Highland Hospital

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 43434 Based on policy review, medical record review, documentation review and staff interviews, the facility failed to ensure that the designated legal guardian was recognized and allowed to make informed care decisions for one (1) out of ten (10) patients (Patient 1) sampled. This failure has the potential to affect all patients. Findings are as follows: A policy “Pre-Admission Screening and Admission Process” effective date 9/2022 states in part, “The Intake Department will provide clinical assessments of all potential patients and referral for the appropriate level of care, to ensure that all assessments are appropriately processed for admission, or assessed for an appropriate determination for level of care. Upon arrival, patients will complete initial paperwork (see paragraph 6. Admission Paperwork, Consents and Acknowledgments) and consent for assessment and be assessed for risk and triaged accordingly. Intake staff will be notified immediately of any concerning behavior by patient and/or family and/or if patient checks “Yes” on Consent for Assessment form to thoughts of suicide and homicide. If patient checks “Yes” or if Intake staff observe concerning behavior, patient and/or family will be moved to more secure and private waiting area or to an Assessment Room to begin the assessment. In either case the Observation Sheet will be initiated. Patients will be admitted to any level of care in the continuum only on the order of a physician with admitting privileges. All patients must meet admission criteria for the level of care to which they are admitted. PROCEDURE: Initial Medical Screening and Psychosocial Assessment 1.1 Qualified Medical Personnel (QMP) provide Initial Assessment/Medical Screening for patients by completing the Medical Screening Form by reviewing self-complete section and taking patient vitals. 1.2 If there are medical outliers, as indicated on the Medical Screening form, QMP will notify the RN and/or the physician as indicated on the Medical Screening form. The physician, in making level of care decisions (either with Highland or another provider), consults the QMP who has assessed the patient and the RN responding for further medical assessment. For patients not appropriate for admission due to medical outliers, an appropriate referral and appropriate transfer (per medical condition) will be arranged. A review of the medical record shows three (3) consents for psychotropic medications. On 7/29/26 for Clonidine 0.1 (zero point one) mg (milligrams) po (orally) qhs (at bedtime) verbal consent to (Adoptive parent) not current legal guardian. On 8/2/26 for Clonidine 0.2 (zero point two) mg po qhs with typed in consent from (Adoptive parent) not current legal guardian. On 8/4/26 for for an increase to Lexapro 10 (ten) mg po qhs to 15 (fifteen) mg po qhs and a verbal from (Adoptive parent) not current legal guardian. (Caregiver A) who has legal guardianship was not given the opportunity to make informed decisions on behalf of patient 1. A review of an the facilities reporting system for patient 1 was conducted. The summary speaks on what happened after the assault but fails to provide facts about the actual assault. The report stated in part, “What is being reported? Incident: A patient safety event that reached the patient, whether or not the patient was harmed. Incident Type: Atypical Discharge, Sub Incident Type: Against Medical Advice.Type of injury: Abrasion/Scrape/Cut-Bruise/ Hematoma. Part of Body Most Affected: Nose-Upper Extremies-Left-Upper Extremies-Right. Brief Summary of Incident: [Patient ’ s] guardian, [adoptive parent] signed patient out AMA due to earlier attack from another peer. Guardian stated [he/she] was pursuing charges related to incident against peer and hospital. Guardian inquiring why patients were not separated after report of first incident, per report, separation was attempted but [patient 1] did not want to be on other hall and walked into the area of 201 where the second incident occurred. Guardian requesting information on other peer, informed guardian that we cannot give that information. Guardian inquired why patient was not immediately sent to ER for evaluation, informed guardian I cannot answer this question due to my not being present at time of event. Guardian expressed dissatisfaction that patient was not released into the care of [family member] who has temporary custody, Guardian requested to record this nurse stating the events of the fight, informed guardian that this nurse was not comfortable being filmed. Guardian made recording of patient’s injuries which include swellinq across bridge of nose, contusion on right shoulder blade, and contusions down left arm. Guardian requested first and last names of all staff involved in case excluding this nurse, as name is on AMA paperwork. Informed guardian I cannot relay this information, but that floor supervisor would be back Monday and may have more information on what she is requesting. Guardian satisfied with answer and exited lobby with patient. CPS case number 69070.”... May it be noted that the guardian referenced in the facilities reporting system is not the person with current guardianship. A review of the notarized temporary guardianship paper effective 7/1/26, indicates that “[Adopted parent] is allowing temporary guardianship for patient 1 to [Caregiver A] as of 7/1/26. [Caregiver A] will be able to make decisions on [his/her] behalf for medical decisions etc. Patient 1 will reside with [Caregiver A]. If there are any questions I can be reached by phone”. A review of consents for admission and treatment were signed by (Adoptive parent) due to (Caregiver A) not being acknowledged as the guardian. An interview was conducted on 8/18/26 at 1:30 p.m. with staff 1. Staff 1 stated in part, “ After looking at the temporary guardian paperwork there was no reason to not accept it. [Caregiver A] was identified in the temporary guardian paper that was notarized and should have been involved in the patient’s care. [Staff 10] stated that the initial referral was faxed on 7/28/2026 at 11:38 p.m. consisting of a cover sheet, abs and referral information. On 7/29/ 2026 at 3:48 a.m. they received a second fax that included the MCM1 (Medical Certification Form), adoption papers and the written temporary guardian paper.” An interview was conducted on 8/18/26 at 9:17 a.m. with staff 5. Staff 5 stated in part, “Consents are on the computer. I thought [he/she] said a different name. I put in the name I thought I heard. I take full responsibility for the mistake. [Adoptive parent] was the one that signed the patient in. I confirmed the name with the identification card. I did not see the temporary guardianship for the patient. I just do the intake assessment. Like name, age, diagnosis, behaviors, legal issues and medications. Then someone else completes a clinical assessment and calls the doctor for approval to admit. We have paper and computerized consents. The intake clinicians do the actual assessment.” An interview was conducted on 8/18/26 at 3:25 p.m. with staff 10. When asked why the temporary custody for patient 1 wasn ’ t honored for admission staff 10 stated in part, “I don’t know how the temporary custody came into play regarding the admission. The hospital scanned over adoption papers, medical information and the temporary custody paperwork. The more information the better so we accepted the referral packet. When asked why the temporary custody wasn ’ t honored, the staff said it would have been honored. Can you explain why the person who has temporary custody was not allowed to participate in the admission process. They should have been allowed. I can’t answer that. Can you explain the admissions process? We get the referral, contact the doctor and they make the decision to accept. The guardian would have to sign them in. In this case, I’m not sure what happened. We always ask for identification because things can always change with kids. But it’s unclear how it happened that the person with temporary custody was omitted from the process. Is making sure that the doctor and unit nurse know who the patient’s representative is pretty important? Yes, and that information gets put in the computer. Again, should the legal temporary custody paperwork have been honored and the representative included in the patient’s admission and treatment? Yes, I don’t know what happened. I wasn’t here and I wasn’t asked about it.””

“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: 43434 Based on policy review, document review, observation and staff interviews, the facility failed to ensure a safe environment of care resulting in a peer to peer assault for two (2) out of the ten (10) patients reviewed (Patients 1 and 2). This failure has the potential to affect all patients. Findings are as follows: A policy titled “PLAN FOR THE PROVISION OF NURSING CARE POLICY” effective 7/1/2022 states in part, “ Nursing Service needs to consider unique regulatory and professional requirements in the design of a staffing plan, this document serves to describe the Plan for the Provision of Nursing Care. II. GOAL OF NURSING CARE ASSIGNMENT: Nursing care assignments, regardless of the reporting relationship of the nursing staff providing such care, shall be commensurate with the qualifications and competency of the individual and shall be designed to meet the identified nursing care needs of patients. III. DEFINITION OF NURSING PRACTICE: A. The practice of nursing includes all functions of care, including basic healthcare, which help people cope with difficulties in daily living associated with their actual or potential health, illness and the treatment thereof, and which requires a substantial amount of scientific knowledge or technical skill. Nursing practice includes all of the following, but is not limited to: B. Direct and indirect patient care services that ensure the safety, comfort, personal hygiene, protection of patients, and the performance of disease prevention and restorative measures by providing adequate nursing staff C. Direct and indirect patient care services, including, but not limited to, the administration of medication and therapeutic agents necessary to implement a treatment, disease prevention or rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist, Nurse Practitioner, Physician ’ s Assistant, or clinical psychologist D. The performance or assigning the task of skin tests, immunization techniques and the withdrawal of human blood from veins E. The performance or assigning the task of completing clinical tests and procedures such as EKGs, completing vital signs, and obtaining weights F. Observation of signs and symptoms of illness, reactions to treatment, general behavior or general condition: 1. Determination of whether such signs, symptoms, reactions, behavior or general appearance exhibits abnormal characteristics 2. Implementation, based on observations of appropriate reporting or referral, standardized procedures, changes in treatment regimen in accordance with standardized procedures or the initiation of emergency procedures IV. PURPOSE: A. To provide safe, effective nursing care designed to support improvements and innovations in nursing practice based on both the needs of the patients to be served and the mission statement. The plan supports both standards of nursing practice and nursing standards of care. B. To identify nursing care needs of the patient using the nursing process. Specifically, registered nurses shall use the assessment skills initially and on an ongoing basis to determine the level of patient care required; necessary interventions will be evaluated for effectiveness and target positive patient outcome as criteria. Modifications shall be made in treatment strategies based on the nurse ’ s evaluation of the patient ’ s response to interventions; thus, ensuring that the delivery of care is representative of the patient ’ s individualized needs. C. The Chief Nursing Officer is responsible and accountable to ensure that consistent standards are utilized. This plan provides an overview of each unit, which includes staffing plans based on acuity data and core staffing data. Criteria have been established for each unit to determine when staffing levels are to be adjusted. Staff adjustments are always based on acuity of patients and specialization of the unit. A qualified nurse is on duty at all times. If supplemental nursing staff from outside agencies are to be utilized, the hospital will verify licensure, CPR, current competency for assignment and will provide orientation either prior to assignment or during their first shift as long as they are reporting to another registered nurse. Complete records for all staff utilized from outside agencies are maintained by the Human Resources Department and are kept on file.. D. Nursing care needs are identified for all patient populations based on the specialized knowledge of registered nurses. The psychiatric nurse will assess nursing care needs based on the understanding of family dynamics, pharmacology, physiology, effectiveness of coping skills, availability of support systems and progression through the adult developmental continuum. E. With timely and adequate supervision from the RN, nursing care may be delegated to other clinical staff based on the registered nurse ’ s evaluation of the staff member ’ s qualifications and competence to deliver safe and effective nursing care. F. The Chief Nursing Officer is responsible for and accountable to ensure that consistent standards are used to monitor and evaluate the quality of care. G. In the event of a disaster, the hospital emergency management plan is implemented for necessary staffing. H. A nursing staff member shall be considered to be competent when he/she completes the job-related specific core competencies. A competent registered nurse is expected to demonstrate the ability to transfer scientific knowledge from social, biological and physical sciences in applying the nursing process, as follows: 1. Formulate a nursing diagnosis through observation of the patient ’ s condition and behavior and through interpretation of information obtained from the patient and others, including the family and healthcare staff. 2. Formulate a plan of care, in collaboration with the patient, family and other healthcare staff, which ensures direct and indirect nursing care services, provides for the patient ’ s safety, comfort, hygiene, protection and for disease prevention and restorative measures 3. Perform skills necessary in response to the identified nursing actions taken. Is able to explain the health treatment to the patient and family and educate the patient and family so they can manage continuing health needs 4. Delegate tasks to subordinates based upon the legal scope of practice of the subordinate and on the preparation, competence, and experience of the coworker. 5. Evaluate the effectiveness of the plan of care and modify the plan as needed 6. Act as an advocate for the patient and family H. All nursing care is planned, prescribed, coordinated and monitored by registered nurses who have a demonstrated competency to do so. Specific tasks/activities may be delegated to other members of the healthcare team who have demonstrated appropriate competency. No task or function may be delegated unless said task is within the scope of practice and job description of the delegate. V. ASSIGNMENT OF STAFF TO PROVIDE NURSING SERVICES: A. Individual patient care assignment is based upon: 1. The complexity of the patient ’ s condition and requirements for nursing care 2. The dynamics of the patient ’ s status, including frequency with which the need for nursing care activities changes 3. The complexity of the assessment required by the patient, including the knowledge and skills required of a nursing staff member in order to effectively complete the required assessment The type of technology employed in providing nursing care, with consideration given to the knowledge and skills required to effectively use the technology 4. The degree of supervision required by each nursing staff member based upon his/her previously assessed level of competency and current competence in relation to the nursing care needs of the patient 5. The availability of supervision appropriate to the assessed and current competency of the nursing staff member(s) being assigned responsibility for providing nursing care to the patient(s) 6. Relevant infection prevention and control and safety issues B. Nursing staff members assigned to a unit other than the one to which they are regularly assigned, may provide those services for which they have demonstrated competency. Basic care (skills not requiring licensure or certification) tasks specifically listed as within the scope of licensure may be provided by any staff member to any patient on any unit, but only those who have demonstrated competency in unit specific critical competency skills may provide those services. C. Nursing staff may receive training and demonstrate competency in managing adult, geriatric, and adolescent units. VI. GENERAL STAFFING GUIDELINES/ASSUMPTIONS UNDER WHICH THE PLAN FOR NURSING STAFF IS BASED: A. There shall be sufficient number of qualified and competent registered nurses on each unit to provide patients with nursing services that require the judgment and specialized skills of the competent registered nurse. Nursing staffing shall also be sufficient to promptly recognize untoward changes in a patient ’ s condition and to intervene appropriately utilizing nursing, medical or hospital staff. In striving to assure optimal, achievable, quality nursing care and a safe patient environment, nursing staffing and patient assignment shall be based upon identified minimum staffing requirements by unit (as delineated within subsequent pages within this document), actual patient needs (as assessed through use of the acuity tool) and the following:B. A registered nurse plans, prescribes, delegates, supervises and evaluates the nursing care of each patient on a 24-hour basis C. A registered nurse makes a patient assessment before delegating appropriate aspects of nursing care to other competent members of the healthcare team and includes considerations that minimize the risk of the transfer of infections and accidental contamination; the patient care assignment is commensurate with the qualifications and competence of each nursing staff member, the identified needs of the patient and the prescribed medical plan D. Responsibility for nursing care related duties is retained by the hospital Nursing Department when nursing students or nursing staff from outside agencies are providing patient care within a patient care unit E. Adequate staffing for nursing staff to participate in educational programs, performance improvement activities and other activities that foster professionalism and innovation in nursing is provided Nursing Services shall define, implement and maintain a system for determining patient requirements for nursing care on the basis of demonstrated patient needs, appropriate nursing intervention and priority for care. This acuity staffing system shall be based upon objective assessment tools that qualify the number of nursing staffing members needed to fulfill patient needs on each unit. The Intake Coordinator and the assigned Nursing Supervisor will collaborate prior to admission placement decisions so that patient care needs can be coordinated with available resources. When needed, the unit charge RN may be consulted to verify the appropriate resources are available to meet the needs of the patient. If not immediately available, the charge RN will notify the Nursing Supervisor of the immediate need(s). F. Individualized, goal-directed nursing care is provided to all patients through use of the nursing process. The Hospital does not utilize any specific model of nursing practice. G. Managers and staff members use the finding from performance improvement activities and feedback from clients to assist in the evaluation of patient care provided. Findings shall be used to compare actual client outcomes with defined standards of care and practice. If staffing is adequate, both in terms of the number and qualifications of staff, correlation between actual health outcomes and standards should be positive. VII. PROCEDURE: A. Master staffing plans for each unit are on file with the Staffing Coordinator. Each unit has a master/core staffing plan that identifies size of the unit, skills mix utilized on the unit, minimum number of staff that will be assigned when any patients are present. Plans include permanently assigned staff and per diem employees. B. Staffing is based upon patient census and acuity. C. Staffing schedules are planned by the Staffing Coordinator in collaboration with the CNO or designee for a month-long period that coincides with at least two (2) pay periods. Based on census and patient acuity, the needs of each unit are evaluated on a shift or partial shift basis by the Nursing Supervisor and Staffing Coordinator, in collaboration with the charge nurse, in order to provide optimal patient care that is fiscally sound. Staffing adjustments, which may include additional staff, cancellation of staff or reassignment of staff, are made by the Staffing Coordinator after consultation with the Nursing Supervisor and schedules are updated as necessary. 24-hour staffing schedules are posted. Master copies of all schedules, daily staffing sheets and acuity reports are kept on file in the hospital Nursing Office for a period of three (3) years. D. Variance between projected needs and actual staffing are described, acknowledged and justified according to census and acuity. E. It is necessary, at times, to reassign nursing staff, on a daily or temporary basis, in order to meet patient care needs. NO NURSING STAFF WILL BE ASSIGNED SPECIFIC TASKS FOR WHICH HE/SHE HAS NOT DEMONSTRATED COMPETENCY. F. All staff are to contact the Staffing Coordinator during the day, the Nursing House Supervisor after hours, when unable to work assigned shift. All calls are to be made two (2) hours prior to start of shift. In the event that a patient care unit has no patients assigned to that unit, nursing staff may be canceled or reassigned. When staff cancellation is necessary, nursing staff is notified one (1) hours before the beginning of the shift for which they were scheduled to work. VIII. ANNUAL EVALUATION OF THE HOSPITAL PLAN FOR THE PROVISION OF NURSING CARE: A. The Plan for the provision of nursing care is evaluated on an annual basis as a preliminary activity to the budgeting process. The Chief Nursing Officer conducts this evaluation with assistance from the Nurse Manager(s) as needed. This evaluation will consider at least the following two factors: 1. The patient requirements for patient care on which the plan for nursing staffing was based 2. Patient care programs or patient populations that were added or eliminated or are planned that have resulted or may result in changes in case mix.” A policy titled “PRECAUTIONS AND OBSERVATION LEVELS” last revised 6/2/2025 states, “ POLICY: Patients clinically presenting a high risk for unsafe behavior shall be placed on the corresponding precaution level to clearly identify the nature of the risk and to increase awareness of the risk of harm to self or others, with consideration given to change in observation level. GUIDELINES: A. Patients shall be informed of the level of observation and precautions at the time instituted and be provided an explanation of what the levels signify and how the observations will be conducted. It is never safe to ask a patient to “contract for safety.” (this only serves to give staff a false sense of safety) B. Patients will be educated regarding symptoms and signs associated with precaution levels and any physical plant issues or medical restrictions that may apply. C. Patient’s level of observation and precautions shall be noted at the time of admission and any time there is a change in the level of observation as follows: a. Physician/Provider orders b. Patient board c. Patient observation round sheet d. Nursing shift progress notes D. A registered nurse may institute precautions and increase level of observation based on clinical assessment, to be followed by a Provider order as soon as possible. It is the responsibility of the nurse to clarify orders that are uncertain immediately with the Physician/Provider. E. An order is required to remove or decrease precaution or observation levels. F. Precautions will be evaluated on a daily basis by the physician/provider and the treatment team. Precautions involving restrictions will be renewed daily. If the patient status changes, the physician/provider will write an order to change the precautions. G. When precautions are ordered, the treatment plan must be revised to indicate goals and interventions. H. Observation Levels a. Routine Observations - At a minimum all patients are placed on routine observations at 15-minute staggered intervals (q15s) b. (Q) 5-minute observation - This level of observation is for patients at a higher level of safety risk than the general population and need a more frequent level of observation. Visual contact will be made with the patient at least every 5- minutes (staggered) and documented accordingly. c. One to One Observation (1:1) - When a patient’s status is clinically deemed to present an imminent risk of danger to self or others, the patient shall be placed on constant, visual observation by a single designated staff member who shall remain readily available, accessible, and have the ability to immediately intervene at all times. I. Precautions: a. Suicide (SI) - Patients who verbalize active suicidal ideation or exhibit self-injurious behavior aimed at suicide. i. A safety search of patients’ belongings will be completed per shift to ensure any items that may be used to self-harm are confiscated ii. Staff may ask patient to remain in patient common area. iii. Patient may be restricted to unit if ordered by provider iv. Roomed closest to the nurse’s station v. Positive reinforcement should be given as patient continues to show insight and voice safety. b. Danger to Others / Assault (A)- Patients who have a history of aggression or assault, are threatening violence or are identified at risk of violence may be placed on precaution. i. If at any time the patient is determined to be aggressive or have active homicidal ideation, ‘A’ precautions may be ordered by a physician/provider. ii. Patient will not be assigned a roommate who is an assault victim iii. Patient will be restricted to the unit if ordered by physician/provider with rationale. iv. Positive reinforcement should be given as patient continues to show insight and voice safety. c. Danger to Self (DTS) - Patients who have inflicted or have threatened or attempted to inflict injury to self or is assessed to be at risk for self-injury may be placed on precautions. i. A safety search of patients’ belongings will be completed per shift to ensure any items that may be used to self-harm are confiscated. ii. Staff may ask patient to remain in patient common area. iii. Patient may be restricted to unit if ordered by physician/provider. iv. Positive reinforcement should be given as patient continues to show insight and voice safety. v. d. Fall - Patients with a recent history of falls or assessed to be at risk for falling will be placed on fall precautions (Policy NR.1.09) i. Patients on fall precautions will be offered yellow skidproof socks, and a ‘banner’ is placed on ObserveSmart. e. Elopement (EP) - Patients who attempt, is threatening to elope or whose behavior indicates intent to elope (e.g., straggling behind when off unit, remaining around exit doors, etc.) will be placed on precautions. i. Will be restricted to unit ii. Will be asked to stay away from doors and exits iii. Will have shoes replaced with skid-free socks f. Sexual Acting Out (SAO) - Patients who have a history of sexual acting out or sexual assault, or are identified at risk for sexual aggression, sexualized behavior or accusations will be placed on precautions based on the level of risk assessed and may include: i. May be placed in a blocked room / no roommate depending on the specific SAO behavior ii. Implementation of prescribed distance from peers iii. Increase in observation level beyond Q15s may be ordered iv. Assignment of room close to the nursing station as available v. The Treatment Plan modified to address Individualized goals and interventions to avoid/prevent sexual events/activities.vi. Staff are to observe patient behavior and discourage inappropriate contact/conversation vii. Increased level of observation per physicians’ orders g. Vulnerability (VP) - Patient who are assessed as vulnerable to frailty, disorientation, impaired mobility, wandering, verbally provoking, ability to be sexual intimidated, or at risk for abusive or bully type behaviors will be placed on precautions or observations and may include: i. Assign a room close to the nursing station ii. Provide a private room or room with roommate that is not on SAO precautions iii. Social Separation per Nursing directive. Patients who are separated from other patients to maintain safety by managing/maintaining a calm and therapeutic environment. iv. Review with physician need for Increase observation level beyond Q15s h. Seizures - Patients with a history of seizures or who experience a seizure shall be placed on precautions and may be placed on restrictions from certain activities that may exacerbate condition. i. Place patient on fall precautions ...” A policy titled “Nurse Staffing Plan” effective 7/1/2022 states in part, “PURPOSE: To provide the appropriate number of staff necessary to provide patient care. POLICY: To establish the number and qualifications of staff required to provide direct patient care. PROCEDURE: A core staffing level is determined for each unit consisting of registered nurses, mental health technicians, social workers, and therapists. NURSING: The Director of Nursing/House Supervisor determines staffing assignments based on the programmatic and patient acuity needs. The following specific items are taken into consideration by the nursing supervisor when evaluating staffing needs for the next shift and communicated to the CNO/House Supervisor. Number of patients requiring seclusion/restraint previous shift Number of patients on suicide precautions General acuity/activity level of the unit Scheduled/projected admissions Scheduled discharges Scheduled transportations, appointments for out of hospital medical care, etc. Security of fall potential The established staffing grid is utilized for core staffing, with adjustments made for acuity/activity. Changes in staffing needs during the shift are evaluated by the nursing supervisor and communicated to the DON/Designee. The DON/Designee then utilizes existing in house staff or the PRN pool to meet the identified staffing needs as appropriate and available. Contingency Staffing Plan is that House Supervisors may be asked to be on-call 24/7 to ensure staffing coverage is adequate. Along with House Supervisors the Nurse Managers are often on-call 24/7 to assist with staffing needs. Contracts are also in place with staffing agencies as maintained in Human Resources and/or administration.” A policy titled “Plan for the Provision of Clinical Care in Psychiatric Speciality Areas” effective 5/2026, states in part, “... Policy: The Hospital will provide outstanding psychiatric nursing care in response to the individual needs of patients who have a mental disorder and/or substance use disorder, as outlined in the most current DSM. In support of this mission, the nursing department is committed to delivering high-quality, person-centered care to all patients. Licensed nurses at the Hospital function as interdependent members of the multidisciplinary treatment team. The nurse executive, who is a licensed registered nurse, is responsible for the operation of nursing services, including determining nursing policies and procedures, as well as the staffing plan and matrix. Nursing Standards of Care:... To identify nursing care needs of the patient using the nursing process. Registered nurses shall use the assessment skills initially and on an ongoing basis to determine the level of care; necessary interventions will be evaluated for effectiveness and target positive patient outcomes as criteria. Modifications shall be made in treatment strategies based on the nurse’s evaluation of the patient’s response to interventions; thus, ensuring that the delivery of care is representative of the patient’s individualized needs ... Staffing Plan Guidelines There shall be a sufficient number of qualified and competent Registered Nurses, Licensed Practical Nurses, and BHAs on each unit to provide patients with nursing services that require the judgment and specialized skills of the competent nursing staff. Nursing staffing shall also be sufficient to promptly recognize untoward changes in a patient’s condition and to intervene appropriately utilizing nursing, medical, or Hospital staff 24 hours a day,7 days a week. In striving to ensure optimal, achievable, quality nursing care and a safe patient environment,nursing staffing and patient assignment shall be based upon identified minimum staffing requirements by the unit and the following: Registered Nurse plans, delegates, supervises, and evaluates the nursing care of each patient on a 24-hour basis. Licensed nurses may provide nursing care within the scope of the State Nurse Practice Act. This may include gathering data, such as vital signs, giving medications, and/or evaluating treatment effects. A review of an facilities reporting system for patient 1 was conducted. The summary speaks on what happened after the assault but fails to provide facts about the actual assault. The report stated in part, “What is being reported? Incident: A patient safety event that reached the patient, whether or not the patient was harmed. Incident Type: Atypical Discharge, Sub Incident Type: Against Medical Advice.Type of injury: Abrasion/Scrape/Cut-Bruise/ Hematoma. Part of Body Most Affected: Nose-Upper Extremies-Left-Upper Extremies-Right. Brief Summary of Incident: [Patient ’ s] guardian, [adoptive parent] signed patient out AMA due to earlier attack from another peer. Guardian stated [he/she] was pursuing charges related to incident against peer and hospital. Guardian inquiring why patients were not separated after report of first incident, per report, separation was attempted but [patient 1] did not want to be on other hall and walked into the area of 201 where the second incident occurred. Guardian requesting information on other peer, informed guardian that we cannot give that information. Guardian inquired why patient was not immediately sent to ER for evaluation, informed guardian I cannot answer this question due to my not being present at time of event. Guardian expressed dissatisfaction that patient was not released into the care of [family member] who has temporary custody, Guardian requested to record this nurse stating the events of the fight, informed guardian that this nurse was not comfortable being filmed. Guardian made recording of patient’s injuries which include swellinq across bridge of nose, contusion on right shoulder blade, and contusions down left arm. Guardian requested first and last names of all staff involved in case excluding this nurse, as name is on AMA paperwork. Informed guardian I cannot relay this information, but that floor supervisor would be back Monday and may have more information on what she is requesting. Guardian satisfied with answer and exited lobby with patient. CPS case number 69070.”... A review of the staffing schedule and matrix does show that the matrix is followed on paper. However, through observation and staff interviews it was determined that the staffing matrix is not followed at all times. There were two (2) staff on the unit the night of the incident. An observation was conducted on unit 1E (one east) on 8/18/26 at 1:45 p.m. The unit is U-shaped and split in half. There is a centrally located nurses station that is enclosed behind clear glass and a locked door. There is an AED (Automated External Defibrillator) stored there. The medication room is through the nurses station and also locked with a badge and code. In the medication room, there is one (1) Pyxis and one (1) medication refrigerator, a sink, and supplies. There is a sharps container and a hazardous drug return unit with a lid. There are a total of twenty (20) beds on the unit and two (2) private rooms. There are six (6) bathrooms on the unit, which contain a shower, toilet and sink. Behind the nurses station is a day room with glass walls which contains five (5) round tables and several chairs. There are two (2) time out rooms on the unit, a doctor’s office, a laundry room, and a treatment/ telehealth room. There is a locked back hallway that contains an exam room, offices, and a dietary room. At the time of the observation there were twelve (12) patients in the unit, two (2) nurses and one (1) BHA (Behavior Health Aide). An observation was conducted on unit 2W (two west) on 8/18/26 at 2:15 p.m. The unit is U-shaped and split in half. There is a centrally located nurses station that is enclosed behind clear glass and a locked door. There is an AED (Automated External Defibrillator) stored there. The medication room is through the nurses station and also locked with a badge and code. In the medication room, there is one (1) Pyxis and one (1) medication refrigerator, a sink, and supplies. There is a sharps container and a hazardous drug return unit with a lid. There are a total of twenty (20) beds on the unit and four (4) private rooms. There are six (6) bathrooms on the unit, which contain a shower, toilet and sink. Behind the nurses station is a day room with glass walls which contains five (5) round tables and several chairs. There are two (2) time out rooms on the unit, a doctor’s office, a laundry room, and a treatment/ telehealth room. There is a locked back hallway that contains an exam room, offices, and a dietary room. While in the dietary room it was observed that the microwave, refrigerator, and coffee pot, all had expired inspection stickers on them dated 7/17/25. Staff 3 was made aware and said that (he/she) would see that they were taken care of immediately. At the time of the observation there were thirteen (13) patients in the unit, one (1) nurse and two (2) BHA ’ s (Behavior Health Aide). One (1) of the BHA ’ s was sitting with a one-to-one (1:1). The staffing grid called for another staff member to be staffed on the unit as base staffing. Staff 3 stated that (he/she) was unaware of how many patients were on the unit and called the house supervisor. Staff 3 then reported that another staff member was coming but couldn ’ t be here until after 3:00 p.m. An interview was conducted on 8/19/26 at 9:58 a.m. with staff 3. Staff 3 stated in part, “On admission they [the patients] get a suicide risk assessment. Questions go through a drop-down to prompt the next question. Suicidal, homicidal, then there’s psychosis assessment ... There is a smaller version in the nursing assessment. There are daily questions in the nursing assessment, as well as the evaluation by the provider. This assessment prompts for additional screeners like for aggression or sexually acting out. This works as an acuity assessment which makes the foundation for provider orders. Until recently, the providers were all telehealth, so it is very time consuming to make sure it is accurate. The staff had to be the eyes and ears because you can’t tell things like body language by seeing someone’s shoulders and head on a screen. We use the staffing grid from the [facility] from 2020 for all of our units. It changes a little bit between adolescents and adults. We try to have floats to give breaks, as well as using our nursing supervisors and managers. We have other ancillary staff like teachers, care managers, etc. on the floor. We have to staff for one to ones [1:1’s]. We used to have every five [5] minute checks, but the [facility] has done away with that and now we do every fifteen [15] minute checks. We have to take acuity into account and what else is going on in the unit for additional staff. We take both number and acuity into account. The number, we cannot staff below that. That’s the baseline, but acuity has to be considered. We always follow the grid.” When asked about why staffing was below the grid on 2W (two west) the day before during surveyor observations,staff 3 stated, “The nurse yesterday had misspoke to the supervisor and said that the pending discharge charges had left. We had them at ten [10], not twelve [12] patients. We had therapists on the unit though, all day. There are always two [2] to [3] three other staff members on the unit as well. We were down one [1] staff member for an hour yesterday. We found out yesterday when we did the rounds with you. Had we known we would have had a float to come to that unit. I’m not sure why the nurse didn’t communicate that to us. I will go to the units if I need to, to sit with a one-to-one [1:1] or for breaks. We would have, had we been alerted to that in real time.” Staff 3 continued, “We have a supervisor report that breaks down major events, restraints, seizures, falls, etc. We use that data to determine if we need more staff. It isn’t structured, so it can be inconsistent. I think there are situations where I would like more staff here. But, we use the managers and supervisors to staff when needed. When Summit took over, we lost our med [medication] nurse until we got to a certain number of patients. We have had to pull an extra nurse once to 1E [one east] because everyone was a crushed med. There is no possible way that one [1] nurse could do assessments, safety checks, and not only past meds, but crush all meds for ten [10] or eleven [11] patients. As a base, the grid, I think it is safe. If acuity is higher then we definitely need to upstaff. There isn’t a formal process so it is based on the observations and opinions of the [supervisory] staff. We piloted a process that assigned a number to acuity, but the CNO [chief nursing officer] at the time felt that the numbers ended up equaling what we were doing already, so they did away with the pilot. I guess we could look at that information again to put a more structured process into play. I wasn’t in management at the time, so I’m not sure if staffing was from a grid or acuity then. We have openings. We have a few [staff] on orientation this week, and I have a few nurses that will be on orientation in the next two [2] weeks. When an ‘All Call’ is called, people leave their units to respond to the situation. Off shifts, people that work in maintenance or housekeeping or anyone can respond also. Teachers, case managers, and therapist can often deflect or deescalate a problem that’s ensuing. They can redirect or divert a problem patient’s attention. We have questioned [facility] about the grid. They say that it is a base and we can upstaff if needed. We welcome staff to get a hold of the supervisors and to be proactive if they need more staff. They ask for more staff frequently. I feel like lack of staff has always been a big staff concern. It doesn’t matter if we have four [4] staff members or eight [8] staff members, they always want more staff. When there is more staff, the staff become unproductive. They are on their phones and just get themselves into trouble. Staff wanting more staff isn’t necessarily because of concern or acuity. It is something that is always there. We offer incentives to upstaff when we need to, but we monitor that because the incentives entice people to work over, and if they have done it a few times already that week, we may have to tell them thank you for the offer, but we don’t want them to be over tired. Also, sometimes staff will just stay through a med pass to get that shift through. I think we get a lot of complaints. I would say though seventy five percent [75%] of the complaints we get are from termed staff members. For example, a termed employee worked here with no complaints documented while [he/she] was working here, but once [he/she] found out that [he/she] got reported to the nursing board after [he/she] was terminated, [he/she] had several grievances. We have a corporate tip line and sometimes they are word for word, copy and paste, the same complaints that get reported by the surveyors. We have made a lot of changes and who we accept here. I don’t get patients accepted that are even a quarter of what get referred here. We aren’t taking the higher acuity patients like the ones with court orders that we used to, and I feel like the staff have appreciated that.” An interview was conducted on 8/18/26 at 11:05 a.m. with staff 6. Staff 6 stated in part, “I came through the entrance door and [patient 1] told me that a peer had pushed [him/her] to the floor. At first we didn’t really know if it happened. The nurse noted bruises on back and shoulder. I don’t know who broke up the fight. I took patient 2 to side B. [He/She] was good all day. Then when it came to the second incident, Patient 2 said that a [male/female] patient got broken up with and was crying and hitting head on the wall. [He/She] wanted patient 2 to attack patient 1. The location was at the entrance door. There is a camera up there but it captures the nursing station. When asked how things are when there is only two (2) staff on the unit, staff 6 stated bad. It’s not safe. Three [3] staff to seventeen [17] patients is not safe either. There is no one on the other units to pull from. Yes, we have the response team and if they’re not already doing something they can be there for maybe two [2] minutes or more. They say we don ’ t need more staff only for the high acuity patients. We need more! But we don’t get more. I haven’t seen or heard staff being rude or demeaning to patients. The staff here treat everybody great. I’ve not heard of any staff here putting people down or mistreating the patients. The staff are really nice people. They are who I come here to work with. There just isn’t enough staff. People are always willing to pick up and stay late. We just don’t have enough people available to work. People aren’t going to do this job for seventeen dollars [$17] an hour. The supervisors and administrators are aware. They just say that they’re doing their best. The staffing is bad. Especially on the weekends. I feel like care can be jeopardized by the lack of staffing, more so on the children’s units.” An interview was conducted on 8/18/26 at 11:40 a.m. with staff 7. Staff 7 states in part, “I’m aware of the peer to peer incident on [2] west. I do work on that unit but I go wherever the schedule says to. I have worked sixteen [16] hours just me and a nurse. I pick up shifts to help out. There’s not enough staff. Ideally, the more staff you have the better it is. You can do more with the patients. I wanted to take the kids out last Saturday, it was a pretty day, but I couldn’t because there was no one to stay and cover the patients that can’t leave the unit. They all had to stay in. That’s not fair to the patients that are allowed out. If you have a good group of kids on the unit you might could do it with two [2] people.If there are only two [2] staff and a brawl happens, one [1] person would have to run to the phone to call and ‘All Call ’ . They say staffing goes by the grid based on how many people are on the unit. Sometimes they will add another person if we have a rough group and acuity is high. The house supervisor would be the one to assign the extra person. I have seen a lot of people come and go over the years. Mental health isn’t for everyone. I pick up a lot. It’s by choice. I could always use some extra money. I do like what I do here. They offered for me to work extra today, but I’m tired from working sixteen [16] hours yesterday, so I told them that I can’t.” An interview was conducted on 8/18/26 at 11:55 a.m. with staff 8. Staff 8 stated in part, “Staffing depends on how many patients there are. I feel like the staffing is safe on the floors. There’s typically a nurse plus a med nurse and one [1] or two [2] others on the floor.” An interview was conducted on 8/18/26 at 12:23 p.m. with staff 9. Staff 9 stated in part, “I’m the charge nurse on the unit. The patient came to me to get something for pain. [He/She] had bruises on back and shoulder. The patient said [he/she] fell in [his/her] room and did it. When it was phone call time, [he/she] was on the phone with [caregiver A] and was crying. Afterward, she came back and asked what would you do if a patient fought another patient? I told [him/her] we would separate the patients and investigate it. The patient then told me that [patient 2] had beat her up. I moved the patient to side B and the Behavior Health Associate (BHA) stayed in the hall on the B side. The patient refused to move to the B side, so I told [him/her] to stay at the nursing station. I went to attend to another situation and the patient must have walked into the seclusion hallway. I saw [patient 2] follow [him/her]. I was coming through the nurses station and I saw [patient 1] on the floor and [patient 2] standing over [him/her] with [his/her] fist in the air. I called a response team for help. I couldn’t keep two [2] patients separated and check [patient 1] out at the same time. I did the incident report and contacted [caregiver B]. The first time was over the fall. Then, I had to contact [him/her] again to clarify the situation from the first incident and tell [him/her] about the second. I also told [him/her] it’s [his/her] right to press charges. [He/She] said they would be picking the patient up. That’s what happened and they left against medical advice (AMA). When asked why the temporary custody paperwork wasn’t honored, staff 9 said that only a guardian could sign the paperwork. I found out later that [caregiver A] was a temporary guardian. I could only release it to a guardian or mom. When asked about staffing vs acuity needs, staff 9 said we need more staff. They follow the grid. The grid is supposed to account for acuity. I’m not sure that it does. That’s what I am told. I feel like limited staff affects patient safety. As a matter of fact, I have even asked for more staff today. I told them if I didn’t get more staff than I want hazard pay to cover for when they fire me for making a mistake. Today we don’t even have a float. That’s why my manager is on the floor covering for me right now to come to this interview. I love my job. I work extra so that the kids don’t have to suffer. I have four pending discharges and two pending admissions today.” An interview was conducted on 8/19/26 at 10:35 a.m. with staff 11. Staff 11 stated in part, “We have fourteen [14] patients on the unit today with two [2] staff from 7:00 a.m. to 9:30 a.m. We should have had three [3] to start with. Having only two [2] staff is very dangerous. If one [1] or two [2] of those [males/females] were to get into it, I couldn’t do anything. There are six [6] foot and two-hundred [200] pound kids on the unit. I would have to wait for help to come. Was the manager or supervisor made aware that the unit was out of staffing matrix? Yes, and they called someone in but it took two [2] and a half hours. It’s just dangerous.””

“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: 43434 Based on policy review, documentation review, observation and staff interviews the facility failed to provide adequate staffing to safely monitor and provide care to ten (10) out of ten (10) sampled patients. This failure to maintain a safe environment and appropriate staffing resulted in an unmonitored patient to patient aggressive incident and caused physical harm to patient 1. This failure has the potential to affect all patients. Findings are as follows: A policy titled “HIGHLAND HOSPITAL PATIENT ’ S RIGHTS AND RESPONSIBILITIES” no date, states in part, “... 3) You have the right to quality care that is suited to your needs, delivered promptly and safety by a well-trained staff ... A policy titled “Nurse Staffing Plan” effective 7/1/2022 states in part, “PURPOSE: To provide the appropriate number of staff necessary to provide patient care. POLICY: To establish the number and qualifications of staff required to provide direct patient care. PROCEDURE: A core staffing level is determined for each unit consisting of registered nurses, mental health technicians, social workers, and therapists. NURSING: The Director of Nursing/House Supervisor determines staffing assignments based on the programmatic and patient acuity needs. The following specific items are taken into consideration by the nursing supervisor when evaluating staffing needs for the next shift and communicated to the CNO/House Supervisor. Number of patients requiring seclusion/restraint previous shift Number of patients on suicide precautions General acuity/activity level of the unit Scheduled/projected admissions Scheduled discharges Scheduled transportations, appointments for out of hospital medical care, etc. Security of fall potential The established staffing grid is utilized for core staffing, with adjustments made for acuity/activity. Changes in staffing needs during the shift are evaluated by the nursing supervisor and communicated to the DON/Designee. The DON/Designee then utilizes existing in house staff or the PRN pool to meet the identified staffing needs as appropriate and available. Contingency Staffing Plan is that House Supervisors may be asked to be on-call 24/7 to ensure staffing coverage is adequate. Along with House Supervisors the Nurse Managers are often on-call 24/7 to assist with staffing needs. Contracts are also in place with staffing agencies as maintained in Human Resources and/or administration.” A policy titled “Plan for the Provision of Clinical Care in Psychiatric Speciality Areas” effective 5/2026, states in part, “... Policy: The Hospital will provide outstanding psychiatric nursing care in response to the individual needs of patients who have a mental disorder and/or substance use disorder, as outlined in the most current DSM. In support of this mission, the nursing department is committed to delivering high-quality, person-centered care to all patients. Licensed nurses at the Hospital function as interdependent members of the multidisciplinary treatment team. The nurse executive, who is a licensed registered nurse, is responsible for the operation of nursing services, including determining nursing policies and procedures, as well as the staffing plan and matrix. Nursing Standards of Care:... To identify nursing care needs of the patient using the nursing process. Registered nurses shall use the assessment skills initially and on an ongoing basis to determine the level of care; necessary interventions will be evaluated for effectiveness and target positive patient outcomes as criteria. Modifications shall be made in treatment strategies based on the nurse’s evaluation of the patient’s response to interventions; thus, ensuring that the delivery of care is representative of the patient’s individualized needs ... Staffing Plan Guidelines There shall be a sufficient number of qualified and competent Registered Nurses, Licensed Practical Nurses, and BHAs on each unit to provide patients with nursing services that require the judgment and specialized skills of the competent nursing staff. Nursing staffing shall also be sufficient to promptly recognize untoward changes in a patient’s condition and to intervene appropriately utilizing nursing, medical, or Hospital staff 24 hours a day,7 days a week. In striving to ensure optimal, achievable, quality nursing care and a safe patient environment,nursing staffing and patient assignment shall be based upon identified minimum staffing requirements by the unit and the following: Registered Nurse plans, delegates, supervises, and evaluates the nursing care of each patient on a 24-hour basis. Licensed nurses may provide nursing care within the scope of the State Nurse Practice Act. This may include gathering data, such as vital signs, giving medications, and/or evaluating treatment effects. “ A Registered Nurse makes a patient assessment before delegating appropriate aspects of nursing care to other competent members of the healthcare team and includes considerations that minimize the risk of the transfer of infections and accidental contamination; the patient care assignment is commensurate with the qualifications and competence of each nursing staff member, the identified needs of the patient, and the prescribed medical plan. A BHA can assist the RN with delegated tasks such as obtaining vital signs, assisting with personal care and hygiene of the patient, assisting with meals, providing patient supervision and monitoring the patient on their individual prescribed level of observation, can conduct educational groups, provide supervision of visitation, in some cases when competent may assist in obtaining phlebotomy and lab specimens, assist with checking in patient belongings, and ensuring the unit is safe and free from contraband. (This list may not be all-inclusive) “ Responsibility for nursing care-related duties is retained by the Hospital Nursing Department when nursing students or nursing personnel from outside agencies are providing patient care within a patient care unit. “ Adequate staffing for nursing personnel to participate in educational programs, performance improvement activities, and other activities that foster professionalism and innovation in nursing is provided. RNs are not required in lntensive Outpatient programs. The Nursing Department shall define, implement, and maintain a system for determining patient requirements for nursing care based on demonstrated patient needs, appropriate nursing intervention, and priority for care. This acuity staffing system shall be based upon objective assessment tools that qualify the number of nursing staffing members needed to fulfill patient needs on each unit. The Assessment Coordinator utilizes input from the Chief Executive Officer, the unit charge nurses, or designee prior to admission placement decisions so that patient care needs can be coordinated with available resources. lndividualized, goal-directed nursing care is provided to all patients using the nursing process. The Nursing Department uses findings from performance improvement activities and feedback from clients to assist in the evaluation of patient care provided. Findings shall be used to compare actual client outcomes with defined standards of care and practice. If staffing is adequate, both in terms of the number and qualifications of staff, the correlation between actual health outcomes and standards should be positive”.... A review of a job description titled “REGISTERED NURSE ACUTE” states in part, “PURPOSE STATEMENT: The Registered Nurse is responsible for providing nursing care to patients. Supervising care treatment and services of patient care provided by LPNs, CNAs and other staff on assigned unit and shift. Developing, implementing, and evaluating an individual plan of care for each patient. Assessment and re-assessment of patients. Communicating appropriate information with the interdisciplinary team. Reporting patient concerns and changes in condition to supervisor and/or physician in a timely manner ... Monitors patient acuity, census, staffing needs, and makes arrangements for coverage as needed, following established guidelines. Assures thorough, accurate documentation is completed for all patients on each shift and patient assignment sheets are completed daily and tasks are carried out as assigned. Gives thorough report to oncoming staff, supervisors, and physician. Provides coverage in emergency services as needed ... Complies with organizational policies, procedures, performance improvement initiatives and maintains regulatory and industry standards.”... A review of the staffing schedule and matrix does show that the matrix is followed on paper. However, through observation and staff interviews it was determined that the staffing matrix is not followed at all times. An observation was conducted on unit 2W (two west) on 8/18/26 at 2:15 p.m. At the time of the observation there were thirteen (13) patients in the unit, one (1) nurse and two (2) BHA ’ s (Behavior Health Aide). One (1) of the BHA ’ s was sitting with a one-to-one (1:1). The staffing grid called for another staff member to be staffed on the unit as base staffing. Staff 3 stated that (he/she) was unaware of how many patients were on the unit and called the house supervisor. Staff 3 then reported that another staff member was coming but couldn ’ t be here until after 3:00 p.m. An interview was conducted on 8/19/26 at 9:58 a.m. with staff 3. Staff 3 stated in part, “On admission they [the patients] get a suicide risk assessment. Questions go through a drop-down to prompt the next question. Suicidal, homicidal, then there’s psychosis assessment ... There is a smaller version in the nursing assessment. There are daily questions in the nursing assessment, as well as the evaluation by the provider. This assessment prompts for additional screeners like for aggression or sexually acting out. This works as an acuity assessment which makes the foundation for provider orders. Until recently, the providers were all telehealth, so it is very time consuming to make sure it is accurate. The staff had to be the eyes and ears because you can’t tell things like body language by seeing someone’s shoulders and head on a screen. We use the staffing grid from the [facility] from 2020 for all of our units. It changes a little bit between adolescents and adults. We try to have floats to give breaks, as well as using our nursing supervisors and managers. We have other ancillary staff like teachers, care managers, etc. on the floor. We have to staff for one to ones [1:1 ’ s]. We used to have every five [5] minute checks, but the [facility] has done away with that and now we do every fifteen [15] minute checks. We have to take acuity into account and what else is going on in the unit for additional staff. We take both number and acuity into account. The number, we cannot staff below that. That’s the baseline, but acuity has to be considered. We always follow the grid.” When asked about why staffing was below the grid on 2W (two west) the day before during surveyor observations,staff 3 stated, “The nurse yesterday had misspoke to the supervisor and said that the pending discharge charges had left. We had them at ten [10], not twelve [12] patients. We had therapists on the unit though, all day. There are always two [2] to [3] three other staff members on the unit as well. We were down one [1] staff member for an hour yesterday. We found out yesterday when we did the rounds with you. Had we known we would have had a float to come to that unit. I’m not sure why the nurse didn’t communicate that to us. I will go to the units if I need to, to sit with a one-to-one [1:1] or for breaks. We would have, had we been alerted to that in real time.” Staff 3 continued, “We have a supervisor report that breaks down major events, restraints, seizures, falls, etc. We use that data to determine if we need more staff. It isn’t structured, so it can be inconsistent. I think there are situations where I would like more staff here. But, we use the managers and supervisors to staff when needed. When Summit took over, we lost our med [medication] nurse until we got to a certain number of patients. We have had to pull an extra nurse once to 1E [one east] because everyone was a crushed med. There is no possible way that one [1] nurse could do assessments, safety checks, and not only past meds, but crush all meds for ten [10] or eleven [11] patients. As a base, the grid, I think it is safe. If acuity is higher then we definitely need to upstaff. There isn’t a formal process so it is based on the observations and opinions of the [supervisory] staff. We piloted a process that assigned a number to acuity, but the CNO [chief nursing officer] at the time felt that the numbers ended up equaling what we were doing already, so they did away with the pilot. I guess we could look at that information again to put a more structured process into play. I wasn’t in management at the time, so I’m not sure if staffing was from a grid or acuity then. We have openings. We have a few [staff] on orientation this week, and I have a few nurses that will be on orientation in the next two [2] weeks. When an “All Call” is called, people leave their units to respond to the situation. Off shifts, people that work in maintenance or housekeeping or anyone can respond also. Teachers, case managers, and therapist can often deflect or deescalate a problem that’s ensuing. They can redirect or divert a problem patient ’ s attention. We have questioned [facility] about the grid. They say that it is a base and we can upstaff if needed. We welcome staff to get a hold of the supervisors and to be proactive if they need more staff. They ask for more staff frequently. I feel like lack of staff has always been a big staff concern. It doesn’t matter if we have four [4] staff members or eight [8] staff members, they always want more staff. When there is more staff, the staff become unproductive. They are on their phones and just get themselves into trouble. Staff wanting more staff isn’t necessarily because of concern or acuity. It is something that is always there. We offer incentives to upstaff when we need to, but we monitor that because the incentives entice people to work over, and if they have done it a few times already that week, we may have to tell them thank you for the offer, but we don’t want them to be over tired. Also, sometimes staff will just stay through a med pass to get that shift through. I think we get a lot of complaints. I would say though seventy five percent [75%] of the complaints we get are from termed staff members. For example, a termed employee worked here with no complaints documented while [he/she] was working here, but once [he/she] found out that [he/she] got reported to the nursing board after [he/she] was terminated, [he/she] had several grievances. We have a corporate tip line and sometimes they are word for word, copy and paste, the same complaints that get reported by the surveyors. We have made a lot of changes and who we accept here. I don’t get patients accepted that are even a quarter of what get referred here. We aren’t taking the higher acuity patients like the ones with court orders that we used to, and I feel like the staff have appreciated that.” An interview was conducted on 8/18/26 at 11:05 a.m. with staff 6. Staff 6 stated in part, “...When asked how things are when there is only two (2) staff on the unit, staff 6 stated bad. It ’ s not safe. Three [3] staff to seventeen [17] patients is not safe either. There is no one on the other units to pull from. Yes, we have the response team and if they’re not already doing something they can be there for matwo [2]minutes or more. They say we don’t need more staff only for the high acuity patients. We need more! But we don’t get more. I haven’t seen or heard staff being rude or demeaning to patients. The staff here treat everybody great. I ’ ve not heard of any staff here putting people down or mistreating the patients. The staff are really nice people. They are who I come here to work with. There just isn’t enough staff. People are always willing to pick up and stay late. We just don ’ t have enough people available to work. People aren ’ t going to do this job for seventeen dollars [$17] an hour. The supervisors and administrators are aware. They just say that they ’ re doing their best. The staffing is bad. Especially on the weekends. I feel like care can be jeopardized by the lack of staffing, more so on the children’s units.” An interview was conducted on 8/18/26 at 11:40 a.m. with staff 7. Staff 7 states in part, “I’m aware of the peer to peer incident on [2] west. I do work on that unit but I go wherever the schedule says to. I have worked sixteen [16] hours just me and a nurse. I pick up shifts to help out. There ’ s not enough staff. Ideally, the more staff you have the better it is. You can do more with the patients. I wanted to take the kids out last Saturday, it was a pretty day, but I couldn ’ t because there was no one to stay and cover the patients that can ’ t leave the unit. They all had to stay in. That ’ s not fair to the patients that are allowed out. If you have a good group of kids on the unit you might could do it with two [2] people.If there are only two [2] staff and a brawl happens, one [1] person would have to run to the phone to call and ‘All Call’ . They say staffing goes by the grid based on how many people are on the unit. Sometimes they will add another person if we have a rough group and acuity is high. The house supervisor would be the one to assign the extra person. I have seen a lot of people come and go over the years. Mental health isn’t for everyone. I pick up a lot. It’s by choice. I could always use some extra money. I do like what I do here. They offered for me to work extra today, but I’m tired from working sixteen [16] hours yesterday, so I told them that I can’t.” An interview was conducted on 8/18/26 at 12:23 p.m. with staff 9. Staff 9 stated in part, “... I couldn ’ t keep two [2] patients separated and check [patient 1] out at the same time... When asked about staffing vs acuity needs, staff 9 said we need more staff. They follow the grid. The grid is supposed to account for acuity. I’m not sure that it does. That’s what I am told. I feel like limited staff affects patient safety. As a matter of fact, I have even asked for more staff today. I told them if I didn’t get more staff than I want hazard pay to cover for when they fire me for making a mistake. Today we don’t even have a float. That’s why my manager is on the floor covering for me right now to come to this interview. I love my job. I work extra so that the kids don’t have to suffer. I have four pending discharges and two pending admissions today.” An interview was conducted on 8/19/26 at 10:35 a.m. with staff 11. Staff 11 stated in part, “we have fourteen [14] patients on the unit today with two [2] staff from 7:00 a.m. to 9:30 a.m. We should have had three [3] to start with. Having only two [2] staff is very dangerous. If one [1] or two [2] of those [males/females] were to get into it, I couldn’t do anything. There are six [6] foot and two-hundred [200] pound kids on the unit. I would have to wait for help to come. Was the manager or supervisor made aware that the unit was out of staffing matrix? Yes, and they called someone in but it took two [2] and a half hours. It’s just dangerous.””

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 53453 Based on observation and staff interview, the facility failed to ensure an acceptable level of safety and quality by not performing annual safety checks on the appliances in the dietary room in one (1) of two (2) units observed. This failure has the potential to adversely affect all patients admitted to 2W (two west). Findings include: A policy was requested for safety and equipment checks and none was provided. An observation was conducted on 8/18/26 at 2:15 p.m. on unit 2W (two west). While in the dietary room, it was observed that the refrigerator, microwave and coffee pot all had expired green maintenance check stickers dated 7/17/25. An observation was conducted on 8/19/26 at 1:18 p.m. on unit 2W (two west). While in the dietary room, it was observed that the refrigerator, microwave, and coffee pot all had expired green maintenance check stickers dated 7/17/25, despite informing staff 3 and staff 12 on 8/18/26. An interview was conducted on 7/17/26 at 4:20 p.m. with staff 12. Staff 12 stated, “We check the green tags on some things but we do not have a policy or written process as to how we do it. We take a monthly stroll through all of the units and check and replace them as they need it. I know that we have several that have expired in July, but we haven ’ t had time to get those because of the construction going on. I ’ ll send [my employee] a message to have them done by the end of the month.” Staff 12 confirms that the checks were not done on the dietary unit of 2W (two west).”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 43434 Based on policy review, documentation review and staff interview, the facility failed to follow their grievance policy by not providing the patient written notice of it’s decision and the steps taken to investigate the grievance (patient 2). This failure has the potential to effect all patients. Findings are as follows: A policy “Abuse and Neglect of Individuals Served, HR 320”, effective date 1/1/24, states in part, “ ... Policy: It is the policy of the Company that any instances of physical, psychological, sexual, verbal or any other forms of abuse or neglect by a Team Member toward an individual served will not be tolerated. All Team Members are required to report any suspected abuse and/or neglect to their immediate supervisor or Risk Manager. The facility will cooperate in the prosecution of appropriate criminal charges against any Team Member that has engaged in abuse or neglect. Procedure: Each Team Member will be informed of the policies which define abuse and neglect and actions to take when abuse or neglect is suspected during their initial orientation and yearly thereafter. Physical abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation of punishment, with resulting physical harm, pain, or mental anguish. Psychological abuse occurs when words or actions result in fear or break-down of a person’s self-esteem such as threats, ridicule, isolation, intimidation, or harassment. Any sexual conduct with an individual served is considered sexual abuse. Neglect is a form of abuse in which there is failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility will maintain a Patient Advocate and a mechanism for reporting, investigating and remedying violations. If any incident is reported involving a Team Member, they will be immediately suspended pending investigation. If the investigation confirms the reported incident, the abuse or neglect of individuals served is considered cause for immediate termination. A Team Member who is aware of abuse or neglect and does not report it will also be considered for corrective action. In accordance with state laws, abuse and neglect will be reported to the appropriate licensure and regulatory agencies. The facility will notify and cooperate with law enforcement agencies to pursue criminal charges where appropriate.” ... A policy “GRIEVANCE AND COMPLAINT PROCESS”, revised 5/30/25 states in part, “POLICY: It is the policy of Highland Hospital to provide patients, their families, and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within 48 hours. Registering a grievance or complaint will not compromise a patient’s or family’s future access to Hospital services and treatment. Likewise, employees shall not be compromised, in any way, for reporting incidents. PURPOSE: To educate patients on the grievance process. To educate staff and so that staff can ensure the Grievance Process occurs without impediments or delay. To establish a process for prompt resolution of patient complaints and/or grievances. To increase patient satisfaction and promote the resolution of conflicts in a non-adversarial manner. DEFINITIONS: A ‘patient grievance’ is defined as a formal, written or verbal complaint which is filed by a patient, when a patient issue cannot be resolved promptly (within the same shift) by staff present. A ‘patient complaint’ is an allegation or source of dissatisfaction expressed verbally or in writing. Complaints relevant to change in bedding, housekeeping of a room, and serving preferred food and beverages are expectations which require the implementation of a relatively minor change in a timelier manner than a written response. OBJECTIVE: To provide a mechanism to report and process grievances or complaints that ensures immediate and appropriate action and resolution; ensures all employees know how to process grievances and complaints; and to ensure timely, proper and efficient documentation of grievances. PROCEDURE: 1. During the admissions process patients/families are advised of their rights to initiate a grievance concerning the quality of care during their stay at Highland Hospital. Currently, each patient is provided with a copy of The Complaint Process which addresses the following: a. Patient can submit grievance 24 hours per day written or oral. b. Patient advocate will contact patient within 3 working days of complaint. c. Patient Advocate will require a written response within three business days from the supervisor of the department to whom the complaint was filed. d. If Patient is not satisfied with response to complaint they can file a grievance. 2. The Grievance Process which addresses the following: a. Name and phone number of staff person to contact in order to file a grievance. a. Patient can submit grievance 24 hours per day written or oral. b. Patient advocate will contact patient within 3 working days of complaint. c. Patient Advocate will require a written response within three business days from the supervisor of the department to whom the complaint was filed. d. If Patient is not satisfied with response to complaint they can file a grievance. 2. The Grievance Process which addresses the following: a. Name and phone number of staff person to contact in order to file a grievance.” ... A policy “ ABUSE REPORTING - ADULT/CHILD AND DOCUMENTATION” last reviewed 12/23 states, “POLICY: Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protective Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services / Adult Protective Services Form will be completed and sent to DHHR following any report of suspected and/or neglect of patients. indicating possible abuse (bruises, broken bones, etc.). 2. Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. 3. The staff member will complete a CPS/APS Reporting form (see attached). 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a “Special Entry Note” - Date and time of phone call. - Completion of CPS/APS Reporting Form - Information sent to CPS or APS. - CPS/APS form in chart. - Case number or Case worker name.” A review of an investigation documentation for (patient 2) alleged sexual assault was conducted. The investigation was determined to be incomplete and had no written conclusion. There was no evidence that the patient was notified of the outcome of the investigation. An interview was conducted on 7/15/26 at 11:50 a.m. with staff 1. Staff 1 stated in part, “There doesn’t seem to be any documentation indicating that the patient was notified of the outcome of the allegations. I think there is room for improvement in the investigation process. This is something we will be looking at to improve.””

“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: 38282 Based on document review, medical record review, and staff interview, the facility failed to ensure a patient received care in a safe setting, as a patient had a history of self-harm and gained access to contraband with the potential for causing injury (patient #1). This failure has the potential to adversely affect all patients receiving treatment at the facility. Findings include: A review of the “Highland Hospital Contraband List”, revised 04/2025, was conducted and revealed the following list of contraband “Not Allowed (Please try to send home if possible): “Cigarettes/lighter/vape; All medications; Any items with a battery/charging cord; All jewelry; and All markers/pencils/pens.” There was a list of exceptions that included, but was not limited to, “Prescription and over-the-counter medications will be locked up in intake via RN or Nursing Supervisor until Pharmacy can verify.” A review of the medical records for patient #1, date of admission 04/12/26 to the present, was completed. Patient #1 was admitted with a diagnosis that included cellulitis and major depressive disorder; and had a history of self-injurious behavior and multiple admissions to the facility. The list of personal belongings upon admission did not include a nose ring or a vape. A review of the incident report sheets, revealed that from 04/12/26 to the present patient #1 had fourteen (14) incidents; eight (8) of which involved contraband, or potential contraband. The incidents included, but was not limited to: On 04/12/26 at 8:45 p.m., the patient initiated an altercation with a peer resulting in a bloody nose from the nose ring. The patient refused to remove the nose ring, and it remained with the patient. On 04/13/26 at 8:55 p.m., the patient stated they took a Depakote from home and was sent to the emergency department (ED) for evaluation. Once at the ED, they stated there was no Depakote, they just wanted to leave the building. Depakote levels were obtained, within normal limits. On 04/21/26 at 12:24 p.m., the patient was found with an electronic smoking device (vape) that had been brought in by the patient on admission and handed off to a peer prior to the body search. On 05/01/26 at 8:45 p.m., they stuck their nose ring in their thigh deep enough to curl back around. Sent to the ED to remove it, ED found a piece of plastic stuck in (his/her) nose. X-rays done to look for additional contraband, but none was found. On 05/15/26 at 5:45 p.m., small cut/laceration on left hand. Patient cut self with a bracelet with sharp beads and pieces of a pen that they stole from the visiting social worker’s bag. On 05/22/26 at 9:05 p.m., patient grabbed name badge from behavior health associate and attempted to elope. Placed in hold and badge retrieved. Staff noticed the wound on left hand reopened, and the patient stated used the spring from an ink pen taken previous to open it. On 05/23/26 at 4:15 p.m., inserted pieces of a broken spoon into the wound on the left hand and showed it to the nurse. The patient was sent to the ED for stitches. On 05/31/26 at 9:00 p.m., stitches removed by the patient and a broken piece of crayon inserted into left hand wound, sent to ED for removal. An interview was conducted on 06/17/26 at 9:15 a.m. with staff #3, who described the intake process, “The patient registers at the desk and they do an intake assessment. The patient is then brought to the unit for a body search and logging of all belongings that are bagged up and taken to the basement. Their clothing is washed and returned to them. The body search is done in the bathroom with two [2] same sex staff. We even have them squat and cough. Jewelry is on the contraband list. We asked [patient #1] for the nose ring, but [he/she] refused. When there was a fight that made [his/her] nose bleed because of the nose ring we asked for it again, but [he/she] refused. We are not going to place a patient in a hold to remove body jewelry. We were able to retrieve the nose ring when [he/she] had to go to the ED to have it removed from their leg. Upon return, we gave [him/her] a little rubber spacer. I have no explanation for the vape found on [him/her] days later. I know [he/she] stole a pen from [his/her] case manager who came for a visit. [He/she] was also found with a gift card and said the case manager had brought it to [him/her].” Staff #3 then concurred that the patients would be safer if all belongings and contraband were removed in admissions prior to the patient coming to the floor; and the case manager should have notified staff of the gift card; and should not have brought a purse into the visitation. An interview was conducted on 06/16/26 at 1:25 p.m. with staff #10. Regarding patient #1, staff #10 stated, “At the time [he/she] stuck the nose ring in [his/her] leg, [he/she] was not ordered 1:1, but was ordered 1:1 following that incident. I saw the spoon in [his/her] hand. The handle was shoved in all the way, and if you pushed on the spoon part, the handle would raise the skin in [his/her)] hand up - like it was just under the skin on the top of [his/her] hand with the spoon sticking out by the thumb and the handle down at the base of the pinky finger. I think an LPN was 1:1 at that time and they didn’t even know when it had happened. I was not here for the crayon incident, but I’m pretty sure they had privileges for crayons. Not any more of course. One of the problems is consistency with the 1:1 staff. The newer staff aren’t used to being strict and adhering to the rules, and [he/she] manipulates them easier than the staff who have been here longer. We try to keep the more seasoned staff with [him/her]. [He/she] is very comfortable here and knows who lets [him/her] get by with things and who doesn’t. [He/she] wants to stay here, and does things to ensure that [he/she] can stay longer.” An interview was conducted on 06/17/26 at 9:37 a.m. with staff #15. Regarding patient #1, staff #15 stated, “I have known [patient #1] a long time. [He/she] has been here a lot, and when they are here they stay a long time. [He/she] has burned a lot of bridges in the community and is difficult to place. [He/she] had a nose ring in for several days, but when [he/she] went to the ED to have it removed the ED staff were handing it back to [patient #1], but the behavior health associate [BHA] took it. We will return it to [him/her] at discharge. [He/she] has a rubber spacer in now. I was taking over the 1:1 with [patient #1] for the crayon incident. At the time, [he/she] was allowed to have crayons. [He/she] was using the crayon to remove the stitches and the crayon broke and [he/she] couldn’t get it out. [He/she] did it when the other BHA and I were changing shifts. [He/she] is very quick and sneaky and takes advantage of every situation. I saw the crayon in [his/her] hand and told the nurse, who called the doctor, and [he/she] was sent to the ED. [He/she] lost more privileges. We removed everything from the room while [he/she] was gone and did a body search in the bathroom with two [2] same-sex staff upon [his/her] return.” An interview was conducted on 06/17/26 at 10:49 a.m. with staff #17 regarding intakes and contraband. Staff #17 stated, “We ask patients to remove all jewelry. They usually give it willingly. If they refuse to remove piercings we will not place them in a hold to remove it. Sometimes the piercings are stuck and they cannot remove them. We will continue to ask for them throughout the stay, but are not going to force them to give it over. We do have the soft plastic spacers they can use. We do not get a physician order for them to keep it, or discuss it in the treatment team meetings, or document it anywhere in the chart.” Staff #17 concurred that all jewelry is on the contraband list, and there are no exceptions listed for jewelry in that policy.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 38282 Based on document review, patient medical record review, and staff interview, nursing failed to follow the hospital contraband policy regarding a nose ring, resulting in self-injury to a patient requiring emergency department (ED) treatment (patient #1). This failure has the potential to affect all patients admitted to the facility. Findings include: A review of the “Highland Hospital Contraband List”, revised 04/2025, was conducted and revealed the following list of contraband “Not Allowed (Please try to send home if possible);” included but not limited to: All jewelry. There were no exceptions listed regarding jewelry. A review of the medical records for patient #1, date of admission 04/12/26 to the present, was completed. Patient #1 was admitted with a diagnosis that included cellulitis and major depressive disorder and had a history of self-injurious behavior and multiple admissions to the facility. The list of personal belongings upon admission, and another inventory list completed on 04/26/26, did not include a nose ring. A review of the incident reports revealed on 04/12/26 at 8:45 p.m., the patient initiated an altercation with a peer resulting in a bloody nose from the nose ring. The patient refused to remove the nose ring, and it remained with the patient. A chemical restraint and a physical hold were initiated, and a twenty-four (24) hour social separation was added to the precautions. All protocols were followed. On 05/01/26 at 8:45 p.m., they stuck their nose ring in their thigh deep enough to curl back around. Sent to the ED to remove it, ED found a piece of plastic stuck in (his/her) nose. X-rays done to look for additional contraband, but none was found. An interview was conducted on 06/17/26 at 9:15 a,m., with staff #3, who described the intake process, “The patient registers at the desk and they do an intake assessment. The patient is then brought to the unit for a body search and logging of all belongings that are bagged up and taken to the basement. Their clothing is washed and returned to them. The body search is done in the bathroom on the unit with two [2] same sex staff. We even have them squat and cough. Jewelry is on the contraband list. We asked [patient #1] for the nose ring, but [he/she] refused, so we let them keep it. When there was a fight that made [his/her] nose bleed because of the nose ring, we asked for it again, but [he/she] refused. We are not going to place a patient in a hold to remove body jewelry. We were able to retrieve the nose ring when [he/she] had to go to the ED to have it removed from their leg. Upon return, we gave [him/her] a little rubber spacer. Staff #3 then concurred that the patients would be safer if all belongings and contraband were removed in admissions prior to the patient coming to the floor. An interview was conducted on 06/17/26 at 9:37 a.m. with staff #15. Regarding patient #1, staff #15 stated, “[He/she] had a nose ring in for several days, but when [he/she] went to the ED to have it removed, the ED staff were handing it back to [patient #1], but the Behavior Health Associate (BHA) took it. We will return it to [him/her] at discharge. We locked it up. I am not sure if it was documented anywhere. [He/she] has a rubber spacer in now.” An interview was conducted on 06/17/26 at 9:50 a.m. with staff #16 regarding patient #1’s intake. Staff #16 stated, “I do a lot of intakes. I do not recall this one. I do not recall the nose ring. I know they have a plastic spacer now. All jewelry is on the contraband list.” An interview was conducted on 06/17/26 at 10:49 a.m. with staff #17 regarding intakes and contraband. Staff #17 stated, “We ask patients to remove all jewelry. They usually give it willingly. If they refuse to remove piercings we will not place them in a hold to remove it. Sometimes the piercings are stuck and they cannot remove them. We will continue to ask for them throughout the stay, but are not going to force them to give it over. We do have the soft plastic spacers they can use. We do not get a physician order for them to keep it, or discuss it in the treatment team meetings, or document it anywhere in the chart.” Staff #17 concurred that all jewelry is on the contraband list, and there are no exceptions listed for jewelry in that policy.””

“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: 46199 Based on medical record review, interview, and observation the facility failed to provide a safe setting for one (1) of ten (10) patients (patient 1). The failure has the potential to negatively impact all patients receiving care at the facility. Findings include: A medical record review was conducted for patient 1. The record contains an entry titled “Initial Psychiatric Evaluation Acute” completed on 2/15/26 at 1:36 p.m. by staff 11 which includes a section titled “History of Present Illness” which states, in part, “ ...Admitted for Suicidal Ideations and behaviors. Banging [his/her] head on the wall and refrigerator. Tried to take off seat belt and jump out of the moving vehicle. The day before [he/she] had to be restrained by [foster parent] to keep [him/her] from running out into the road to kill [himself/herself]. [He/She] also threatened to kill nurse at the hospital with scissors from the nurse. Has done the same things for ‘a few years’. Never admitted inpatient before, per the patient ...” The record includes an entry titled “Progress Note” completed on 2/18/26 at 1:52 p.m. by staff 8 which states, “Patient seen in craft room. Patient [Pt] was over at cabinets and drawer front fell and hit [his/her] right foot. Already bruising. Pt has limited range of motion [ROM]. Pulses present and equal. X-ray order placed. Ice pack applied.” The record includes a document titled “Radiology Report” with a report date of 2/19/26 at 3:18 p.m. which states, in part, “Conclusion: No acute osseous abnormality. Consider a repeat multi-view study in one [1] week or sooner if symptoms continue to persist or progress.” An interview was conducted on 3/4/26 at 11:06 a.m. with staff 2. Staff 2 was asked if a work order had been placed to repair the cabinet in the craft room. Staff 2 stated, “I contacted [staff 12] and asked if a work order had been placed and [he/she] said there was no work order for the cabinets.” Staff 2 further stated there was no incident report or work order filed related to the incident that occurred on 2/18/26 in the craft room. An observation was conducted in the Craft Room, which is in the basement of the hospital, on 3/4/2026 at 8:40 a.m., accompanied by staff 2. The room is locked and cannot be accessed by patients unless accompanied by staff. At the time of the observation, there were no staff or patients present in the room. There are long cabinets on two (2) sides of the room with multiple drawers in each. Staff 2 and the surveyor opened these drawers, and it was noted that of the twenty-seven (27) drawers in the cabinet, two (2) had drawer faces that came off upon opening.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 46199 Based on medical record review, policy review and interview the nursing failed to notify the patient’s parent/guardian of an injury for one (1) of ten (10) patients (patient 1). The failure has the potential to negatively impact all patients receiving care at the facility. Findings include: A medical record review was conducted for patient 1. The record contains an entry titled “Initial Psychiatric Evaluation Acute” completed on 2/15/26 at 1:36 p.m. by staff 11 which includes a section titled “History of Present Illness” which states, in part, “ ...Admitted for Suicidal Ideations and behaviors. Banging [his/her] head on the wall and refrigerator. Tried to take off seat belt and jump out of the moving vehicle. The day before [he/she] had to be restrained by [foster parent] to keep [him/her] from running out into the road to kill [himself/herself]. [He/She] also threatened to kill nurse at the hospital with scissors from the nurse. Has done the same things for ‘a few years’. Never admitted inpatient before, per the patient ...” The record includes an entry titled “Progress Note” completed on 2/18/26 at 1:52 p.m. by staff 8 which states, “Patient seen in craft room. Patient [Pt] was over at cabinets and drawer front fell and hit [his/her] right foot. Already bruising. Pt has limited range of motion [ROM]. Pulses present and equal. X-ray order placed. Ice pack applied.” The record includes a document titled “Radiology Report” with a report date of 2/19/26 at 3:18 p.m. which states, in part, “Conclusion: No acute osseous abnormality. Consider a repeat multi-view study in one [1] week or sooner if symptoms continue to persist or progress.” May it be noted, there is no documentation in the medical record indicating that patient 1’s guardian was notified of this injury. A policy was reviewed titled “Allegations of Patient Abuse” reviewed 12/24. The policy has a section titled “POLICY” which states, “Any allegations, by patient or others, of patient abuse by hospital staff, physicians, allied health professionals or other patients will be viewed with the utmost seriousness. All allegations will be fully investigated. The hospital staff, physicians or allied health professional will be immediately removed from patient care and suspended for the duration of the investigation. Should an allegation prove to be valid, immediate action will be taken, including possible termination and/or withdrawal of privileges...6. Notification of the patients family and/or guardian will occur as directed by the physician.” An interview was conducted on 3/2/26 at 1:56 p.m. with staff 7. Staff 7 was asked about patient 1’s interaction with a roommate. Staff 7 stated, “I remember that the roommate had asked [him/her] if they could kiss [him/her]. Apparently the roommate said they had to kiss since they were roommates. The roommate was moved to another room.” Staff 7 was asked if they had notified patient 1’s guardian about [his/her] foot injury. Staff 7 stated, “I was told by the physician assistant [PA] that assessed [his/her] foot and that there was an x-ray ordered and ice was applied. I’m not sure what day that happened, I’m pretty sure I would’ve contacted the guardian.” An interview was conducted on 3/3/26 at 1:00 p.m. with staff 8. Staff 8 was asked if there were any circumstance where the word “starve” would be used to indicate treatment for a patient. Staff 8 stated, “We may add diet orders for patients that are diabetic or pre-diabetic. Some patients may have to fast for lipids, and we may monitor the intake for diabetic patients but not starve.” Staff 8 was asked about patient 1’s injury in the craft room. Staff 8 stated, “My office is adjacent to the craft room, and they go to craft room at 1:15 p.m., after school. The patient wasn’t supposed to be messing with the cabinet. I didn’t see the actual incident, but I did see the patient after it happened. I didn’t think it was broken but I ordered an x-ray anyway. If it had looked bad I would’ve sent [him/her] out to the Emergency Room [ER]. I told the staff in the craft room to put in an incident report since I wasn’t actually there when it happened. The activity director was supposed to put in a work order to repair the cabinet. I called the floor and told staff 6 to make sure that when the x-ray company came for another patient that they also x-rayed patient 1. I’m not sure where the breakdown occurred.””

“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: 43434 Based on medical record review, documentation review, observation, video review and staff interviews, the facility failed to ensure that guardians were notified in a timely manner that patients had eloped. The failure to follow facility policy affected two (2) out of ten (10) patients (patients 1 and 2) reviewed and has the potential to affect all patients receiving services. Findings: A medical record review was conducted on patient 1. Patient 1 was a voluntary admission to the facility on 7/15/25, for depression and substance abuse. The patient has an extensive history of substance abuse and impulsive behaviors. This is the patient’s second admission for substance abuse, depression and self-harm. The last hospitalization was March 2025. Patient 1 has current pending legal issues and is on probation. Patient 1 was admitted to the two (2) west unit. While there the patient received daily group therapy, individual therapy, milieu therapy and medication management. On 7/18/25, around 3:30 p.m., the patient, along with peers from the unit, left the gym to return to the unit. As staff was unlocking the gate coming from the courtyard, a peer fell to the ground and appeared to be suffering a seizure. While the staff were attending to the medical emergency, patient 1 and another peer (patient 2) ran to the side gate and climbed over the fence and eloped down the street. A document titled “HEALTHCARE SAFETY ZONE, Live Event, Event Number: 78257”, completed on 7/18/25, was reviewed. The report stated in part, “ ...Brief Summary of Incident: Patient on their way back from the gym with staff. When staff opened gate to the yard, peer fell to the ground with what appeared to be a seizure. While staff was distracted, with the medical emergency, patient climbed the fence and eloped. Staff and CPD [Charleston Police Department] looking for patient” ... A review of a document titled “Narrative Note”, dated 7/18/25 at 3:30 p.m., completed by staff 5 states, “Patients on their way back from the gym with staff. When staff opened gate to the yard peer fell to the ground with what appeared to be a seizure. While staff was distracted, with the medical emergency, patient climbed the fence and eloped. Staff and CPD [Charleston Police Department] looking for patient”. A review of a document titled “Narrative Note”, dated 7/18/25 at 3:30 p.m., completed by staff 5 states, “Father called an notified of patients elopement. Father requested to speak with nurse supervisor, call transferred to supervisor”. A review of a document titled “Narrative Note”, dated 7/18/25 at 5:00 p.m., completed by staff 3 states, “This writer was notified by the Youth Services Nurse Manager that [patient 1] had eloped from the courtyard, and requested that this writer contact 911. This writer contacted 911 at 1545 [3:45 p.m.] and provided demographics and description of patient. Demographics and patient picture provided to the receptionist to provide to the police upon arrival”. A review of a document titled “Narrative Note”, dated 7/18/25 at 8:33 p.m., completed by staff 4 states, “Spoke with [patient’s] [guardian], [patient’s family member], at length beginning at 7:32 PM regarding elopement. Answered all of [guardian’s] questions, including police involvement and multiple staff searching for [patient]. Informed [him/her] of precipitating events. [Guardian] asked if the law enforcement can take [patient] directly to detention once located instead of returning to [facility]. Stated [patient] is on house arrest and elopement is a violation of his/her probation. Informed [him/her] that the police will need to make that decision and recommended that [he/she] speak with police directly with this request. Informed [guardian] that [he/she] will be contacted with any new updates. Informed [staff 3], [staff 13], [staff 14], [staff 7] and [staff 2]”. A review of a document titled “Narrative Note”, dated 7/18/25 at 8:40 p.m., completed by staff 4 states, “Addendum: [Guardian] stated that [patient] may be headed toward [his/her] mother’s home ... [Guardian] provided consent for staff to contact [mother] should it be necessary”. Review of a document titled “City of Charleston, West Virginia Police Department”, was reviewed. The police report states, “Reported at 07/18/25 1645 [4:45 p.m.] ...Incident Code 7903: Juvenile Runaway ...Victim [Patient 1]”. A review of video from the exterrior entrance gate was completed on 8/4/25 at 1:15 p.m. The video shows that at 3:39:46 p.m., patient 1’s knee is seen at the fence and patient 2 is in the middle section of the fence, starting to climb. Patient 1 comes into view at 3:39:52 p.m. and is still on the fence on the outside at 3:39:53 p.m. and on the ground by 3:39:56 p.m. Patient 1 takes off running down Noyes Avenue. Patient 2 is struggling at the top of the fence at 3:39:56 p.m. At 3:40:00 p.m., patient 2 is on the ground outside the fence and heads down Noyes Avenue. A review of a document titled “Employee Corrective Action”, dated 8/6/25, states, “It was determined during an elopement event that [staff 5] did not notify the guardian as per policy. During documentation review it was noted the time of the note did not match the time of the event. Response: [Staff 5] will be provided with policy of Elopement Protocol. [Staff 5] will receive training upon [his/her] return from the Nurse Educator”... A tour and observation of the courtyard was completed on 8/4/25 at 1:30 p.m. Once you come out of the locked facility, you enter a locked fenced in area. There is a walkway that extends to the left and right of the building. This area is fenced in on both the left and right with an eight (8) foot fence and locked gates on each end. The one area to the right above the fence where the gate is located has been altered to make climbing over seemingly impossible. The gate to the left and on the side of Noyes Avenue on the southeast side of the hospital has not been altered. There is a chain link fence that has three (3) sections. There is the middle section with the gate and two (2) side panels. The fence goes up and tilts backward. There are ten clamps that are attached to the metal poles on each section which makes a small protruding offset to the fence line. The clamps protruding position could allow for someone to place a foot on it and secure their footing. The left side above the fence has an open space between the building and the fence. It was noted that there was a camera on the Noyes Avenue side of the hospital that does face the side gate where the patient could be seen climbing the fence. An interview was conducted on 8/5/25 at 8:47 a.m. with staff 2. Staff 2 stated, “it is the expectation that the [guardian or legal representative] would be contacted immediately after you tend to the patients. I agree that three (3) hours later is concerning. We will be doing additional training on these matters. The fence is being addressed as well. We will be using a poly carbon plastic to cover the sections of the fence. It is durable and it has no sharp edges and would be impossible to climb. This will be completed in the near future, we have already contacted the company, and they will be coming out to measure in the next few days”. An interview was conducted on 8/5/25 at 10:30 a.m. with staff 4. Staff 4 stated, “A notification of elopement should be done immediately”... An interview was conducted with staff 5 on 8/5/25 at 9:45 a.m. Staff 5 stated, “I was the charge nurse that day. The therapist had completed group therapy and was taking the kids to the gym around 2:30 p.m. I was at my desk with staff 14, when staff 14 said the kids were going over the fence. I got on the walkie talkie and announced that there was an issue. I told [staff 12]. [Staff 12] said [he/she] was going to call it in, but [he/she] didn’t. I couldn’t tell who the patients were that went over the fence until someone came up and told me. I didn’t find out right away. I called the [guardian] at 6:30 p.m., yes, it was three (3) hours later. The [guardian] was returning a call about medications. I didn’t think [he/she] knew but I wasn’t sure. I wanted to verify it first, then I called back and told [him/her]. I don’t remember the protocol elopement. I do know we do incident reports and notifications for every incident. I was not present at the incident; I only saw it on camera”. An interview was conducted with staff 13 on 8/6/25 at 10:45p.m. Staff 13 stated, “...Usually the charge nurse handles that. If it is a medical emergency, they deal with that first. But I would expect that [he/she] would call once all the details are gathered, usually within an hour”...”

“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: 37324 Based on observation, record review, and staff interview the hospital failed to maintain the facility as indicated by water leaks, stained ceiling tiles, lack of hot water in 2 bathrooms, and exposed electrical wiring to ensure the safety of the patients. These failures have the potential to cause harm to all employees and patients. Findings include 1. Observation on 3/5/24 at approximately 12:00 p.m., revealed approximately six (6) ceiling tiles which appeared water stained in Office 208 of the Old Building. 2. Observation on 3/5/24 at approximately 12:06 p.m., revealed missing ceiling tile in the Business Office Bathroom of the Old Building. 3. Observation on 3/5/24 at approximately 12:13 p.m., revealed a window air conditioner loaded with dust/debris in the Kitchen Pre-Wash Area. 4. Observation on 3/5/24 at approximately 12:14 p.m., revealed an insulated plumbing line coming from the ceiling in the Kitchen Pre-Wash Area, which appeared to be stained with a black substance. 5. Observation on 3/5/24 at approximately 12:15 p.m., revealed the ceiling tile above the window air conditioner in the Kitchen Pre-Wash Area, which was peeling and appeared loaded with dust/debris. 6. Observation on 3/5/24 at approximately 12:24 p.m., revealed the men’s and women’s restrooms in the basement of the Old Building near the Recreation Lounge (Room B21), which were missing ceiling tile. 7. Observation on 3/5/24 at approximately 12:25 p.m., revealed the men’s and women’s restrooms in the basement of the Old Building were closed off and labeled as “out of order”, but were found to be unsecured and appeared to have been used. Interview with the Maintenance Acute Technician noted that these restrooms have been “out of order” for approximately three (3) years due to the missing ceiling not being replaced and plumbing that needs repaired in these restrooms. 8. Observation on 3/5/24 at approximately 12:26 p.m., revealed exposed electrical wiring, which was not contained in a junction box, above the ceiling in the Men’s Restroom near the Dining Room in the basement of the Old Building. 9. Observation on 3/5/24 at approximately 12:36 p.m., revealed approximately five (5) ceiling tiles in the Medical Records Storage room in the basement of the Old Building, which appeared to be water stained. 10. Observation on 3/5/24 at approximately 12:41 p.m., revealed ceiling tile outside of the Men’s Restroom near Room B57 in the basement of the Old Building near Room B57, which appeared to be water stained. 11. Observation on 3/5/24 at approximately 1:04 p.m., revealed approximately seven (7) ceiling tiles in Medical Records (Room B57) in the basement of the Old Building, which appeared to be water stained. 12. Observation on 3/5/24 at approximately 1:09 p.m., revealed approximately twelve (12) ceiling tile in the corridor in the basement of the Old Building, which appeared to be water stained. 13. Observation on 3/5/24 at approximately 1:13 p.m., revealed a toilet in the Women’s Restroom in the basement of the Old Building, which had a significant water leak from the back of the toilet that ran across the restroom floor when flushed. 14. Observation on 3/5/24 at approximately 1:15 p.m., revealed two (2) hand sinks in the Women’s Restroom in the basement of the Old Building, which did not have hot water for hand washing. 15. Record review on 3/5/24 at approximately 3:49 p.m., revealed no documentation of any work orders that may have been entered by staff, related to the noted issues in the basement area of the Old Building, which may have been received or addressed by Maintenance/Facilities, as there was no available documentation of work orders for the previous twelve (12) months. 16. Interview on 3/5/24 at approximately 3:50 p.m., with the Director of Plant Operations and the Director of Quality/Risk Management verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 3/5/24 at approximately 5:24 p.m. The facility failed to maintain a safe environment as a potential fall risk was identified from a leaking toilet in the basement area, no hot water was available at hand sinks in the basement women’s restroom, ceiling tile was water stained throughout the basement areas, and exposed electrical wiring was identified in accessible “out of order” restrooms in the basement area. These failures have the potential for patients and staff to be exposed to environmental and electrical issues. (IJ) was called on 03/05/24 at 2:41 p.m. and removed on 03/05/24 at 5:02 p.m after onsite verification of interventions. Condition level non-compliance remains. The following interventions were implemented to resolve the IJ: The basement bathrooms intended for patient use in the basement of the Old Building will not be utilized until the leaking toilet and hot water have been repaired. The stained ceiling tile throughout the basement areas of the Old Building have been ordered for replacement. The “out of order” men’s and women’s restrooms near the Dining Room water-stain dyed and locked to prevent entry.”