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Based on observation, staff interviews, and review of maintenance records on 09/09/25, the facility did not construct, install and maintain the building systems to ensure life safety for patients.

The cumulative effect of environment deficiencies are not compliant with 42 CFR 482.41(a) was NOT MET resulted in the Hospital's inability to ensure a safe environment for the patients.

Findings include:

The facility was found to contain the following deficiencies:
K345 Fire Alarm System - Testing and Maintenance
K353 Sprinkler System - Maintenance and Testing
K362 Corridors - Construction of Walls
K511 Utilities - Gas and Electric
K521 HVAC
K712 Fire Drills
K761 Maintenance, Inspection & Testing - Doors
K918 Electrical Systems - Essential Electric Systems

Refer to the full description at the cited K tags.

Based on observation, record review and interview facility staff failed to provide a safe environment in 1 of 3 group rooms (Occupational Therapy Room) in a total of 3 group rooms observed.

Findings Include:

A review of the facility policy #CL 87109 titled, "Search of a Patient" last revised 02/19/2020 revealed, "...Contraband is broadly defined as any item that is forbidden and potentially hazardous to clients and staff..."

During an observation of the facility's Occupational Therapy room on 09/10/2025 at 12:12 PM, observed 11 pushpins on the tack board.

During an interview on 09/10/2025 at 12:13 PM with RN (Registered Nurse) I and Occupational Therapist Supervisor H, both stated that pushpins would not be allowed on the unit.

Based on record review and interview the facility failed to review 91 of 117 policies every 3 years in 1 of 1 of policy review.

Findings include:

A review of the facility policy #HHS 8101 titled, "Policy on Policies" last revised 08/01/2023 revealed, "... policies will be reviewed within three (3) calendar years of last review or revision..."

A review of the facility's list of policies (no title) with columns titled, "Origination Date," "Review Date- Most Recent," and "Revision Date- Most Recent" revealed that 91 out of 117 policies were not reviewed every 3 years per facility policy.

During an interview on 09/10/2025 at 9:06 AM, Compliance Analyst R stated that the facility is trying to get on a 3-year cycle for reviewing policies, per their policy.

Based on record review and interview, the facility staff failed to complete the History and Physical exam for patients admitted to the facility within 24 hours per policy for 2 of 30 medical records reviewed (Patients #17, 29) in a total universe of 30 medical records reviewed.

Findings include:

A review of the facility's "Mental Health Center Bylaws, Rules, and Regulations, last approved 08/22/2024 revealed, "... All patients shall be given a physical examination by the General Medicine Consultant or their designee within 24 hours of admission, and the examination and patient's medical history shall be completed and documented in the patient's record within 24 hours of admission..."

A review of Patient #17's medical record revealed an admission date of 8/22/2025 at 5:35 PM, the history and physical exam was completed on 8/24/2025 at 1:07 PM.

A review of Patient #29's medical record revealed an admission date of 03/22/2025 at 1:00 AM, the history and physical exam was completed on 03/24/2025 at 11:29 AM.

During an interview on 09/09/2025 at 3:30 PM, the medical record findings were discussed with and confirmed by Patient Care Coordinator C who stated the medical history, and the physical exam is expected to be completed within 24 hours of admission to the facility.

Based on record review and interview, the facility failed to have a written process for reviewing new medication orders during off hours when a pharmacist is not immediately available for 22 of 22 patients (Pt's #2, 3, 8, 9, 11, 13, 15, 18, 19, 23, 24, 30, 4, 6, 7, 10, 17, 25, 26, 27, 28, 29) in a total of 30 records reviewed.

Findings include:

A review of facility policy #CL 87097 last revised 09/04/2025 titled, "Prescriber Orders," revealed no evidence of a process in place for reviewing medications prior to administering the first dose of medication after hours when a pharmacist is not immediately available.

A review of 30 medical records revealed 12 patients (Pt's. #2, 3, 8, 9, 11, 13, 15, 18, 19, 23, 24, 30) were all admitted to the facility after 4:30 PM Monday through Thursday and there was no evidence of a review of orders being completed prior to the potential first dose of medication(s) given.

A review of 30 medical records revealed 10 patients (Pt's #4, 6, 7, 10, 17, 25, 26, 27, 28, 29) were all admitted to the facility after 4:30 PM on a Friday or the weekend and there was no evidence of a review of orders being completed prior to the potential first dose of medication(s) given.

During an interview on 09/09/2025 at 2:20 PM, Pharmacist N stated that for patients admitted after 4:30 PM, a pharmacist would not review the medications until next business day or, if admitted on the weekend, would review on Monday.

During an interview on 09/10/2025 at 1:15 PM, Administrator A stated there was not a policy in place for review of medications when patients are admitted during off hours.

Based on record review, observation, and interview, facility staff failed to discard 5 of 5 expired medications and 4 of 4 expired supplies in 2 of 2 medication rooms observed.

Findings include:

A review of the facility's policy titled, "Medication Disposal for Inpatient..." last revised 10/2010 revealed, "... 1.3 Quantities of expired oral or injectable meds (medications)... should be bagged and marked expired and returned to Nursing Administrators for disposal... Ointments, creams... can be disposed of in the garbage..."

During a tour and observation of medication rooms 1 and 2 with RN (Registered Nurse) Supervisor S on 09/09/2025 at 10:45 AM observed the following expired medications and supplies in medication rooms 1 and 2:

-One (1) 100 count bottle of Vitamin C capsules with an expiration date of 08/2025.
-Nine (9) tablets of Denture Cleaner with an expiration date of 07/2025.
-One (1) tube of 1 ounce (oz) Preparation H with an expiration date of 08/2025.
-One (1) tube of 3.5 oz Icy Hot Balm with an expiration date of 05/2025.
-One (1) Tubersol TB Test, 5 Tu/0.1mL, 1mL Vial with a "do not use" date of 08/26/2025.
-One (1) 100 count box of 3 milliliter (mL) syringes with an expiration date of 07/31/2025.
-Twenty-one (21) 1 mL 27 g (gauge)x ½" Tuberculin syringes with an expiration date of 10/28/2024.
-One (1) 18 oz bottle of Hand Sanitizer with Aloe with an expiration date of 03/2025.
-One (1) 67.6 oz bottle of Purell Hand Sanitizer with an expiration date of 07/2023.

During an interview on 09/09/2025 at 11:15 AM, RN Supervisor S stated that she would discard the expired supplies and medications since they are past expiration date.

Based on observation, staff interviews, and review of maintenance records on 09/09/2025, the facility did not construct, install and maintain the life safety systems for patients.

The cumulative effect of environment deficiencies with 42 CFR 482.41(b) Standard: Safety from Fire was NOT MET resulted in the Hospital's inability to ensure a safe environment for the patients.

Findings include:

The facility was found to contain the following deficiencies.
K345 Fire Alarm System - Testing and Maintenance
K353 Sprinkler System - Maintenance and Testing
K362 Corridors - Construction of Walls
K511 Utilities - Gas and Electric
K521 HVAC
K712 Fire Drills
K761 Maintenance, Inspection & Testing - Doors
K918 Electrical Systems - Essential Electric Systems

Refer to the full description at the cited K tags.

Based on record review and interview, facility staff failed to assess the ongoing risk of the spread of Tuberculosis (TB) in 14 out of 14 (Dietary Supervisor J, Dietician AA, Dietary Aide BB, Medical Director CC, Patient Care Coordinator C, Ocupational Therapist (OT) Y, OT Supervisor H, Registered Nurse (RN) L, Social Worker DD, Psychiatric Service Coordinator B, RN M, RN Supervisor S, Psychiatric Tech EE, Medical Nurse Practitioner (NP) Z and Psychology NP FF) employee files reviewed and failed to maintain employee vaccination records for 11 out of 14 (Dietary Supervisor J, Dietician AA, Dietary Aide BB, OT Y, OT Supervisor H, RN L, Social Worker DD, Psychiatric Service Coordinator B, RN M, RN Supervisor S, Psychiatric Tech EE and Medical NP Z) direct patient care staff in a total sample of 14 personnel files reviewed.

A review of facility policies revealed no active policies in place to monitor ongoing risk/assessment for TB.

A review of facility policy, "Administrative Policy and Procedure Manual Vol.II, Ch.1 Recruitment and Selection" last revised August 2025 revealed, "... Individuals hired for certain County positions must have completed specific physical examinations and other tests prior to the commencement of their employment. Examples of these examinations and evaluations include ...Rubella, Rubeola, and Hepatitis B Titer ..."

A review of personnel files on 9/10/2025 at 9:00 AM revealed no documented evidence for ongoing assessment of TB risk in employees for Dietary Supervisor J, Dietician AA, Dietary Aide BB, Medical Director CC, Patient Care Coordinator C, OT Y, OT Supervisor H, RN L, Social Worker DD, Psychiatric Service Coordinator B, RN M, RN Supervisor S, Psychiatric Technician EE, Medical NP Z and Psychology NP FF.

A review of personnel files on 9/10/2025 at 9:00 AM revealed no documented evidence of vaccination records for Dietary Supervisor J, Dietician AA, Dietary Aide BB, OT Y, OT Supervisor H, RN L, Social Worker DD, Psychiatric Service Coordinator B, RN M, RN Supervisor S, Psychiatric Technician EE and Medical NP Z.

During an interview on 9/10/2025 at 1:11 PM, Patient Care Coordinator C stated that there is a yearly questionnaire that should be filled out to assess TB risk.

During an interview on 9/10/2025 at 11:23 AM, Human Resources (HR) Representative X stated that required vaccinations are done at the health clinic and are not kept in the employee file. No evidence of the required vaccinations were provided.

During an interview on 9/10/2025 at 2:00 PM, Administrator A stated that the "TB risk assessment policy is currently in draft form" and that there is no active policy that they are following to assess for ongoing TB risk in their employees.

Based on record review, observation, and interview, facility staff failed to perform hand hygiene per policy in 1 of 4 patient care observations (Patient #6) performed, failed to prevent potential exposure to blood borne pathogens in 1 of 1 injection (Patient #6) in a total of 4 observations of patient care observed, and failed to maintain a clean and sanitary environment free from sources of contamination in 1 of 1 nursing unit observed.

A review of facility policy #CL 87139 titled, "Hand Washing and Hand Hygiene" last revised 12/9/2020 revealed, "1. Hand hygiene/hand washing to be performed before and after patient contact..."

A review of facility policy #CL 87054 titled, "Disposal of Contaminated Syringes" last revised 1/8/2021 revealed, "... workforce members shall dispose of contaminated needles in a safe manner in accordance with Occupational Safety and Health Administration (OSHA) standards."

During a tour and observation of the nursing unit on 09/09/2025 at 11:20 AM with Patient Care Coordinator C, the following was observed:
Patient room 146 and room 152 had multiple pencil eraser size areas of exposed sheet rock and chipped paint on the walls that did not allow the areas to be cleanable or wipeable.
Multiple paper decorations and paper notices that were not cleanable or wipeable taped to the walls in the nursing unit.

During an observation of care on 9/9/2025 at 4:20 PM, Registered Nurse (RN) O entered Patient #6's room, placed gloves on and gave a subcutaneous injection in the right arm without performing hand hygiene. After completing the subcutaneous injection, RN O closed the safety needle device with her fingers putting her at risk of a needle stick injury.

During an interview on 09/09/2025 at 11:30 AM, Patient Care Coordinator C stated they were not aware of the paint chips or exposed sheet rock and didn't know who was responsible for checking for this problem.

During an interview on 9/10/2025 at 7:51 AM, Patient Care Coordinator C stated that hand hygiene should be performed before starting, upon completion of medication administration, and upon entering and exiting a patient room.

During an interview on 9/10/2025 at 10:55 AM, when asked if it would be appropriate to close a dirty needle after injection with your fingers, RN I stated, "No."


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