETOX) The policy did not define the meaning of any of the above-listed precautions. The policy did not outline specific criteria or patient history that would trigger these precautions to be ordered / initiated b. Patient Observation Form and Precaution Policy not consistent: Review of the current “Patient Observation Form Q 15” utilized by the facility showed the following precautions listed on the top of the page are not listed in the policy: -Suicide -Homicide -Assault -SAO ( aggressor) -SAO ( victim) Record review of the policy “Precaution Levels” showed the following precautions are listed in the policy are not listed on the “Patient Observation Form Q 15 “ utilized for patient monitoring: - Danger to Self (DTS); - Danger to Others (DTO);- - Vulnerability ( VP); - Elopement (EP);- - Seizure (SP); - Detoxification ( DETOX) c. Staff knowledge of precaution levels was inconsistent: During interviews conducted on 1/9/2024 and 1/10/2024 between 10: 30 AM and 12:15 PM , showed the following: Staff ID-I, RN: named falls and suicide precautions ; was unaware of any precautions related to sexually acting out Staff ID-M, mental health tech (MHT) could not describe what “vulnerability” or “homicide “precautions meant.”