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Based on record review and interview, the CEO impeded the survey process and failed to provide requested documentation related to the management of the hospital. The deficient practice is evidenced by failure of the CEO to provide documentation the facility was current with payments of state employment taxes and federal employee Social Security and Medicare withholdings as required by state and federal laws.
Findings:

Review of the Governing Body Bylaws, no date of initiation or review, but provided to the surveyor as the current bylaws, revealed in part, " The CEO shall be selected and employed by Corporation, after consultation with the Board, and shall be its direct executive representative in the management of the Hospital. The CEO shall have authority, and be held responsible for administering the Hospital in all of its activities, subject only to such policies as may be adopted and such or as may be issued by the Corporation, He/ She shall act as the authorized representative of the Board and Corporation if Corporation has not formally designated some other person for the specific purpose. Corporation, through the CEO, shall be solely responsible for the selection of key management personnel for the operation of the Hospital." And "Chief Executive Officer's Responsibility-6.3(g)-Supervising business affairs to ensure that funds are collected and expended to the best possible advantage."

During the entrance conference, the surveyor requested documentation to verify the facility was paying applicable state employment taxes and federal employee Social Security and Medicare withholdings as required by law.

During tour of the facility, interviewed employees verified they were aware of financial issues related to the owner of the hospital and verified a few of the departments had experienced shortages of supplies which had not yet affected patient care. S2CNO verified there had been no problems with payment of the employees, but was unsure about the payment of unemployment taxes including Social Security and Medicare withholdings as well as contributions to the employee retirement plans.

On 09/22/2025 at 12:00 PM, the surveyor reviewed the provided documents requested during the entrance conference. Review of the documents failed to reveal tax and withholding documents and the documents were request for a second time. At the time of the second request, S3CFO stated corporate office had that information, and she was not sure she could get this from corporate.

On 09/22/2025 at 2:00 PM, an interview was conducted with S1CEO who requested a release of information to obtain the requested information of federal and state employment tax filings for 2025. Surveyor completed form and delivered to S1CEO to fax to corporate.

On 09/22/2025 at 3:40 PM, an interview was conducted with S1CEO who reported the corporate office will not provided the requested information of federal and state employment tax filings for 2025.

At the time of exit on09/22/2025 at 4:00 PM, the requested documents had not been provided and the surveyor was not provided alternative evidence of compliance with submission of state employment and federal employee Social Security and Medicare with holdings.

Based on record reviews and staff interviews, the facility failed to ensure the medical staff was accountable to the governing body for the quality of the medical care provided to patients. The deficient practice is evidenced by 1) failure to develop and implement a policy for special precautions used on the Behavioral Health Unit for 1 (#2) of 3 (#1-#3) sampled patients; 2) failure to ensure the availability of appropriate supplies for point or care testing for 1 (#3) of 3 (#1-#3) sampled patients; and 3)Failure to ensure the availability of appropriate equipment for elective surgeries performed at the hospital.

Findings:

1) Failure to develop and implement a policy for special precautions used on the Behavioral Health Unit for 1 (#2) of 3 (#1-#3) sampled patients.

Review of Patient #2's medical record revealed Patient #2 was admitted to the BHU (Behavioral Health Unit) on 09/15/2025 for Impulse Control Disorder. Upon admission the provider ordered violence precautions for Patient #2. Further review of Patient #2's medical record did not reveal any indications that violence precautions was being initiated/followed.

In an interview on 09/18/2025 at 12:58 PM, S4QPR verified the facility did not have a policy on violence precautions.

2) Failure to ensure the availability of appropriate supplies for point or care testing for 1 (#3) of 3 (#1-#3) sampled patients

Review of Patient #3's medical record revealed Patient #3 has a history of Diabetes and provider ordered Accuchecks before meals. Further review of Patient #3's nursing notes revealed on 09/15/2025 at 5:32 AM "Put in order for lab to come draw blood glucose due to limited test strips".

In an interview on 09/18/2025 at 3:07 PM, S4QPR verified the hospital had limited supplies of glucometer strips due to financial issues, and glucometer strips were only used for emergencies and quality controls. S4QPR revealed routine Accuchecks would be done by venipuncture lab analysis due to limited supplies from 09/09/2025 to 09/15/2025.

3)Failure to ensure the availability of appropriate equipment for elective surgeries performed at the hospital.

During the tour of the facility on 09/22/2025 between 11:35 to 12:25 PM, S1CNO reported elective ophthalmology surgeries have been deferred to other facilities due to the hospital's debt to Sightpath. S1CNO reported the facility did not schedule the elective ophthalmology surgeries for the month of September 2025, but Sightpath balance should be paid by October 2025 so ophthalmology surgeries can be scheduled.

Review of the hospital's financial statements for Sightpath dated 09/11/2025 revealed a balance of $64, 120.62 and was verified by C3CFO.

Based on record review and interview, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care of each patient as evidence by failing to ensure the provider was notified when patient had a change in condition for 1 (#3) of 3 (#1-#3) sampled patients reviewed.
Finding:

Review of Patient #3's medical record revealed Patient #3 was admitted on 09/13/2025 with the following diagnosis: Altered Mental Status, Anxiety, and Self-Endangering Behavior. Further review of Patient #3's nursing notes on 09/16/2025 at 11:12 PM revealed Patient #3 experienced increased agitation, violence, and delusional unable to redirect, so provider notified via communication applications which provider didn't respond.

In an interview on 09/18/2025 at 3:20 PM, S2CNO revealed the Behavioral Health Unit (BHU) staff communicate with providers via Netsphere, a communication application. S2CNO reports there was no policy/protocol for the use of Netsphere or provider response time. S2CNO verified that BHU staff should have called Patient #3's provider to report exacerbated condition.

Based on record review and interview, the hospital failed to ensure 1 (#2) of 3 (#1-#3) client medical records contained a plan of care addressing all of the patient's medical conditions as identified problems.
Findings:

Review of the hospital facility's policy number AS-2021 titled "Admission/Assessment", last reviewed 10/2024 revealed in part: "POLICY: Each patient admitted to the facility shall receive an initial comprehensive assessment by a qualified individual, as well as ongoing assessments throughout treatment, so that a plan of care can be developed to best meet their initial and ongoing care needs. PROCEDURE: The ongoing treatment need assessments shall be structured to identify facilitating factors and possible barriers to the patient reaching his/her goals including the presenting problems and needs."

Review of Patient #2's medical record revealed Patient #2 was admitted to theBehavioral Health Unit (BHU) on 09/15/2024 for Impulse Control Disorder. Upon admission, the provider ordered aspirations precautions, bleeding precautions, and violence precautions. Further review of Patient #2's nursing care plan did not reveal any nursing diagnosis or interventions which addressed the aspiration, choking, and violence precautions ordered by the provider.


On 09/18/2025 at 12:58 PM, an interview was conducted with S4QPR who verified the above mentioned information.