California Rehabilitation Institute, LLC

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient Rights was met, as evidenced by: 1. The facility failed to ensure that its nursing staff managed and relieved pain for two of 30 sampled patients (Patient 21 and Patient 24), in accordance with the facility’s policy regarding pain management when: 1.a. Patient 21 experienced headache with a pain level of five (5) out of ten (10) on a numeric rating scale (0-10, a pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain) on 1/5/2026 at 6:24 p.m. after experiencing a fall and was not administered pain medication. This deficient practice had the potential to cause Patient 21 to continue to suffer in pain and discomfort and negatively impact Patient 21 by limiting their ability to participate in daily living activities. (Refer to A-0129) 1.b. Patient 24 experienced left groin pain rated as eight (8) out of ten and seven (7) out of ten, on a numeric rating scale, on 4/23/2026 at 5 p.m. (before occupational therapy- a service designed to help a patient regain or maintain the skills needed to safely perform daily activities) and at 6:45 p.m. (after OT therapy), respectively, but did not receive any pain medication to relieve pain. This deficient practice had the potential to cause Patient 21 to continue to suffer in pain and discomfort and negatively impact Patient 21 by limiting their ability to participate in daily living activities. (Refer to A-0129) 2. The facility failed to ensure nursing staff implemented fall prevention interventions (strategies, medical protocols, and environmental modifications used to reduce the risk of patients falling and suffering injuries) appropriately for one of 30 sampled patients (Patient 21), in accordance with the facility’s policy for fall prevention, when Registered Nurse (RN 6) set Patient 21’s bed alarm at Zone 2 (level 2, bed alarm would trigger when a patient’s back was off the bed) sensitivity with the right top bed side rail down for Patient 21 on 1/5/2026. This deficient practice resulted in Patient 21 falling and sustaining a head injury on 1/5/2026. (Refer to A-0144) 3. The facility failed to ensure that an allegation of physical abuse (any intentional, non-accidental use of physical force that causes pain, injury, or physical harm to another person), for one of 30 sampled patients (Patient 11) was reported to the California Department of Public Health (CDPH) immediately, in accordance with the facility’s policy regarding abuse reporting. This deficient practice had the potential to delay initiation of timely investigation and protective interventions by regulatory authorities, thereby placing Patient 11 and other patients at the facility at risk for ongoing abuse, neglect, and unsafe conditions. (Refer to A-0145) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by: 1. The facility failed to ensure nursing staff accurately completed the Columbia Suicide Severity Rating Scale (C-SSRS, a suicide-risk screening tool), received adequate training on how to access and use the C-SSRS within the electronic medical record (EMR, the electronic version of the medical chart), reassessed suicide risk after changes in a patient’s condition, implemented suicide-precaution interventions, and developed and implemented a nursing care plan addressing suicide risk for one (1) of 30 sampled patients (Patient 1), in accordance with the facility’s policies regarding early recognition/intervention for change of condition, patient assessment/reassessment, care planning, and suicide risk precautions. These deficient practices resulted in Patient 1 being found unresponsive (not reacting to stimuli), pulseless (no detectable heartbeat), and cyanotic (bluish discoloration caused by lack of oxygen) with shoelaces around Patient 1’s neck following an apparent suicide attempt on 10/31/2025. Patient 1 was transferred to the emergency department and pronounced deceased (died) the same day (10/31/2025). These deficient practices also placed other patients at risk, such as those with suicidal ideation (thoughts of suicide), suicide attempts, depression (a medical condition causing persistent sadness or loss of interest), behavioral health conditions, or altered mental status (changes in awareness or cognition), by hindering proper identification of high-risk individuals and the implementation of necessary suicide prevention measures. (Refer to A-0395) 2. The facility failed to ensure its nursing staff identified a change in condition and notify the physician for one of 30 sampled patients (Patient 21), in accordance with facility’s policy and procedure regarding patient change in condition management, when Patient 21 experienced increased headache at 9:39 p.m. (three (3) hours later) after sustaining head injury from a fall on 1/5/2026 at 6:24 p.m. This deficient practice had the potential to result in the physician not being able to evaluate Patient 21’s increased headache for possible worsening of head injury which is necessary to provide appropriate and timely interventions including but not limited to transferring Patient 21 to an outside facility in order to receive a computerized tomography head (CT head, imaging test to check for blood vessels blockages or bleeding in the brain, and other brain injury) imaging. (Refer to A-0395) 3. The facility failed to ensure nursing staff developed and implemented an individualized nursing care plan (a structured, written roadmap that outlines a patient’s health conditions, specific needs, and the nursing interventions required to facilitate recovery), in accordance with the facility’s policy regarding care plans, for one (1) of 30 sampled patients (Patient 1), to address Patient 1’s recent suicide attempt. The facility failed to ensure Patient 1’s nursing care plan addressed a documented suicide-risk history, prior suicide?prevention interventions, environmental safety interventions, and increased monitoring needs. This deficient practice resulted in a lack of suicide precautions, environmental safety interventions, and increased monitoring for Patient 1. Patient 1 was later found unresponsive (not awake and not responding to stimulation), pulseless (without a detectable heartbeat), and cyanotic (bluish discoloration caused by a lack of oxygen) with shoelaces wrapped around the neck following an apparent suicide attempt by hanging on 10/31/2025. In addition, this deficient practice had the potential to affect other facility patients requiring nursing care plans related to suicide?risk assessment and patient-safety interventions by not ensuring their care plans were completed and implemented. (Refer to A-0396) 4. The facility failed to ensure nursing staff reassessed one (1) of 30 sampled patients (Patient 1), after a documented change in condition. Patient 1 changed from being oriented (able to correctly recognize person, place, time, and situation) from 10/22/2025-10/29/2025 to having confusion (impaired awareness or thinking) and disorientation (inability to correctly recognize person, place, time, or situation) from 10/30/2025-10/31/2025. The facility failed to ensure nursing staff reassessed Patient 1 after the documented confusion and disorientation, and failed to implement nursing assessments, in accordance with the facility’s “Change in Patient Condition - Early Recognition and Intervention” policy and procedure. This deficient practice resulted in the failure to identify and address Patient 1’s acute (sudden) change in mental status (level of awareness, thinking ability, orientation, behavior, and emotional functioning), which prevented timely nursing interventions and increased monitoring that may have mitigated Patient 1’s suicide risk. This deficient practice also had the potential to affect other facility patients who experience a change in condition by not ensuring these patients receive timely reassessments and appropriate nursing interventions necessary to maintain patient safety. (Refer to A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 46333 Based on interview and record review, the Governing Body (GB, group of legally responsible team for the overall conduct, operations, and oversight of a hospital [facility]) failed to ensure facility leadership, nursing services, and Quality Assessment and Performance Improvement (QAPI, a hospital-wide program required to systemically identify, monitor, evaluate, and improve patient safety and quality of care) program implemented effective oversight systems to identify, analyze, and correct nursing competency, suicide-risk screening, staff education, and patient safety failures, including failure of the Root Cause Analysis (RCA, a systemic process use to identify underlying causes of adverse events and system failures) to identify nursing issues related to the death of one (1) of 30 sampled patients (Patient 1). The Governing Body failed to ensure: 1. Nursing staff were trained and competent to accurately complete the Columbia Suicide Severity Rating Sale (C-SSRS, a standardized suicide risk screening tool); 2. Nursing leadership Identify and corrected competency gaps related to the Epic (electronic medical record software system) update affecting suicide risk screening workflow. 3. QAPI identified and monitored failures related to nursing reassessment, suicide prevention and competency validation; and 4. Corrective actions addressed underlying system failures contributing to Patient 1’s unrecognized suicide risk. These deficient practices resulted in failures of Governing Body oversight related to nursing competency, staff education, and patient safety monitoring. These deficient practices contributed to Patient 1’s unrecognized high-suicidal risk and had the potential to affect patients requiring suicide-risk assessment and monitoring. Findings: During an interview on 5/4/2026 at 4:30 p.m. with the Administrator (a facility leader who sits on the Governing Body and serves as a senior?level operational leader), the Administrator (ADM) stated that the Governing Body was responsible for “supervising everybody,” ensuring departments completed their responsibilities, and maintaining a safe environment for patients. ADM further stated that the Governing Body oversaw policies, including those governing education processes related to Epic (the hospital’s electronic medical record system) updates and staff education. During the same interview on 5/4/2026 at 4:30 p.m. with the ADM, ADM stated that Patient 1’s suicide event was discussed with the GB, but it was not documented in the GB’s meeting minutes. ADM stated that the RCA (Root Cause Analysis) was initiated. ADM further stated, “We talked about it, but did not review the corrective plan.” ADM also stated that when there was an unusual occurrence involving a patient death, there should be an ad hoc meeting (an impromptu, unplanned gathering organized to address a specific, immediate issue or opportunity) with the GB. ADM confirmed that an ad hoc meeting would allow the interdisciplinary bodies involved to discuss the RCA and the corrective action plan. ADM stated there was no ad hoc meeting with the GB regarding the Patient 1 incident. During a concurrent interview and record review on 5/1/2026 at 1:29 p.m. with the Chief Nursing Officer (CNO, Senior nursing executive in a hospital, who oversee all nursing operations, patient care standards, and policy implementation), the facility’s online suicide prevention training titled “Suicide Prevention,” and “Suicide Prevention Review (MT CIR-IPR-HBOP 2026’s,” materials were reviewed. The training materials did not include instructions regarding how to access the complete C-SSRS questionnaire within the EMR. The CNO confirmed nursing staff were not trained in how to access the full suicide questions. The CNO stated if nurses were unable to access the complete questions, they could ask incorrect questions and fail to identify high suicide risk patients. During an interview on 4/30/2026 at 3:06 p.m. with the Senior Director of Quality (SQR), SQR confirmed the RCA did not identify that nursing staff were unable to access Question 6 within the EMR (EMR, computerized patient medical record system) and did not identify failures in staff education following the Epic update. During an interview on 4/30/2026 at 1:12 p.m. with the Nurse Development Specialist/Clinical Educator (NDS 1, a designated nursing leader responsible for developing, coordinating, and validating the education, competencies, and ongoing training of nursing staff), NDS 1 stated she (NDS 1) was not responsible for suicide-risk screening education and did not conduct competency validation regarding the C-SSRS workflow within Epic. During an interview on 5/4/2026 at 3 p.m. with the Regional Clinical Reeducator (RCE), RCE confirmed staff were “only reeducated if there is potential incident” and confirmed that she (RCE) was not aware that the 2025 Epic update changed how Question 6 displayed within the EMR. During a concurrent observation and interview on 4/30/2026 from 3:46 p.m. - 4:16 p.m. with RN 2, RN 3, and RN 4, each nurse was unable to correctly access or verbalize the complete wording of Question 6 within the C-SSRS assessment and did not know selecting “show row info” within Epic would expand the question. If question 6 was expanded, it would indicate, “Have you ever done anything, started to do anything, or prepared to do anything to end your life?” During a concurrent interview and record review on 4/30/2026 at 12:11 p.m. with RN 1, Patient 1’s medical record; the C-SSRS screening, dated from 10/22/2025 - 10/31/2025, was reviewed. RN 1 confirmed that the C-SSRS screening indicated “No” responses despite documented suicide attempt history within the medical record. RN 1 confirmed Patient 1 would have been considered high suicide risk if the documented history had been recognized. During a review of the facility’s “Patient Safety & Quality Assessment and Performance Improvement Plan (QAPI), dated January 2026, the QAPI plan indicated, “The Hospital’s Patient Safety and Quality Assessment and Performance Improvement (QAPI) Program creates an environment that encourages error identification remediation, non-punitive reporting, and prevention of recurrences through education, system redesign, and/or process improvement. It emphasizes the important processes or outcomes related to patient care and Hospital operations and delineates the roles and responsibilities of leadership, physicians and other clinicians and support staff in designing, measuring, assessing and improving performance ... The Governing Board bares ultimate responsibility for assuring the quality and appropriateness of patient care and Hospital operations provided by its leaders, physicians and other clinicians and support staff. The Governing Board shall ensure that there is an on-going systematic interdisciplinary mechanism to measure, assess and improve the Hospital’s ability to do the right thing and to do it well for suspected or potential opportunities to improve patient care processes, outcomes and hospital operations. During a review of the facility’s Governing Board Bylaws (the formal written rules adopted by a hospital’s Governing Board that establish the structure, authority, responsibilities, and operational processes of the hospital’s highest governing entity. These bylaws outline how the Governing Board conducts its business and the scope of powers it delegates to hospital leadership), dated 2/9/2026, the bylaws indicated, “The Governing Board is hereby authorized by the Board of Managers for the functions enumerated below, subject to Hospital policies and these Bylaws: Ensuring that there is an effective, Hospital-wide Quality Improvement program to evaluate the provision of care and making decisions regarding quality of service to be made available at the Hospital, which includes establishing a mechanism for review of the quality of care services provided by individuals who are not subject to the Medical Staff privilege delineation process.” During a review of the facility’s policy and procedure (P&P) titled, “Suicide Risk and Precautions,” dated 7/1/2025, the P&P indicated, “During the admission assessment, the nurse will complete and document a suicide risk screen using the CSSR-S (Columbia Suicide Severity Rating Scale) ...The nurse will reassess risk as needed if the patient displays changes in condition, mental/emotional status or change in behavior indicating a possible change in risk ... Any staff member with knowledge of suicidal manifestation(s), e.g., expression of suicidal ideation and/ or intent, revelation of recent attempt, will take appropriate action: immediately notify the patient’s attending physician or, if unavailable, a consulting physician, medical director and/or psychologist. Maintain direct contact with the patient while awaiting medical response. The Charge Nurse/House Supervisor may initiate suicide monitoring (1 :1 direct observation)...Assess clinical areas to identify objects that could be used for self-harm and remove when possible from the area around a patient ... Suicide Precaution Plan of Care (POC) and documentation: When a patient is identified as at risk, initiate the Suicide Precaution POC to address safety needs and document plan to mitigate identified risk ... An assessment of environmental features is conducted upon identification of suicide risk; items or objects that have the potential for self-harm are removed/secured and the environment is modified for enhanced safety as the medical condition allows.” During a review of the facility’s policy and procedure (P&P) titled, “Nursing Plan for the Provision of Patient Care,” dated 10/1/2023, the P&P indicated: Registered nurses were responsible for collecting assessment data, identifying patient problems, establishing appropriate diagnoses, developing goals, implementing interventions, and evaluating patient responses to care.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure that its nursing staff managed and relieved pain for two of 30 sampled patients (Patient 21 and Patient 24), in accordance with the facility’s policy regarding pain management when: 1. Patient 21 experienced headache with a pain level of five (5) out of ten (10) on a numeric rating scale (0-10, a pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain) on 1/5/2026 at 6:24 p.m. after experiencing a fall and was not administered pain medication. 2. Patient 24 experienced left groin pain rated as eight (8) out of ten and seven (7) out of ten, on a numeric rating scale, on 4/23/2026 at 5 p.m. (before occupational therapy- a service designed to help a patient regain or maintain the skills needed to safely perform daily activities) and at 6:45 p.m. (after OT therapy), respectively, but did not receive any pain medication to relieve pain. These deficient practices had the potential to cause Patient 21 and Patient 24 to continue to suffer in pain and discomfort and negatively impacting Patient 21 and Patient 24’s mood and limiting their ability to participate in daily living activities. Findings: 1. During a review of Patient 21’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/1/2026, the “H&P” indicated, Patient 21 was admitted to the facility for on-going 24/7 rehabilitation nursing (a specialized field dedicated to helping patients recover from debilitating injuries, surgeries, or illnesses. The primary goal is to help individuals regain their independence, adapt to permanent changes, and improve their overall quality of life) and physiatry (a branch of medicine focused on diagnosing, preventing and treating condition that affect someone’s movement, function and daily life) oversight of Patient 21’s medical and rehabilitation needs following a traumatic brain injury (caused by a bump, blow, or jolt to the head or penetrating object that disrupts normal brain function). During a review of Patient 21’s physician note (physician narrative note), dated 1/5/2026, the physician note indicated, Patient 21 fell while attempting to stand up unassisted at bedside. The physician note also indicated Patient 21 reported hitting his (Patient 21’s) head and had throbbing left temporal (left side of the head in the temple area) headache. During an interview on 5/4/206 at 3:42 p.m. with Nurse Manager (NM 1), NM 1 stated nursing staff should address and manage a patient’s pain to keep a patient comfortable. During a review of Patient 21’s “Medication Administration Record (MAR, record of medications given to patients),” dated 1/5/2026, the “MAR” indicated, Patient 21 had a standing order to give acetaminophen (medication to treat mild pain) 650 milligrams (mg, unit of measure) by mouth every six (6) hours as needed for mild pain (score of 1-3). During a concurrent interview and record review on 5/4/2026 at 3:50 p.m. with Nurse Manager (NM 1), Patient 21’s “Pain Assessment” flowsheet, dated 1/5/2026, was reviewed. The “Pain Assessment” flowsheet indicated, on 1/5/2026 at 6:24 p.m., Patient 21 complained of headache with a pain level of five out of ten (5/10- indicates moderate pain) on a numeric rating scale (0-10, a pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain). The “Pain Assessment” flowsheet did not indicate any pain intervention provided for Patient 21’s pain level of 5/10. NM 1 confirmed that Patient 21 had moderate pain (5/10). NM 1 stated nurses should provide non-pharmacological (without medication) and/or pharmacological (with medication) intervention to address Patient 21’s pain. NM 1 stated there was no documentation to indicate Patient 21’s pain level of 5/10 was addressed and managed on 1/5/2026 at 6:24 p.m. During a review of Patient 21’s “Pain Assessment” flowsheet, dated 1/5/2026, the “Pain Assessment” flowsheet indicated, on 1/5/2026 at 9:39 p.m., Patient 21 had a pain level rated at 9 out of 10 (severe pain) for headache (Patient 21’s previous pain level was 5/10 at 6:24 p.m. which was not addressed by the nursing staff). During a review of Patient 21’s “Medication Administration Record (MAR),” dated 1/5/2026, the MAR indicated, Patient 21 received acetaminophen 650 mg by mouth on 1/5/2026 at 9:39 p.m. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights,” dated 10/2023, the P&P indicated, “Every patient admitted to the Hospital has certain rights and responsibilities. These rights are guaranteed and respected by the personnel of the Hospital, but must also be adhered to by the physicians, families, and visitors of the Hospital ... As a patient, you have the right to ... 11. Receive appropriate assessment and management of your pain, information about pain, pain relief measures and to participate in pain management decisions.” During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 4/2026, the P&P indicated, “Patient shall be informed that pain relief is an important part of their hospitalization. Patients should be informed about pharmacologic and non-pharmacologic options to control pain, and that they may discuss concerns and preferences with the health care team ...” 2. During a review of Patient 24’s “History and Physical (H&P),” dated 4/19/2026, the H&P indicated, Patient 24 was admitted to the facility for on-going 24/7 rehabilitation nursing and physiatry (a branch of medicine focused on diagnosing, preventing and treating condition that affect someone’s movement, function and daily life) oversight of Patient 24’s medical and rehabilitation needs due to lumbar compression (when something in the lower back presses on the spinal cord or nerve roots). The H&P also indicated Patient 24 had functional decline (the gradual or sudden loss of a person’s ability to take care of themselves) and intractable pain (a severe, constant type of chronic pain) from L2-L3 compression fracture (occurs when the second and third lumbar vertebrae [back bone] collapse due to trauma or weak bone density, causing intense, sharp lower back pain). During a concurrent interview and record review with the Quality Coordinator Nurse (QC 1), Patient 24’s “Pain Assessment” flowsheet, dated 4/23/2026, was reviewed. The “Pain Assessment” flowsheet indicated, on 4/23/2026 at 5 p.m., Patient 24 had aching pain at her (Patient 24) left groin with a pain level score eight (8) out of ten (10) on a numeric rating scale, indicating pain severity was severe. The “Pain Assessment” flowsheet also indicated, repositioning (of Patient 24) was provided as a non-pharmacologic pain intervention on 4/23/2026 at 5 p.m. The “Pain Assessment” flowsheet indicated, on 4/23/2026 at 6:45 p.m., Patient 24 had a pain level score of 7/10 post-intervention (after the non-pharmacologic intervention of repositioning Patient 24). QC 1 stated the nurse should provide pain medication to treat Patient 24’s post repositioning pain score of 7/10 because the non-pharmacologic intervention (repositioning done at 5 p.m.) was ineffective. During a review of Patient 24’s physician order, dated 4/18/2026, the physician order indicated there was a standing order to give oxycodone (medication to treat moderate to severe pain) five (5) milligrams (mg, unit of measure) by mouth every four (4) hours as needed for moderate pain and severe pain. During a concurrent interview and record review with QC 1, Patient 24’s Medication Administration Record (MAR), dated from 4/22/2026 to 4/23/2026, was reviewed. The MAR indicated Patient 24 last received oxycodone 5 mg on 4/22/2026 at 10:55 p.m. QC 1 stated Patient 24 did not receive any pain medication to treat Patient 24’s pain level score of 7/10 on 4/23/2026. QC 1 further stated that the nurse should treat Patient 24’s pain so Patient 24 could participate in therapy and other activities. During an interview on 5/4/2026 at 3:42 p.m. with Nurse Manager (NM 1), NM 1 stated nursing staff should address and manage a patient’s pain to keep a patient comfortable. During a concurrent interview and record review on 5/4/2026 at 3:44 p.m. with NM 1, Patient 24’s “Occupational Therapy (OT, a service designed to help a patient regain or maintain the skills needed to safely perform daily activities) Treatment,” dated 4/23/2026 was reviewed. The OT treatment note indicated Patient 24 had OT treatment on 4/23/2026 from 5 p.m. to 6:45 p.m. The OT treatment note also indicated Patient 24 had a pain score of 7/10 at the end of the therapy session (at 6:45 p.m.) and the Occupational Therapist updated Patient 24’s nurse regarding Patient 24’s status (including Patient 24’s pain level). NM 1 stated Patient 24’s nurse should have provided pain medication to manage Patient 24’s pain, otherwise, Patient 24 could continue to remain in pain and affect her (Patient 24’s) mood and appetite. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights,” dated 10/2023, the P&P indicated, “Every patient admitted to the Hospital has certain rights and responsibilities. These rights are guaranteed and respected by the personnel of the Hospital, but must also be adhered to by the physicians, families, and visitors of the Hospital ... As a patient, you have the right to ... 11. Receive appropriate assessment and management of your pain, information about pain, pain relief measures and to participate in pain management decisions.” During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 4/2026, the P&P indicated, “Patient shall be informed that pain relief is an important part of their hospitalization. Patients should be informed about pharmacologic and non-pharmacologic options to control pain, and that they may discuss concerns and preferences with the health care team ...””

“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: 48212 Based on interview and record review, the facility failed to ensure nursing staff implemented fall prevention interventions (strategies, medical protocols, and environmental modifications used to reduce the risk of patients falling and suffering injuries) appropriately for one of 30 sampled patients (Patient 21), in accordance with the facility’s policy for fall prevention, when Registered Nurse (RN 6) set Patient 21’s bed alarm at Zone 2 (level 2, bed alarm would trigger when a patient’s back was off the bed) sensitivity with the right top bed side rail down for Patient 21 on 1/5/2026. This deficient practice resulted in Patient 21 falling and sustaining a head injury on 1/5/2026. Findings: During a review of Patient 21’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/1/2026, the “H&P” indicated, Patient 21 was admitted to the facility for on-going 24/7 rehabilitation nursing (a specialized field dedicated to helping patients recover from debilitating injuries, surgeries, or illnesses. The primary goal is to help individuals regain their independence, adapt to permanent changes, and improve their overall quality of life) and physiatry (a branch of medicine focused on diagnosing, preventing and treating condition that affect someone’s movement, function and daily life) oversight of Patient 21’s medical and rehabilitation needs following a traumatic brain injury (caused by a bump, blow, or jolt to the head or penetrating object that disrupts normal brain function). During a review of Patient 21’s “Nursing Fall Risk Assessment” flowsheet, dated 1/4/2026 at 8 a.m., the “Nursing Fall Risk Assessment” flow sheet indicated, Patient 21 was assessed using the Morse Fall Risk scale (clinical tools for measuring a patient’s likelihood of falling. 0 - 24 points: low risk, 25 - 45 points: moderate risk, great then 45 points: high risk). The flow sheet also indicated that Patient 21 had a history of fall with secondary diagnosis, Patient 21 used crutches/walker/cane to ambulate (to walk or move around from place to place unassisted), had impaired gait (having an irregular, unsteady, or difficult way of walking), and mental status (describes how well a person’s brain is functioning and how they are experiencing the world) indicated “(Patient 21) overestimates/forget limitations” and resulted to a fall risk score of 90 (high risk). During a review of Patient 21’s “Nursing Note (nursing narrative note),” dated 1/5/2026, the “Nursing Note” indicated, “Patient (Patient 21) was awake, alert and oriented x 1 (means a person is awake and aware, but they only know who they are) baseline for admission, forgetful and impulsive. Patient’s (Patient 21’s) bed alarm started going off, staff and I (RN 6) started running to the room, patient (Patient 21) was found on floor in seated position. Per patient (Patient 21’s) report, he (Patient 21) hit his (Patient 21’s) head on the wall and had a bump in the middle of forehead, that is red, skin intact.” During a review of Patient 21’s physician note (physician narrative note), dated 1/5/2026, the physician note indicated, “Patient (Patient 21) fell while attempting to stand up unassisted at bedside ... patient (Patient 21) endorses hitting his (Patient 21’s) head with throbbing left temporal (left side of the head in the temple area) headache ... New superficial laceration (a minor cut or tear that only affects the outermost layers of the skin) noted along forehead in addition to indurated swelling (a swollen area of skin or tissue that feels abnormally firm, stiff, or hardened to the touch) of unclear duration proximal (meaning close) to the left orbit (the medical name for the left eye socket) along the zygomatic bone (the cheekbone).” During a review of Patient 21’s “Post Fall Huddle Form (a form completed after patient’s fall to evaluate what caused the fall),” dated 1/5/2026, the “Post Fall Huddle Form” indicated, Patient 21 had a fall on 1/5/2026 at 6:24 p.m. The “Post Fall Huddle Form” also indicated, at the time of the fall, Patient 21’s bed alarm was only set to Zone 2 (level 2, bed alarm would trigger when a patient’s back was off the bed). The form indicated that the bed alarm should have been set at a more sensitive setting. The “Post Fall Huddle Form” also indicated, Patient 21’s right top bed side rail was down. During an interview on 4/28/2026 at 11:35 a.m. with RN 9, RN 9 stated that the facility utilized bed alarm as part of fall prevention interventions. RN 9 further stated that different beds had different bed alarm settings. RN 9 further stated bed alarms were set either at the most sensitive, less sensitive and least sensitive and triggered by a patient’s movement. RN 9 further stated the expectation was that staff must respond to the patient’s room immediately whenever a bed alarm was triggered. During an interview on 4/28/2026 at 3:36 p.m. with RN 6, RN 6 stated that the facility bed alarms had three (3) settings: Zone 1 (level 1) was the most sensitive setting in which the bed alarm would trigger when a patient moved legs/arms out of the bed, Zone 2 (level 2) was less sensitive setting in which the bed alarm would trigger when a patient’s back was off the bed or sitting up, and Zone 3 (level 3) was the least sensitive setting in which bed alarm would trigger when a patient was completely off the bed. During an interview on 4/28/2026 at 3:50 p.m. with RN 8, RN 8 stated patients would be assessed for fall risk upon admission. RN 8 further stated if patients were confused and impulsive, staff should set the bed alarm at the most sensitive setting (level 1) to prevent falls. During an interview on 4/29/2026 at 2:32 p.m. with RN 7, RN 7 stated patients who were impulsive (such as Patient 21 who was assessed to be impulsive) should be on Zone 1 (level 1) bed alarm setting. RN 7 said that a level 1 bed alarm setting was the most sensitive setting. RN 7 further stated that patients who were impulsive could easily slide off the bed with just one turn (turning from the bed). During an interview on 4/29/2026 at 10:20 a.m. with the Nurse Manager (NM 2), NM 2 stated the facility had no set protocol to guide what the bed alarm sensitive setting should be set for different patients. NM 2 stated the sensitivity of bed alarm was set by nursing staff per nursing judgement. During an interview on 5/4/2026 at 4:04 p.m. with the Nurse Manager (NM 1), NM 1 stated that interventions for fall prevention would include raising two to three bed side rails up. NM 1 stated that normally nursing staff would keep both bed side rails up to prevent patients from falling. NM 1 further stated nursing staff should put down the top bed side rail down only if a patient was alert and oriented (means the person is awake, aware of their surroundings, and mentally clear), and not for confused and impulsive patients because the patient could fall off from the bed (Patient 21’s right top bed side rail was down at the time of the fall). During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights,” dated 10/2023, the P&P indicated, “These rights are guaranteed and respected by the personnel of the Hospital, but must also be adhered to by the physicians, families, and visitors of the Hospital ... 2. Receive considerate and respectful care, and to be made comfortable .... 15. Receive care in a safe setting ...” During a review of the facility’s policy and procedure (P&P) titled, “Fall and Injury Prevention,” dated 1/2026, the P&P indicated, “Sustainability of a successful fall and injury prevention program depends on leadership support and involvement and the commitment of the hospital staff. Communication, proper documentation and teamwork are vital in the prevention of falls. Reducing the risk of patient falls and injuries may include implementing the following: 1. Risk Assessment ... 3. Environmental modification. 4. Equipment modification ...””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 52001 Based on interview and record review, the facility failed to ensure that an allegation of physical abuse (any intentional, non-accidental use of physical force that causes pain, injury, or physical harm to another person), for one of 30 sampled patients (Patient 11) was reported to the California Department of Public Health (CDPH) immediately, in accordance with the facility’s policy regarding abuse reporting. This deficient practice had the potential to delay initiation of timely investigation and protective interventions by regulatory authorities, thereby placing Patient 11 and other patients at the facility at risk for ongoing abuse, neglect, and unsafe conditions. Findings: During a review of Patient 11’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 7/16/2025, the H&P indicated that Patient 11 was admitted on 7/16/2025 for impaired mobility (means having difficulty moving around freely or doing everyday physical tasks independently) and ability to perform ADL’s (Activity of Daily Living such as grooming and hygiene needs) due to stroke (a medical emergency that happens when blood flow to the brain is stopped or blocked. Without the oxygen and nutrients carried by the blood, brain cells start to die within minutes). During an interview on 4/29/2026 at 11:12 a.m. with the Senior Director of Quality (SDQ 1), SDQ 1 stated that Patient 11 reported to her (Patient 11) provider (physician) at her (Patient 11) follow up appointment that on the morning of 7/28/2025, the night shift nurse hit her (Patient 11) and caused bruising. SDQ 1 stated that Patient 11 did not report the incident (of alleged abuse) to any staff during the time of the alleged incident. During an interview on 5/5/2026 at 4:19 p.m. with SDQ 1, SDQ1 stated the following: -SDQ 1 stated that it was important to report allegations of physical abuse to CDPH to comply with CDPH adverse reporting guidelines so that CDPH can do their investigation to ensure patient safety. -SDQ 1 stated that they (the facility’s leadership team) did not report the alleged physical abuse to CDPH. -SQD 1 stated that their (the facility’s leadership team) understanding was that only sexual abuse and deaths that result from physical abuse should be reported to CDPH. During a review of the facility’s policy and procedure (P&P) titled, “Abuse, Neglect,” dated 1/1/2024, the P&P indicated ... “The Hospital shall actively comply with all CMS (Centers for Medicare & Medicaid Services) requirements related to patient abuse and neglect: ... Protection of Patients: Any allegation of abuse or neglect must result in removal of the patient from potential of further abuse ... The CEO or designee will begin the investigation with the advice and counsel of the Corporate Legal and Human Resources Departments. All relevant State and local laws related to reporting will be complied with fully including calling law enforcement or state required reporting (ex APS [Adult Protective Services]) for any allegation of abuse ... Reporting and Response: All allegations of abuse will be reported to the Hospital’s Governing Board and as possible, appropriate, to applicable state and federal agencies. Any involved employees will be treated in a manner consistent with The Hospitals Human Resources Policies and procedures and reported to the appropriate licensing agency, as applicable.””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI, a hospital-wide program required to systemically identify, monitor, evaluate, and improve patient safety and quality of care) program identified, analyzed, monitored, and implemented effective corrective actions related to nursing failures involving suicide-risk screening (a brief set of questions used by healthcare providers to quickly identify if someone is having thoughts of suicide), nursing reassessment, staff competency validation (the ongoing, systematic process of verifying that a nurse possesses the necessary knowledge, critical thinking skills, and technical abilities to perform their specific clinical duties safely and effectively), staff education, and implementation of suicide precautions for one (1) of 30 sampled patients (Patient 1), in accordance with the facility’s policy regarding QAPI. The facility’s QAPI program failed to identify during the Root Cause Analysis (RCA, a systematic process used to identify the underlying causes of adverse events [It describes an undesirable outcome from a treatment, medication, or procedure that prolongs the hospital stay, requires extra medical intervention, or causes disability or death]) that: 1. Nursing staff incorrectly completed the Columbia Suicide Severity Rating Scale (C-SSRS, a suicide-risk screening assessment tool) despite documented suicide attempt history within the medical record of Patient 1; 2. Nursing staff did not know how to access and display question number 6 within the electronic medical record (EMR, computerized patient medical record system) following the Epic (electronic medical record software system) update; 3. Nursing staff were not re-educated or competency validated following the Epic update affecting the suicide screening workflow; 4. The facility did not identify a designated facility-based educator responsible for competency validation and re-education of nursing staff regarding the updated C-SSRS process; 5. Nursing staff failed to reassess Patient 1 after documented neurological (brain and nervous system) changes including confusion (impaired awareness or thinking) and disorientation (inability to correctly recognize person, place, time, or situation); and 6. Nursing staff failed to initiate suicide precautions and environmental safety interventions despite Patient 1’s documented suicide-risk factors and prior suicide attempt history. These deficient QAPI practices resulted in the facility’s failure to identify and correct system-wide nursing staff competency, education, suicide-risk screening, reassessment, and patient safety process failures related to suicide prevention interventions and monitoring. Patient 1 was subsequently found unresponsive (failing to react or reply to a stimulus), pulseless (without a detectable heartbeat), and cyanotic (bluish discoloration caused by lack of oxygen) following an apparent suicide attempt by hanging on 10/31/2025 and was later pronounced deceased (died). In addition, these deficient QAPI practices had the potential to affect other facility patients requiring suicide prevention interventions. Findings: During a concurrent interview and record review on 4/30/2026 at 10 a.m. with Nurse Manager (NM 1), Patient 1’s “History and Physical (H&P, a comprehensive admission medical assessment),” dated 10/23/2025, was reviewed. The H&P indicated that Patient 1 had a past medical history of benzodiazepine/opioid dependence (physical reliance on benzodiazepine [medications commonly used to treat anxiety] and opioid [a class of natural or synthetic drugs used to relieve pain] medications), anxiety (persistent feelings of fear, nervousness, or worry), and suicidal behavior. The H&P further indicated that Patient 1 “presented with worsening bilateral lower extremity (BLE) numbness (loss of sensation) and weakness, bowel/bladder incontinence (loss of bowel or urinary control), and radicular pain (pain radiating along a nerve pathway), with a spinal cord mass (abnormal growth involving the spinal cord) now s/p (status post; after) T11-L1 laminoplasty (surgical reconstruction of the thoracic [mid] and lumbar [lower] spine) for resection (surgical removal).” During a concurrent interview and record review on 4/30/2026 at 2:18 p.m. with Clinical Neuropsychologist (PHD 1, a specialist who evaluates how brain injuries or medical conditions affect behavior, mood, and thinking skills), Patient 1’s “Neuropsychologist” note, dated 10/26/2025, was reviewed. The note indicated Patient 1 had “a recent overdose on Xanax (alprazolam, a sedative medication classified as a benzodiazepine, used to reduce anxiety), 2/2 (secondary to) a new diagnosis of spinal cord mass (an abnormal growth involving the spinal cord).” Patient 1’s Neuropsychologist note also indicated “History of anxiety/MDD (Major Depressed Disorder; a mental health disorder causing persistent depressed mood) c/b (complicated by) benzodiazepine dependence,” and “made a recent suicide attempt in September 2025 via overdose when he (Patient 1) first learned about his medical diagnosis.” The note further indicated, “The patient (Patient 1) has a family history of complete suicide.” PHD 1 stated “if a patient denied a prior suicide attempt despite documented history of suicide attempt, it should be a concern,” and the nurse should notify the physician for further assessment. PHD 1 stated before further assessment was completed, she (PHD 1) would recommend “a sitter (staff member assigned for continuous patient observation) or nursing staff to remove any environmental risks, such as objects that could be used for self-harm.” During a concurrent interview and record review on 4/30/2026 at 11:40 a.m. with NM 1, Patient 1’s “Neurological” assessment medical record (MR), was reviewed. The MR indicated that Patient 1 was “alert and awake” from 10/22/2025 through 10/29/2025. The MR further indicated that on 10/30/2025 at 8 p.m., Patient 1 developed confusion (impaired awareness or thinking) and disorientation (inability to correctly recognize person, place, time, or situation), and on 10/31/2025 at 8:10 a.m., Patient 1 demonstrated somnolence (a state of drowsiness or abnormal sleepiness characterized by reduced responsiveness), responding only to voice. NM 1 confirmed there was no reassessment completed after the neurological change in condition beginning on 10/30/2025. During a concurrent interview and record review on 5/1/2026 at 9:30 a.m. with NM 1, Patient 1’s medical record (MR) document titled, “Vital Signs,” was reviewed. NM 1 confirmed Patient 1 had a documented confusion on 10/30/2025 at 8 p.m. NM 1 confirmed there was no reassessment of Patient 1’s vital signs after the change in condition until the following morning on 10/31/2025. During a concurrent interview and record review on 5/4/2026 at 1:57 p.m. with NM 1, the facility’s policy and procedure (P&P) titled, “Change in Patient Condition Early Recognition and Intervention,” dated 4/2/2025, was reviewed. The P&P indicated, “that an altered neurological status (a change in brain function such as confusion, disorientation, or decreased alertness) required a targeted head-to-toe reassessment (a full-body nursing examination to detect changes in condition), complete set of vital signs (basic body measurements such as temperature, pulse, breathing rate, and blood pressure) including temperature (body heat level), a pulse oximeter reading (a device measurement of oxygen level in the blood), and a complete pain assessment (a structured evaluation of the presence and severity of pain).” During the same concurrent interview and record review on 5/4/2026 at 1:57 p.m. with NM 1, NM 1 confirmed that Patient 1 did not receive a targeted head-to-toe reassessment, vital signs check, including temperature, pulse oximeter (non-invasive device used to measure the amount of oxygen in the blood) reading, or a complete pain assessment after Patient 1 developed confusion and disorientation (not knowing person, place, or situation) on 10/30/2025. During a concurrent interview and record review on 4/30/2026 at 12:11 p.m. with Registered Nurse (RN 1, a licensed healthcare professional who assesses, treats, and educates patients), Patient 1’s Columbia Suicide Severity Rating Scale (C-SSRS, a suicide-risk screening assessment tool) completed by RN 1, was reviewed. RN 1 documented “No” to all suicide screening questions, including question number 6. RN 1 stated she (RN 1) reviewed Patient 1’s H&P but “missed” the documented suicide attempt history. RN 1 acknowledged Patient 1’s record indicated “recent overdose on benzo (benzodiazepine; medications commonly used to treat anxiety) after learning of spinal tumor.” RN 1 stated if she (RN 1) had recognized the suicide attempt history, she would have documented the patient as high risk, initiated frequent assessments, notified the physician, implemented suicide precautions, and moved the patient (Patient 1 closer to the nurses’ station). During a record review of Patient 1’s MR document titled, “Nursing Note,” dated 10/31/2025, documented by RN 1, the note indicated “I (RN 1) heard an indistinct noise. Found patient (Patient 1) with shoelaces wrapped 3x around his neck, the distal end attached to an IV pole (intravenous pole used to hold intravenous fluids and medications) and his head hanging off of the side of the bed. Patient (Patient 1) was cyanotic (bluish discoloration caused by lack of oxygen) and had no pulse (without a detectable heartbeat) ...” During a concurrent observation, interview and record review for electronic medical records (EMR, electronic version of the medical chart on the computer) demonstration on 4/30/2026 at 3:46 p.m. with Registered Nurse (RN) 2, RN 2 opened the C-SSRS within the EMR and viewed only the abbreviated header “Suicide Behavior Question” for question number 6. RN 2 was unable to locate the complete wording of question number 6. RN 2 did not know that selecting “show row info” within the EMR would expand question number 6 and display the complete suicide behavior question. RN 2 verbalized an incorrect version of question number 6 and did not know the full suicide behavior question number 6 and did not know that the full suicide behavior question number 6 required staff to ask whether the patient had “done anything, started to do anything, or prepared to do anything to end your life.” RN 2 stated that if a patient had a known history of suicide attempt but answered “No” to question number 6, she (RN 2) would answer “yes” on the screening and document that the patient denied the history despite a known documentation of a suicide attempt. During a concurrent observation, interview and record review for electronic medical records (EMR, electronic version of the medical chart on the computer) demonstration on 4/30/2026 at 3:58 p.m. with RN 3, RN 3 opened the C-SSRS within the EMR and viewed only the abbreviated header “Suicide Behavior Question” for question number 6. RN 3 was unable to locate the complete wording of question number 6. RN 3 did not know that selecting “show row info” within the EMR would expand question number 6 and display the complete suicide behavior question. RN 3 verbalized an incorrect version of question number 6 and stated she (RN 3) did not know the full wording of question number 6. RN 3 stated that if a patient had a documented history of suicide attempt but denied suicidal ideation (thoughts of self-harm or suicide), she (RN 3) would answer “Yes” and document a comment because further evaluation would be required. During a concurrent, observation, interview and record review for electronic medical records (EMR, electronic version of the medical chart on the computer) demonstration on 4/30/2026 at 4:16 p.m. with RN 4, RN 4 opened the C-SSRS within the EMR and viewed only the abbreviated header “Suicide Behavior Question” for question number 6. RN 4 was unable to locate the complete wording of question number 6. RN 4 did not know that selecting “show row info” within the EMR would expand question number 6 and display the complete suicide behavior question. RN 4 verbalized an incorrect version of question number 6 and stated that she (RN 4) did not know the full wording of question number 6. RN 4 stated if a patient answered “Yes” to suicide-risk questions, nursing staff would notify the physician, notify the manager, remain with the patient, and initiate suicide precaution. During a concurrent interview and record review on 4/30/2026 at 3:15 p.m. with Senior Quality Director (SQR), SQR confirmed nursing staff must select “show row info” within the EMR to display the complete wording for question number 6 (prompts the RN to ask if the patient has “done anything, started to do anything, or prepared to do anything to end your life.”) on the C-SSRS tool. During a concurrent interview and record review on 5/1/2026 with NM 1, the facility’s online “Suicide Prevention” training module, was reviewed. NM 1 confirmed the training did not include instruction on how to access or display the complete C-SSRS question within the EMR. During an interview on 4/30/2026 at 1:12 p.m. with the Nurse Development Specialist/Clinical Educator (NDS 1), NDS 1 stated she (NDS 1) was not responsible for C-SSRS education and stated the training was completed through a corporate online module. NDS 1 stated she (NDS 1) did not conduct competency validation for nursing staff regarding the use of C-SSRS within the EMR. During an interview by phone on 5/4/2026 at 3 p.m. with the Regional Clinical Reeducator (RCE) and the Senior Director of Education (SDE), the surveyor asked how the facility verified registered nurses (RNs) knew how to access and use the C-SSRS within the EMR. RCE stated nursing staff were trained through routine use of the EMR and were “only reeducated if there is potential incident.” RCE stated regarding question number 6 on the C-SSRS, “We can add the education if we need to.” RCE stated she (RCE) was not aware that nurses were not able to access question number 6 of the C-SSRS on the EMR. RCE further stated the suicide prevention education module had last been reviewed in 2025. RCE stated she was aware of the Epic (electronic medical record system) update but was not aware the update caused question number 6 to no longer automatically display within the C-SRS. RCE stated, “We rely on leaders and manager to tell us what needs to be updated in the modules and Epic.” RCE stated she did not recall hearing there were issues with question number 6 following the Epic update. During a concurrent interview on 4/30/2026 at 3:06 p.m. with SQR, SQR stated the facility completed an RCA (Root Cause Analysis, a systematic process used to identify the underlying causes of adverse events and system failures) after Patient 1’s suicide incident. SQR stated the corrective action plan included identifying patients with suicide attempts or suicidal gestures within six months prior to admission as “higher alert,” referral to Neuropsychology, weekly interdisciplinary (involving multiple healthcare disciplines) discussions regarding risk and protective factors, and increased suicide screening. However, SQR stated the QAPI team “did not identify any nursing issue during the RCA.” During the same interview on 4/30/3036 at 3:06 p.m. with SQR, SQR confirmed Patient 1 screened negative for suicide risk because RN 1 documented “No” to all C-SSRS questions, and therefore suicide precautions and high-risk interventions were not initiated. SQR further confirmed the RCA did not identify that nursing staff were unable to access question number 6 within the EMR, nursing staff were not re-educated following the Epic update, and the facility did not identify a facility-based educator responsible for competency validation regarding the update suicide screening process. During a review of the facility’s policy and procedure (P&P) titled, “Patient Safety & Quality Assessment and Performance Improvement Plan (QAPI),” dated 1/2026, the P&P indicated, “The Hospital’s Patient Safety and Quality Assessment and Performance Improvement (QAPI) Program creates an environment that encourages error identification, remediation, non-punitive reporting, and prevention of recurrences through education, system redesign, and/or process improvement. It emphasizes the important processes or outcomes related to patient care and Hospital operations and delineates the roles and responsibilities of leadership, physicians and other clinicians and support staff in designing, measuring, assessing and improving performance ... Identify the on-going educational needs of leaders, clinicians and support personnel relative to the competencies required to improve patient care processes, outcomes and hospital operations ...” During a review of the facility’s policy and procedure (P&P) titled, “Quality and Risk Management Policy and Procedure,” dated 1/1/2026, the P&P indicated, “The Quality Assurance Performance Improvement (QAPI) Team is the standing interdisciplinary process improvement team for the hospital. The team analyzes trends, identifies and implements actions to be taken, monitors the effectiveness of these actions and makes additional changes as indicated. The QAPI Team will meet at least monthly to review, discuss and prioritize the overall quality efforts of the hospital. Team activities are reported quarterly to the Quality Improvement and Medical Executive Committees and Governing Board.” During a review of the facility’s policy and procedure (P&P) titled, “Suicide Risk and Precautions,” dated 7/1/2025, the P&P indicated, “During the admission assessment, the nurse will complete and document a suicide risk screen using the CSSR-S (Columbia Suicide Severity Rating Scale) ...The nurse will reassess risk as needed if the patient displays changes in condition, mental/emotional status or change in behavior indicating a possible change in risk ... Any staff member with knowledge of suicidal manifestation(s), e.g., expression of suicidal ideation and/ or intent, revelation of recent attempt, will take appropriate action: immediately notify the patient’s attending physician or, if unavailable, a consulting physician, medical director and/or psychologist. Maintain direct contact with the patient while awaiting medical response. The Charge Nurse/House Supervisor may initiate suicide monitoring (1 :1 direct observation) ...Assess clinical areas to identify objects that could be used for self-harm and remove when possible from the area around a patient ... Suicide Precaution Plan of Care (POC) and documentation: When a patient is identified as at risk, initiate the Suicide Precaution POC to address safety needs and document plan to mitigate identified risk ... An assessment of environmental features is conducted upon identification of suicide risk; items or objects that have the potential for self-harm are removed/secured and the environment is modified for enhanced safety as the medical condition allows.” During a review of the facility’s policy and procedure (P&P) titled, “Nursing Plan for the Provision of Patient Care,” dated 10/1/2023, the P&P indicated: Registered nurses were responsible for collecting assessment data, identifying patient problems, establishing appropriate diagnoses, developing goals, implementing interventions, and evaluating patient responses to care.”

“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: 46333 Based on observation, interview, and record review, the facility failed to: 1. Ensure nursing staff accurately completed the Columbia Suicide Severity Rating Scale (C-SSRS, a suicide-risk screening tool), received adequate training on how to access and use the C-SSRS within the electronic medical record (EMR, the electronic version of the medical chart), reassessed suicide risk after changes in a patient’s condition, implemented suicide-precaution interventions, and developed and implemented a nursing care plan addressing suicide risk for one (1) of 30 sampled patients (Patient 1), in accordance with the facility’s policies regarding early recognition/intervention for change of condition, patient assessment/reassessment, care planning, and suicide risk precautions. These deficient practices resulted in Patient 1 being found unresponsive (not reacting to stimuli), pulseless (no detectable heartbeat), and cyanotic (bluish discoloration caused by lack of oxygen) with shoelaces around Patient 1’s neck following an apparent suicide attempt on 10/31/2025. Patient 1 was transferred to the emergency department and pronounced deceased (died) the same day (10/31/2025). These deficient practices also placed other patients at risk, such as those with suicidal ideation (thoughts of suicide), suicide attempts, depression (a medical condition causing persistent sadness or loss of interest), behavioral?health conditions, or altered mental status (changes in awareness or cognition), by hindering proper identification of high?risk individuals and the implementation of necessary suicide prevention measures. 2. Ensure its nursing staff identified a change in condition and notify the physician for one of 30 sampled patients (Patient 21), in accordance with facility’s policy and procedure regarding patient change in condition management, when Patient 21 experienced increased headache at 9:39 p.m. (three (3) hours later) after sustaining head injury from a fall on 1/5/2026 at 6:24 p.m. This deficient practice had the potential to result in the physician not being able to evaluate Patient 21’s increased headache for possible worsening of head injury which is necessary to provide appropriate and timely interventions including but not limited to transferring Patient 21 to an outside facility in order to receive a computerized tomography head (CT head, imaging test to check for blood vessels blockages or bleeding in the brain, and other brain injury) imaging. On 5/1/2026 at 2:48 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Executive Officer (CEO), Senior Director of Quality (SDQ 1), Senior Director of Quality (SDQ 2), Chief Nursing Officer (CNO), Medical Director (MDIR), Nurse Manager (NM 1), Nurse Manager (NM 2) and Quality Coordinator (QC 1). The IJ was called due to the facility’s failure to ensure nursing staff were trained to access and use the Columbia Suicide (death caused by self-directed injurious behavior with intent to die) Severity Rating Scale (C-SSRS, a standardized suicide risk screening tool) within the electronic medical record (EMR, a digital version of a patient’s medical chart). The facility also failed to ensure nursing staff accurately assessed, reassessed, monitored, and responded to Patient 1’s suicide risk (the likelihood that a patient may attempt self-harm or suicide based on clinical signs and behaviors); failed to develop and follow an individualized care plan addressing suicide risk; and did not reassess Patient 1 after changes in condition, including confusion and disorientation (a state of impaired awareness or understanding). These failures likely contributed to the lack of needed suicide-prevention interventions and to Patient 1’s death. On 10/31/2025, Patient 1 was found unresponsive (failing to react or reply to stimuli), pulseless (having no detectable pulse), and cyanotic (bluish discoloration of the skin caused by lack of oxygen) with shoelaces around the neck following an apparent suicide by hanging. Patient 1 was transported to the emergency department and was later pronounced deceased. On 5/4/2026 at 12:28 p.m., the IJ was removed in the presence of the Senior Director of Quality (SDQ 1) and Nurse Manager (NM 1) after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that for immediate action taken by the facility the Chief Nursing Officer re-educated the on-site nursing leadership team on the facility’s Suicide Risk and Precautions policy and the Change of Patient Condition policy. The education emphasized the proper use of the Columbia Suicide Severity Rating Scale (C-SSRS, a standardized tool used to screen for suicide risk) in the electronic medical record (EMR, the digital patient chart). Staff were instructed on how to access expanded suicide-risk questions using “Show Row Info,” including Question 6: Suicide Behavior (a question that identifies past or current actions taken toward self-harm). Education also covered required responses when a patient denies a suicide attempt, but documentation shows a previous attempt. These responses include documenting the patient’s statement, immediately notifying the provider (the licensed practitioner responsible for the patient’s care), placing the patient on 1:1 continuous observation (a safety measure in which one staff member remains with the patient at all times), implementing suicide-prevention interventions (actions taken to reduce risk of self-harm), developing a nursing care plan for suicide risk (a written plan describing patient-specific safety needs), reassessing the patient after any change in condition, and reviewing the History and Physical (H&P, the medical assessment completed at admission) and prior psychiatric or suicide history. Nursing leaders began reeducation immediately, starting with the 5/1/2026 night?shift nurses. The House Supervisor re-screened all inpatients according to policy, and all new admissions were assessed using the updated suicide-risk procedures, including adding care plans when indicated. Additional education was provided to House Supervisors, Nurse Supervisors, Nurse Managers, and Nurse Educators before their next shift. These leaders then completed real-time, in-person training with all Registered Nurses (RNs, licensed nursing staff). Beginning 5/1/2026, all working RNs received this education, and any RN who had not received it by 5/8/2026 was required to complete it before their next shift. New-hire RNs now receive this training during onboarding, and all education is documented through sign-in sheets. The facility also began ongoing monitoring activities. These include weekly interviews of 10 RNs to assess knowledge and use of suicide-risk policies, and weekly audits of 10 patient charts to verify correct C-SSRS completion, accurate suicide-risk documentation, implementation of suicide?prevention precautions, and timely reassessment after changes in condition. An audit tool (a structured checklist used to measure compliance) is used to track results. Monitoring continues weekly until 100% compliance is maintained for three consecutive months, then monthly until compliance is sustained for twelve months. Compliance results are reported monthly to the Quality Improvement Council (the facility’s oversight committee for care quality) and quarterly to the Medical Executive Committee (the committee of medical leadership) and the Governing Board (the facility’s highest oversight authority). Findings: 1. During a concurrent interview and record review on 4/30/2026 at 12:11 p.m. with Registered Nurse (RN) 1, Patient 1’s “History and Physical (H&P, a formal, comprehensive medical assessment conducted by a healthcare provider),” dated 10/23/2025, was reviewed. The H&P indicated Patient 1 had a “recent overdose on benzos (benzodiazepine, medications commonly used to treat anxiety [persistent feelings of fear, nervousness, or worry]) after learning of spinal tumor (an abnormal mass of tissue resulting from uncontrolled cell growth).” RN 1 stated, “I missed it (referring to Patient 1’s recent benzodiazepine overdose).” RN 1 confirmed she (RN 1) answered “No” to all suicide screening question on the C-SSRS, including question number 6 regarding prior suicide attempts. RN 1 stated that while she (RN 1) was stationed outside Patient 1’s room with the door partially open, she (RN 1) heard a gagging sound. RN 1 stated when she (RN 1) entered the room, she found Patient 1 with a shoelace around the neck attached to an intravenous (IV, a tube inserted into a vein to deliver fluids or medications) pole. RN 1 stated Patient 1 was cyanotic (bluish discoloration caused by lack of oxygen) and pulseless (having no detectable pulse). During an interview on 4/30/2026 at 1 p.m. with RN 1 (Registered Nurse, a licensed healthcare professional who provides direct patient care), RN 1 stated Patient 1 was somnolent (abnormally sleepy or difficult to keep awake), had a urinary tract infection (UTI, an infection involving the bladder or urinary system), and was not feeling well. RN 1 stated she (RN 1) remained outside Patient 1’s room because of Patient 1’s condition. RN 1 stated she (RN 1) had no concern regarding suicide risk (likelihood a person may attempt to end their life) because Patient 1 denied suicidal ideation (thoughts of wanting to end one’s life) and appeared happy about going home. RN 1 confirmed she was unaware Patient 1 had a recent suicide attempt (an act in which a person tries to end their life) by overdose. During the same interview on 4/30/2026 at 1 p.m. with RN 1, RN 1 stated Patient 1 was not on high-risk monitoring (increased observation for patient safety) or 1:1 monitoring (continuous one-to-one staff observation). RN 1 stated that after learning of the documented suicide-attempt history, this would indicate Patient 1 was high-risk for suicide (at elevated danger for self-harm), and she (RN 1) would have initiated one-to-one staff observation and increased assessments, physician notification (informing the doctor of concerning findings), suicide precautions (measures taken to reduce risk of self-harm), room placement closer to the nurses’ station (relocating the patient for closer supervision), and sitter precautions (continuous observation by staff assigned to maintain patient safety). RN 1 stated she (RN 1) would also have implemented environmental safety precautions (removing items that could be used for self-harm), including removing ligature risks (objects capable of being used for hanging or strangulation). During a concurrent observation, interview and record review for electronic medical records (EMR, electronic version of the medical chart on the computer) demonstration on 4/30/2026 at 3:46 p.m. with Registered Nurse (RN) 2, RN 2 opened the C-SSRS within the EMR and viewed only abbreviated header “Suicide Behavior Question” for question number 6. RN 2 was unable to locate the complete wording of question number 6. RN 2 did not know that by selecting “show row info” within EMR, this would expand question number 6 and display the complete suicide behavior question. RN 2 verbalized an incorrect version of question number 6 and did not know the full suicide behavior question number 6 and did not know that the full suicide behavior question number 6 required staff to ask whether the patient had “done anything, started to do anything, or prepared to do anything to end your life.” RN 2 stated if patient answered “yes” to suicidal ideation questions, nursing staff would implement sitter precautions, environmental safety check (an inspection of the physical environment to identify and remove hazards, reducing risks of suicide, self-harm, or violence), provider notification, and Neuropsychiatry (the medical field that treats mental health symptoms like depression (a medical condition causing persistent sadness or loss of interest), anxiety, or confusion directly caused by physical damage to the brain) evaluation. RN 2 stated nursing staff would remain with the patient until additional evaluation was completed. During a concurrent observation, interview and record review for electronic medical records (EMR, electronic version of the medical chart on the computer) demonstration on 4/30/2026 at 3:58 p.m. with RN 3, RN 3 opened the C-SSRS within the EMR and viewed only the abbreviated header “Suicide Behavior Question” for question number 6. RN 3 did not know how to display the full wording of question number 6 and was unable to verbalize the complete wording of the question. RN 3 stated that if a patient had a known history of suicide attempt but denied that they had history of attempted suicide during screening, she (RN 3) would answer “yes” and document a comment because additional evaluation would be required by a qualified clinician. During a concurrent observation, interview and record review for electronic medical records (EMR, electronic version of the medical chart on the computer) demonstration on 4/30/2026 at 4:16 p.m. with RN 4, RN 4 opened the C-SSRS within the EMR and viewed only the abbreviated header “Suicide Behavior Question” for question number 6. RN 4 was unable to identify how to expand the suicide screening questionnaire to display the full wording of question number 6. RN 4 stated question number 6 asked “Do you have a plan to kill yourself,” but when surveyor showed RN 4 to click on “Show Row Info,” the detailed questions under question number 6 was displayed. The question number 6 indicated asking: “Have you ever done anything, started to do anything, or prepared to do anything to end your life?” RN 4 stated that if a patient answered “yes,” nursing staff would notify the manager, remain with the patient, and notify the physician. During a concurrent interview and record review on 5/1/2026 at 1:29 p.m. with the Chief Nursing Officer (CNO, Senior nursing executive in a hospital, who oversee all nursing operations, patient care standards, and policy implementation), the facility’s online suicide prevention training titled “Suicide Prevention,” and “Suicide Prevention Review (MT CIR-IPR-HBOP 2026’s” materials, were reviewed. The training materials did not include instructions regarding how to access the complete C-SSRS questionnaire within the EMR. The CNO confirmed nursing staff were not trained in how to access the full suicide questions. The CNO stated if nurses were unable to access the complete questions, they could ask incorrect questions and fail to identify high suicide risk patients. During an interview on 4/30/2026 at 1:12 p.m. with nurse Development Specialist/Clinical Educator (NDS 1), NDS 1 stated she (NDS 1) was not responsible for training nursing staff regarding the C-SSRS and stated the suicide prevention module had been completed by the corporate team. During an interview on 5/4/2026 at 3 p.m. with the Regional Clinical Reeducator (RCE) and the Senior Director of Education (SDE), the surveyor asked how the facility verified registered nurses (RNs) knew how to access and use the C-SSRS within the EMR. RCE stated nursing staff were trained through routine use of the EMR and were “only reeducated if there is potential incident.” RCE stated regarding question number 6 on the C-SSRS, “We can add the education if we need to.” RCE stated she was not aware that nurses were not able to access question number 6 of the C-SSRS on the EMR. RCE further stated the suicide prevention education module had last been reviewed in 2025. RCE stated she was aware of the Epic (electronic medical record system) update but was not aware the update caused question number 6 to no longer automatically display within the C-SSRS. RCE stated, “We rely on leaders and manager to tell us what needs to be updated in the modules and Epic.” RCE stated she did not recall hearing that there were issues with question number 6 following the Epic update. During a concurrent interview and record review conducted on 4/30/2026 at 10 a.m. with Nurse Manager (NM 1), Patient 1’s History and Physical (H&P, a comprehensive medical assessment completed upon admission), dated 10/23/2025, was reviewed. The H&P indicated: “Per chart review, patient (Patient 1) had a recent overdose on benzo (benzodiazepines, medications commonly used to treat anxiety) after learning of a spinal tumor (an abnormal mass of tissue resulting from uncontrolled cell growth).” -The H&P further indicated that Patient 1 had benzo/opioid dependence (opioids: a class of natural or synthetic drugs used to relieve pain), anxiety (persistent feelings of fear, nervousness, or worry), and suicidal behavior. It also indicated worsening bilateral lower extremity (BLE) numbness (loss of sensation in both legs), BLE weakness, bowel and bladder incontinence (loss of control of bowel or urinary function), and radicular pain (pain radiating along the path of a nerve), associated with a spinal cord mass (abnormal growth involving the spinal cord). -The H&P additionally indicated that Patient 1 required rehabilitation “to improve functional outcomes (the measure of a patient’s ability to perform everyday tasks independently and safely after an injury, illness, or surgery) related to impaired mobility (difficulty moving independently), activities of daily living (ADLs, routine self-care tasks), transfers (moving from one surface or position to another), and other self-care deficits (an individual is unable to independently perform the basic tasks required to look after their own health and well-being).” -NM 1 confirmed that patients with a documented recent suicide attempt must trigger safety interventions, such as assigning a sitter (continuous observation) and ensuring the environment was free of sharps (pointed objects) and ligature risks (objects that could be used for self-harm). During a concurrent interview and record review on 4/30/2026 at 2:18 p.m. with the Clinical Neuropsychologist (PHD 1, a specialist who evaluates how brain injuries or medical conditions affect behavior, mood, and thinking skills), Patient 1’s “Neuropsychologist” note, dated 10/26/2025, was reviewed. The note indicated Patient 1 had “a recent overdose on Xanax (alprazolam, a sedative medication classified as a benzodiazepine, used to reduce anxiety), 2/2 (secondary to) a new diagnosis of spinal cord mass (an abnormal growth involving the spinal cord).” The note indicated, “It is important to note that he (Patient 1) made a recent suicide attempt (an act in which a person tries to end their life) in September 2025 via overdose when he (Patient 1) first learned about his medical diagnosis.” -The note further indicated that Patient 1 was “taking extra doses of his Xanax in moments where he felt depressed (a medical condition involving persistent sadness or loss of interest).” The note also indicated that the patient (Patient 1) had “a family history of completed suicide (a fatal self-harm act).” The note also indicated that Patient 1’s “responses on psychometric measure of mood (a standardized mental-health assessment used to evaluate emotional symptoms) indicated clinically significant symptoms of depression at this time.” -The note further indicated Patient 1 was “experiencing acute adjustment difficulties (emotional distress related to adapting to a major life change) to his current medical situation and functional decline (a decreased ability to perform normal daily activities).” The note indicated, “Current Mood: The patient (Patient 1) is experiencing adjustment difficulties to his medical condition; behavioral and supportive interventions will be provided as indicated and mood will be monitored for acute changes.” -PHD 1 stated Patient 1 was admitted on 10/22/2025, she (PHD 1) saw Patient 1 “two times,” and Patient 1 “was very open.” PHD 1 stated she “noted a history of SI (suicidal ideation, thoughts of wanting to end one’s life) and suicide attempt.” PHD 1 stated Patient 1 “acknowledged that he (Patient 1) had attempted suicide but regretted it and said it was a rushed decision.” -PHD 1 stated, “If a patient answers ‘no’ to all suicide-screening questions despite a documented history of suicide attempt, it should be a concern.” PHD 1 stated “the nurse should notify the physician for further assessment.” PHD 1 further stated that before an assessment could be completed, she “would have recommended a sitter (continuous one-to-one staff observation for patient safety) or nursing staff to remove any environmental risks (objects that could be used for self-harm) and to supervise medications.” PHD 1 stated she (PHD 1) recommended keeping the door open, removing sharp objects, and removing ligature risks (objects that can be used for hanging or strangulation). PHD 1 stated, “If the patient denies SI, a holistic review should still be taken, and staff should remain vigilant and continue monitoring.” PHD 1 further stated, “The Columbia screen (C-SSRS, Columbia Suicide Severity Rating Scale, a standardized tool used to assess suicide risk) should be done more frequently.” During an interview on 4/30/2026 at 2:21 p.m. with the Chief of Neuropsychology (CDPD), CDPD stated that when a patient denied a prior suicide attempt despite documented history, the likelihood of isolation and self-harm increased and required enhanced clinical vigilance and direct monitoring. During a concurrent interview and record review conducted on 4/30/2026 at 12:02 p.m. with NM 1, Patient 1’s medical record (MR) document titled “Neurological Assessment,” was reviewed. The MR indicated that on 10/30/2025, Patient 1 was described as “confused (having difficulty thinking clearly)” and “disoriented to place (unable to correctly identify where they are).” The flowsheet further indicated that on 10/31/2025 at 8:10 a.m., Patient 1 “responds to voice (a clinical observation of the patient reacts or becomes alert when spoken to).” NM 1 confirmed that there had been no documented reassessment of neurological (a structured evaluation of a patient’s brain and nervous system function, including orientation, alertness, behavior, and motor responses) condition, suicide risk, or vital signs (a clinical measurement that indicate essential body functions) after Patient 1 experienced the change in condition (an alteration from the patient’s normal physical or mental status that requires reassessment and appropriate interventions) on 10/30/2025. During a concurrent interview and record review on 4/30/2026 at 12:05 p.m. with NM 1, Patient 1’s nursing care plan (a written plan outlining patient-specific nursing needs and safety strategies), was reviewed. The care plan did not include interventions addressing suicide risk (the likelihood a person may attempt to end their life), recent suicide attempts (any self-harm action with intent to die that occurred shortly before admission), environmental safety precautions (steps to remove hazards that could be used for self-harm), increased monitoring (closer observation of the patient for safety), suicide reassessment (repeat evaluation of suicide risk after any change in condition), or sitter precautions (1:1 staff observation in which a staff member remains with the patient at all times for safety). NM 1 stated, “There was no nursing care plan initiated that addresses suicide precaution (measures taken to prevent a patient from harming themself).” During a concurrent interview and record review on 5/4/2026 at 1:57 p.m. with NM 1, the facility’s policy and procedure (P&P) titled, “Change in Patient Condition Early Recognition and Intervention,” dated 4/2/2025, was reviewed. The P&P indicated, “that an altered neurological status (a change in brain function such as confusion, disorientation, or decreased alertness) required a targeted head-to-toe reassessment (a full-body nursing examination to detect changes in condition), complete set of vital signs (basic body measurements such as temperature, pulse, breathing rate, and blood pressure) including temperature (body heat level), a pulse oximeter reading (a device measurement of oxygen level in the blood), and a complete pain assessment (a structured evaluation of the presence and severity of pain).” NM 1 confirmed that Patient 1 did not receive a targeted head-to-toe reassessment, vital signs check, including temperature, pulse oximeter reading, or a complete pain assessment after Patient 1 developed confusion and disorientation (not knowing person, place, or situation) on 10/30/2025. During a review of Patient 1’s MR document titled “Discharge Summary,” dated 10/31/2025, the MR indicated that Patient 1 was found unresponsive (not awake and not responding to stimulation) with shoelaces around the neck following an apparent suicide attempt (an act in which a person tries to end their own life) by hanging (a form of self-harm involving pressure on the neck that blocks breathing). The MR indicated cardiopulmonary resuscitation (CPR, emergency chest compressions and breathing support to restore circulation and breathing) was initiated, return of spontaneous circulation (ROSC, the heart beginning to beat effectively again on its own) was achieved, and Patient 1 was transferred to the emergency department (hospital unit that provides urgent treatment for life?threatening conditions) where death was pronounced. -The MR further indicated Patient 1 had a history of depression (a medical condition causing persistent sadness or loss of interest), anxiety (persistent feelings of fear, nervousness, or worry), and a recent suicide attempt (an act of trying to end one’s life) by benzodiazepine overdose (taking an excessive amount of sedative medication used to treat anxiety or insomnia [difficulty sleeping]) after learning of the spinal tumor diagnosis (identification of an abnormal mass of tissue growing in or near the spine). During a review of the facility’s policy and procedure (P&P) titled, “Suicide Risk and Precautions,” dated 7/1/2025, the P&P indicated, “During the admission assessment, the nurse will complete and document a suicide risk screen using the CSSR-S (Columbia Suicide Severity Rating Scale) ...The nurse will reassess risk as needed if the patient displays changes in condition, mental/emotional status or change in behavior indicating a possible change in risk ... Any staff member with knowledge of suicidal manifestation(s), e.g., expression of suicidal ideation and/or intent, revelation of recent attempt, will take appropriate action: immediately notify the patient’s attending physician or, if unavailable, a consulting physician, medical director and/or psychologist. Maintain direct contact with the patient while awaiting medical response. The Charge Nurse/House Supervisor may initiate suicide monitoring (1 :1 direct observation)...Assess clinical areas to identify objects that could be used for self-harm and remove when possible from the area around a patient ... Suicide Precaution Plan of Care (POC) and documentation: When a patient is identified as at risk, initiate the Suicide Precaution POC to address safety needs and document plan to mitigate identified risk ... An assessment of environmental features is conducted upon identification of suicide risk; items or objects that have the potential for self-harm are removed/secured and the environment is modified for enhanced safety as the medical condition allows.” During a review of the facility’s policy and procedure (P&P) titled, “Nursing Plan for the Provision of Patient Care,” dated 10/1/2023, the P&P indicated: Registered nurses were responsible for collecting assessment data, identifying patient problems, establishing appropriate diagnoses, developing goals, implementing interventions, and evaluating patient responses to care. During a review of the facility’s policy and procedure (P&P) titled, “Change in Condition Early Recognition and Intervention,” dated 4/2/2025, the P&P indicated: “Rapidly identify changes in condition to address and prevent further deterioration. Provide parameters for significant change in patient condition. Provide guidelines for patient assessment. A clinical finding that is considered a significant change in condition, and unless ordered by the provider, should follow the process of assessment, documentation and notification. Changes in condition, include but are not limited to those described below. Other changes in condition not described below will follow the same process for assessment, documentation and notification ... Changes may include, but are not limited to: New onset worsening of level of consciousness (LOC) and/or or neurological status such as confusion ...Assessment: - A targeted head to toe assessment will be performed along with consultation(s) as appropriate decided upon by the clinical team ... - A complete set of vital signs including temperature - Sepsis screen - Pulse oximeter reading - A complete pain assessment.” During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Assessment/Reassessment,” dated 1/1/2026, the P&P indicated, “Patients are reassessed to determine their response to treatment, when a significant change occurs in patient condition, when a significant change occurs in the patient’s diagnosis or based on patient need/request for treatment and/or medication.” 2. During a review of Patient 21’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/1/2026, the “H&P” indicated, Patient 21 was admitted to the facility for on-going 24/7 rehabilitation nursing (a specialized field dedicated to helping patients recover from debilitating injuries, surgeries, or illnesses. The primary goal is to help individuals regain their independence, adapt to permanent changes, and improve their overall quality of life) and physiatry (a branch of medicine focused on diagnosing, preventing and treating condition that affect someone’s movement, function and daily life) oversight of Patient 21’s medical and rehabilitation needs following a traumatic brain injury (caused by a bump, blow, or jolt to the head or penetrating object that disrupts normal brain function). During a review of Patient 21’s “Nursing Fall Risk Assessment” flowsheet, dated 1/4/2026 at 8 a.m., the “Nursing Fall Risk Assessment” flow sheet indicated, Patient 21 was assessed using Morse Fall Risk scale (clinical tools for measuring a patient’s likelihood of falling. 0 - 24 points: low risk, 25 - 45 points: moderate risk, great then 45 points: high risk). The flowsheet also indicated that Patient 21 had history of fall with secondary diagnosis, used crutches/walker/cane to ambulate (to walk or move around from place to place unassisted), had impaired gait (having an irregular, unsteady, or difficult way of walking), and mental status (describes how well a person’s brain is functioning and how they are experiencing the world) indicated Patient 21 “overestimates/forget limitations” and resulted to a fall risk score of 90 (high risk). During a review of Patient 21’s “Nursing Note (nursing narrative note),” dated 1/5/2026, the “Nursing Note” indicated, “Patient (Patient 21) was awake, alert and oriented x 1 (means a person is awake and aware, but they only know who they are) baseline for admission, forgetful and impulsive. Patient’s (Patient 21’s) bed alarm started going off, staff and I (Registered Nurse [RN] 6) started running to the room, patient (Patient 21) was found on floor in seated position. Per patient (Patient 21’s) report, he (Patient 21) hit his (Patient 21’s) head on the wall and had a bump in the middle of forehead, that is red, skin intact.” During a review of Patient 21’s physician note (physician narrative note), dated 1/5/2026, the physician note indicated, “Patient 21 fell while attempting to stand up unassisted at bedside ... patient (Patient 21) endorses hitting his (Patient 21’s) head with throbbing left temporal headache (left side of the head in the temple area) ... New superficial laceration (a minor cut or tear that only affects the outermost layers of the skin) noted along forehead in addition to indurated swelling (a swollen area of skin or tissue that feels abnormally firm, stiff, or hardened to the touch) of unclear duration proximal (meaning close) to the left orbit (the medical name for the left eye socket) along the zygomatic bone (the cheekbone) ... Plan to continue to monitor ... if new neuro deficits (a loss or decrease in brain, spinal cord, or nerve function), worsening of HA (headache) or AMS (altered mental status) arise, plan to transfer patient (Patient 21) for CT head (computerized tomography head scan, imaging test to check for blood vessels blockages or bleeding in the brain, and other brain injury) imaging.” During an interview on 5/1/2026 at 9:47 a.m. with physician (MD 5), MD 5 stated Patient 21 was under his (MD 5’s) care and was aware Patient 21 experienced a fall at the facility. MD 5 stated despite Patient 21 having sustained head injury from a fall, Patient 21 did not show any change in mental status, slurred speech or any focal weakness so it was appropriate to keep Patient 21 at the facility and monitored. MD 5 stated any increased headache would warrant nursing staff to notify physician so physician could evaluate Patient 21. MD 5 further stated Patient 21 was sent out to another facility’s emergency department for evaluation per Patient 21’s family request. During a concurrent interview and record review on 5/1/2026 at 9:55 a.m. with the Quality Coordinator Nurse (QC 1), Patient 21’s “Pain Assessment” flowsheet, dated 1/5/2026, was reviewed. The “Pain Assessment” flowsheet indicated that on 1/5/2026, Patient 21 had headache with a pain level score of 5/10 (indicates moderate pain) on a numeric rating scale (0-10, a pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain) on 1/5/2026 at 6:24 p.m., 0/10 on 1/5/2025 at 8 p.m. and 9/10 on 1/5/2026 at 9:39 p.m. QC 1 stated that there was increased headache (as documented for Patient 21 [9/10 at 9:39 p.m.]), and nursing staff should have informed the physician regarding the change in condition for increased headache. QC 1 further stated there was no documentation which indicated that physician was contacted regarding Patient 21’s increased headache at 9:39 p.m. on 1/5/2026. During a concurrent interview and record review on 5/1/2026 at 3:15 p.m. with the Medical Director (MDIR), Patient 21’s “Pain Assessment” flowsheet, dated 1/5/2026, was reviewed. The “Pain Assessment” flowsheet indicated that on 1/5/2026, Patient 21 had a headache with a pain level score of 5/10 at 6:24 p.m., 0/10 at 8 p.m. and 9/10 at 9:39 p.m. MDIR stated the nurse should have contacted the physician regarding Patient 21’s worsening headache (at 9:39 p.m.) so that the physician could evaluate the patient (Patient 21) regarding the need for CT head imaging. During an interview on 5/4/2026 at 3:50 p.m. with Nurse Manager (NM 1), NM 1 stated Patient 21’s worsening of headache (on 1/5/2026 at 9:39 p.m.) could suggest potential neurological condition change or worsening of head injury. NM 1 further stated the nurse should notify physician so that physician could reassess and direct further care for Patient 21. During a review of Patient 21’s “Nursing Note,” dated 1/5/2026, the “Nursing Note” indicated, on 1/5/2026 at 10:05 p.m. Patient 21 was transported via ambulance to another acute care general hospital per family request. During a review of the facility’s policy and procedure (P&P) titled, “Change in Patient Condition Early Recognition and Intervention,” dated 4/2025, the P&P indicated, “A clinical finding that is considered a significant change in condition, and unless ordered by the provider, should follow the process of assessment, documentation, and notification ... Acute, unexplained, onset of pain: Change in patient’s baseline pain pattern ... A targeted head to toe assessment will be performed along with consultation(s) as appropriate decided upon by the clinical team ... It is the House/Nursing Supervisors responsibility to ensure that the attending physician or in-house internal medicine consultant is notified expeditiously. If they cannot be notified timely, the Medical Director and the Administrator on call should be notified.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure nursing staff developed and implemented an individualized nursing care plan (a structured, written roadmap that outlines a patient’s health conditions, specific needs, and the nursing interventions required to facilitate recovery), in accordance with the facility’s policy regarding care plans, for one (1) of 30 sampled patients (Patient 1), to address Patient 1’s recent suicide attempt. The facility failed to ensure Patient 1’s nursing care plan addressed a documented suicide-risk history, prior suicide-prevention interventions, environmental safety interventions, and increased monitoring needs. This deficient practice resulted in a lack of suicide precautions, environmental safety interventions, and increased monitoring for Patient 1. Patient 1 was later found unresponsive (not awake and not responding to stimulation), pulseless (without a detectable heartbeat), and cyanotic (bluish discoloration caused by a lack of oxygen) with shoelaces wrapped around the neck following an apparent suicide attempt by hanging on 10/31/2025. In addition, this deficient practice had the potential to affect other facility patients requiring nursing care plans related to suicide-risk assessment and patient-safety interventions by not ensuring their care plans were completed and implemented. Findings: During a record review of Patient 1’s History and Physical (H&P, a comprehensive admission medical assessment), dated 10/23/2025, the H&P indicated: “Per chart review, Patient 1 had a recent overdose on benzo (benzodiazepines, medications commonly used to treat anxiety [persistent feelings of fear, nervousness, or worry]) after learning of a spinal tumor (an abnormal mass of tissue resulting from uncontrolled cell growth).” During concurrent interview and record review on 4/30/2026 at 10 a.m. with Nurse Manager (NM) 1, Patient 1’s “Neuropsychology (specialized field within psychology that focuses on understanding how a person’s brain health affects their thinking, emotions, and behavior)” note, dated 10/26/2025, was reviewed. The note indicated Patient 1 had “family history of complete suicide (a fatal self-harm act).” The note further indicated Patient 1 experienced “clinically significant symptoms of depression.” During a concurrent interview and record review on 4/30/2026 at 12:05 p.m. with NM 1, Patient 1’s nursing care plan (a structured, written roadmap that outlines a patient’s health conditions, specific needs, and the nursing interventions required to facilitate recovery), was reviewed. NM 1 confirmed there was no nursing care plan addressing Patient 1’s suicide-risk history, prior suicide-prevention interventions, or increased monitoring needs. NM 1 confirmed no care plan for suicide precautions was initiated and stated that when a patient had a recent suicide attempt, a nursing care plan must be developed to ensure patient safety. During a concurrent interview and record review on 4//30/2026 at 12:10 p.m. with NM1, the facility’s sample of a care plan titled, “Suicide Prevention,” was reviewed. The sampled care plan included: -Place sign of the door notifying visitors/staff to check at the nurse station before entering -Locate patients close to nurse’s station if possible -Ensure window is locked -Discuss plan of care during handoff (shift-to-shift transfer of patient responsibility) and patient safety huddles (brief team meetings focused on immediate safety concerns). -Ensure safe environment, complete safety checklist with 1:1 sitter (continuous one-to-one staff observation) each shift -Do a complete environmental safety scan of the room and remove object that patient could use ... -maintain constant vigilance with regard to what in the room taken in the room by anyone. -NM 1 confirmed that this “Suicide Prevention” care plan was not developed for Patient 1. During a concurrent interview and record review on 4/30/2026 at 12:11 p.m. with Registered Nurse (RN 1, a licensed healthcare professional who assesses, treats, and educates patients), Patient 1’s Columbia Suicide Severity Rating Scale (C-SSRS, a suicide-risk screening assessment tool), completed by RN 1, was reviewed. RN 1 documented “No” to all suicide screening questions despite Patient 1 having a documented prior suicide attempt history within the medical record. RN 1 stated that if she (RN 1) had recognized the documented suicide attempt history, she (RN 1) would have identified Patient 1 as high risk, initiated suicide precautions, notified the physician, and implemented increased monitoring interventions. During the same interview on 4/30/3306 at 12:11 p.m. with RN 1, RN 1 stated that if Patient 1 had been identified as high suicide risk, nursing interventions would have included moving Patient 1 closer to the nurses’ station and implementing sitter (continuous one-to-one staff observation). RN 1 also confirmed that they (the facility staff) would have started an environmental safety check to remove any sharps object or ligature risks (items that could be used for hanging or strangulation). During an interview on 4/30/3036 at 2:21 p.m. with Neuropsychologist (PHD 1, a clinician specializing in brain behavior assessment)), PHD 1 stated if a patient denied a prior suicide attempt despite documented history, “that would increase the risk of isolation and put them (the patients) at higher risk for self-harm.” PHD 1 stated that before a complete assessment could be conducted, nursing staff should implement safety interventions including removal of environmental risks, provide supervision, and monitoring. During a review of Patient 1’s “Discharge Summary,” dated 10/31/2025, the summary indicated Patient 1 was found “unresponsive with shoelaces around his neck, pulseless and cyanotic, after an apparent suicide attempt by hanging.” During a review of the facility’s policy and procedure (P&P) titled, “Suicide Risk and Precautions,” dated 7/1/2025, the P&P indicated, “For any patient with a positive suicide risk ... the SAFE-T protocol (Suicide Assessment Five-Step Evaluation and Triage, a standardized process used to assess suicide risk and determine appropriate interventions) will be completed ...maintain direct contact with the patient ...initiate suicide monitoring and assess clinical areas to identify objects that could be used for self-harm and remove when possible.” During a review of the facility’s policy and procedure (P&P) titled, “Nursing Plan for the Provision of Patient Care,” dated 10/1/2023, the P&P indicated: Registered nurses were responsible for collecting assessment data, identifying patient problems, establishing appropriate diagnoses, developing goals, implementing interventions, and evaluating patient responses to care.”

“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: 46333 Based on interview and record review, the facility failed to ensure nursing staff reassessed one (1) of 30 sampled patients (Patient 1), after a documented change in condition. Patient 1 changed from being oriented (able to correctly recognize person, place, time, and situation) from 10/22/2025-10/29/2025 to having confusion (impaired awareness or thinking) and disorientation (inability to correctly recognize person, place, time, or situation) from 10/30/2025-10/31/2025. The facility failed to ensure nursing staff reassessed Patient 1 after the documented confusion and disorientation, and failed to implement nursing assessments, in accordance with the facility’s “Change in Patient Condition - Early Recognition and Intervention” policy and procedure. This deficient practice resulted in the failure to identify and address Patient 1’s acute (sudden) change in mental status (level of awareness, thinking ability, orientation, behavior, and emotional functioning), which prevented timely nursing interventions and increased monitoring that may have mitigated Patient 1’s suicide risk. This deficient practice also had the potential to affect other facility patients who experience a change in condition by not ensuring these patients receive timely reassessments and appropriate nursing interventions necessary to maintain patient safety. Findings: During a concurrent interview and record review on 4/30/2026 at 11:40 a.m. with Nurse Manager (NM 1), Patient 1’s Neurological Assessment Flowsheet, was reviewed. The flowsheet indicated Patient 1 was alert and awake from 10/22/2025 through 10/29/2025, then on 10/30/2025 at 8:00 p.m. developed confusion (impaired awareness or thinking) and disorientation (inability to correctly recognize person, place, time, or situation), and on 10/31/2025 at 8:10 a.m. demonstrated somnolence (a state of drowsiness or abnormal sleepiness characterized by reduced responsiveness), responding only to voice. NM 1 confirmed no neurological reassessment was completed after the change in Patient 1’s condition beginning on 10/30/2025. During a concurrent interview and record review on 5/1/2026 at 9:30 a.m. with NM 1, Patient 1’s Vital Signs (basic body measurements such as temperature, pulse, breathing rate, and blood pressure) Report, dated 10/30/2025, was reviewed. NM 1 confirmed Patient 1 had a documented confusion on 10/30/2025 at 8:00 p.m. and confirmed there was no reassessment of vital signs after the change in condition until the following morning on 10/31/2025. During a concurrent interview and record review on 5/4/2026 at 1:57 p.m. with NM 1, the facility’s policy and procedure titled “Change in Patient Condition - Early Recognition and Intervention,” dated 4/2/2025, was reviewed. The policy required that an altered neurological status (a change in brain function such as confusion, disorientation, or decreased alertness) be followed by: -A targeted head-to-toe reassessment (a full-body nursing examination to detect changes in condition), -A complete set of vital signs (temperature, pulse, breathing rate, and blood pressure), -A pulse oximeter reading (a device measurement of oxygen level in the blood), and -A complete pain assessment (a structured evaluation of the presence and severity of pain). -NM 1 confirmed Patient 1 did not receive a head-to-toe reassessment, repeat vital signs (including temperature), pulse oximeter reading, or complete pain assessment after developing confusion and disorientation on 10/30/2025. During review of Patient 1’s Discharge Summary, dated 10/31/2025, the summary indicated Patient 1 was found “unresponsive with shoelaces around his neck, pulseless (without a detectable heartbeat) and cyanotic (bluish discoloration caused by a lack of oxygen), after an apparent suicide attempt by hanging.” During review of the facility’s policy and procedure (P&P) titled, “Change in Condition,” the policy indicated that nursing staff was to reassess the patient, complete repeat vital signs, document interventions, and update the patient’s plan of care when a patient experienced a significant change in condition. During review of the facility’s policy and procedure (P&P) titled “Nursing Plan for Provision of Patient Care,” dated 10/1/2023, the policy indicated nursing staff were responsible for “assessment,” “planning,” “delivery,” and “evaluation of care,” and were expected to identify significant patient problems and implement appropriate nursing interventions.”