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Based on review of records, observations, and interviews, the facility failed to ensure processes were developed with effective implementation of those processes that protected the rights of patients by:

- Addressing grievances,
-Notifying parents or guardians of allegations of sexual assault, and
-Investigating allegations of sexual assault.

More specifically, the facility failed to protect the rights of 16 out of 16 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16) who had complained of abuse. This was evidenced by:


a. There were nine patients who discharged from the facility Against Medical Advice (AMA) on 2/27/22. On facility AMA forms, the parents and guardians of nine adolescent patients (Patient #1, #2, #3, #4, #5, #6, #7, #9, #10) wrote complaints of sexual assaults, verbal abuse by staff, patients not being allowed to call home, and the facility having a hostile environment and being unsafe for children. These grievances were not addressed or investigated by the facility.

Cross reference FED - A0123 - PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION - CFR 482.13(a)(2)(iii)

b. There was no evidence parents or guardians were notified about alleged sexual assaults for 6 of 6 patients (Patient #11, #12, #13, #14, #15, #16) who submitted written complaints to the facility on 2/24/22.

Cross reference FED - A0123 - PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION - CFR 482.13(a)(2)(iii).

c. There was no evidence that there were any investigations conducted by the facility for 3 of 6 patients (Patient #9, #12, #13) who complained on 2/24/22 of sexual assaults (cross reference tag A0145).

Cross reference FED - A0145 - PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT - CFR 482.13(c)(3)

Based on record review, interview, and policy review, the facility failed to investigate grievances from 9 out of 9 patients who discharged Against Medical Advice (AMA) on 2/27/22 (Patient #1, #2, #3, #4, #5, #6, #7, #9, #10), and failed to notify patients' parents or guardians of alleged sexual assaults reported by patients on 2/24/22, for 7 of 7 patients (Patient #9, #11, #12, #13, #14, #15, #16).

Findings included:

Facility policy titled, "General Grievances and Patient Advocacy", policy #10359580, last revised 10/2021, showed that a patient grievance is a formal or informal written complaint from a patient or patient's representative. The grievance may be allegations of abuse, neglect, and/or facility's compliance with Medicare's Conditions of Participation.

The policy further showed that all written or verbal complaints of abuse, neglect, and patient harm, are considered grievances.

In addition, the policy showed that the Patient Advocate or Designee would investigate grievances and would monitor the protection of patient rights.

Review of another facility policy titled, "Sexually Acting Out", #10359909, last revised 12/2019, showed that Sexually Acting Out (SAO) is defined as a sexual act against someone without that person's consent. This included unwanted sexual contact, defined as intentional touching either directly or through clothing, of the genitalia, breast, inner thigh, and buttocks. Also, SAO included noncontact such as making sexual comments.

The policy also showed that the facility would investigate SAO events immediately, as well as inform the parents and guardians of patients who were involved.

Record review of AMA forms at time of survey showed on 2/27/22, there were nine patients who discharged from the facility Against Medical Advice (AMA); On facility AMA forms, the parents and guardians of nine adolescent patients (Patient #1, #2, #3, #4, #5, #6, #7, #9, #10) complained of sexual assaults, verbal abuse by staff to patients, patients not being allowed to call home, the facility was unsafe for children, there was a hostile environment in the facility, fear for child's safety, the facility not meeting patients' emotional and physical needs, and the facility had unsanitary conditions and inedible food.

The AMA forms also contained the signatures of staff: Charge Nurse (CN) Staff #6, Intake Registered Nurse (RN) #8, House Supervisor (HS) Staff #13, Medical Doctor (MD) Staff #4, and MD Staff #5.

The AMA forms showed the following:

On Patient (Pt) #1's AMA form, it showed that on 2/27/22 the patient's mother complained of verbal abuse, retaliation [by staff to patient], facility was not caring for or meeting patients' mental/emotional needs, her daughter's anxiety and depression were ten times worse since admittance, and she was scared for her daughter's mental and physical well-being and safety.

On Pt #2's AMA form signed 2/27/22, it showed that the patient's mother complained that she was informed staff were verbally abusive, staff retaliated against children, the facility was not meeting the emotional needs of children, [staff] calling children "hoes", staff on the unit denying one child her clothes as punishment, and the mother feared for her child's emotional and physical well-being.

On Pt #3's AMA form signed 2/27/22, it showed the patient's mother complained that children were being told to kill themselves by staff, verbal abuse by staff to patients, staff cursed at patients, and staff not allowing patients to call parents or guardians.

On Pt #4's AMA form signed 2/27/22, it showed the patient's mother complained of child endangerment, hostile environment in facility, verbal abuse by staff to patients, staff encouraging patients to kill themselves, the facility was not safe, and staff emotionally abused her child who was already unstable.

On Pt #5's AMA form signed 2/27/22, it showed that the patient's father complained that his daughter claimed a nurse opened her door while she was dressing and kept staring at her, also the daughter stated that a nurse told a patient to kill themselves, and there were fights and verbal abuse on the unit.

On Pt #6's AMA form signed 2/27/22, it showed the patient's guardian complained of inappropriate treatment to patient, hostile environment in the facility, verbal abuse by staff to patients, patients not allowed to exercise rights to call home, unsanitary conditions and inedible food in the facility.

On Pt #7's AMA form signed 2/27/22, it showed that the mother had complained that "This is NOT a safe place for children".

On Pt #9's AMA form signed 2/27/22, it showed that the patient's guardian had complaints about staff, there was another girl sexually assaulting the patient and others, and did not feel the facility was safe.

On Pt #10's AMA form signed 2/27/22 by the patient's father, there was no written complaint. However, the father still discharged his daughter and was present when all the other patients were discharged AMA.

During an interview on 3/4/22 at 2:10 pm with CN Staff#6, who had been present at the time the nine patients discharged AMA, he stated nine parents wanted to remove their child AMA on 2/27/22. This was a Sunday during visitation. He added that he did not really know what was happening and there were a million random reasons for parents wanting to remove their children AMA, so he helped discharge the patients.

During another interview on 3/10/22 at 3:05 pm, CN Staff #6 stated that he heard one of the complaints from parents was about staff telling patients to kill themselves, that there may have been allegations of sexual assaults, and parents were upset with the facility's service. In addition, CN Staff #6 stated that a sexual assault is anything kids say about sexual things to another patient. He went on to say that several police had showed up to the facility at the time the nine patients were discharging AMA and was under the impression that parents had called the police.

In an interview on 3/7/22 at 4:00 pm, HS Staff #13 stated that during the time of the nine patients discharging AMA on 2/27/22, CN Staff #6 had called him requesting assistance, and he had obliged the request. Although record review of AMA forms showed HS Staff #13 had signed his name below the complaints of parents alleging sexual abuse (along with all the other complaints from parents and guardians), he stated during interview that he was not aware of any sexual assaults regarding these patients. However, HS Staff #13 stated that he was aware of some reports of sexual inappropriateness between patients, such as boundary issues involving patients touching each other over their clothes. HS Staff #13 also stated that CN Staff #6 heard verbal complaints from the parents and guardians of the patients for 30 minutes during the time they were taking their children out AMA, but could not persuade the parents to let their children stay in the facility. HS Staff #13 further added that he called CEO-Staff #1 who then came to the facility.



Record review of handwritten patient complaints, which were submitted to Patient Advocate (PA)-Staff #21 on 2/24/22, showed the following:

There were five written grievances submitted from patients (Patient #9, #12, #13, #14, #15) who alleged non-consensual sexual contact:

Patient #9 wrote that Patient #11 assaulted her by rubbing her hand up and down her leg.

Patient #12 wrote that she had been sexually touched by Patient #11, was forced to touch Patient #11's vagina, had her breasts felt by Patient #11, and was forced to kiss Patient #11 three times. Patient #12 added that it made her very uncomfortable. In addition, Patient #12 wrote that patient #11 was trying to force Patient #16 to kiss her too, but he pulled away. Patient #11 then slapped Patient #16.

Patient #13 wrote that Patient #11 assaulted her by rubbing her legs against hers;
Patient #14 wrote that Patient #11 had been sexually assaulting her in different ways, such as telling her she wanted to have sex together, grabbing her buttocks in the hallways, touching her breasts, and asking if she could touch Patient #14's genitals. Patient #11 wrote that this made her feel very uncomfortable and it 'triggered' her.

Patient #15 wrote that Patient #11 rubbed her thigh, kept asking her to make out and to give her a hickey, and pressured her to be "sexual" together.

Patient #11 did not submit a written complaint.

Patient #16 did not submit a written complaint.

In an interview on 3/10/22 at 1:25 pm, PA Staff #21 stated he was aware about the nine patients discharging AMA on 2/27/22 and knew the parents and guardians had grievances. He added that he did not investigate the grievances or make contact with the parents and guardians. When questioned if he had communicated with any of the parents or guardians from the six patients who on 2/24/22 alleged sexual assault, PA Staff #21 stated he had not, nor had he investigated any of the grievances.

Record review of clinical charts of the seven patients involved with the written grievances from 2/24/22, failed to show that parents or guardians were notified.

In an interview on 3/10/22 at 4:30 pm, CEO Staff #1 and Director of Quality (QD)-Staff #2 acknowledged that the parents' and guardians' written complaints on the AMA forms from 2/27/22 should have been treated as grievances. Also, the parents & guardians of the patients involved in the 2/24/22 complaints should have been notified.

Based on Observation, interview, and policy review, the facility failed to ensure a safe environment for patients, as shown by:

A. Staff being unable to open a locked emergency crash cart on a unit;
B. The presence of expired supplies available for patient use;
C. The presence of sharp pens available for patient use.

Findings included:

Review of policy titled, "Resuscitation", policy #10858879, last revised 01/2022, showed that the emergency crash carts in the facility contained supplies needed for use on people in the event of patient life support emergencies. Also, the policy stated that the contents of the cart were to be checked every month.

Observation on 3/3/22 at 3:00 pm of the facility's Meadows unit with CEO Staff #1, Director of Quality (QD) Staff #2, Environment of Care director (EOC) Staff #14, and Charge Nurse (CN) Staff #22, showed there was an Exam Room used to examine patients on the unit. Inside this room was an emergency crash cart for patient use. When asked to open the locked crash cart to access the contents, CN Staff #22 was unable to do do so, despite several tries. EOC Staff #14 was unable to open it as well. House Supervisor (HS) Staff #13 was called into the room. Despite several tries, Staff # 13 was also unable to open the cart.

In an interview with Staff #1, #2, #14, #22, and #13 at the time of finding, they acknowledged that not being able to open the crash cart put patients at risk.

In addition, inside the Exam Room were several items in cabinets that were expired:

-A bottle of "TRUE METRIX" control solution used to measure blood sugar, expired 3/31/21 (lot #9BC2A36);

-14 tests for the presence of the Covid-19 virus, named "Veritor System SARS-CoV-2 Device", expired 2/9/22 (lot #1237958).

-A box of "OneStep + Strep A Dipstick" testing strips used to check patients for Streptococcus A, expired 10/31/21 (lot #STA9112048), and;

-Ten 'red top' laboratory tubes used for blood samples, expired 11/30/21 (lot #9340826).

Continued observation of facility showed that the emergency supply room contained expired food:

-30 quart-sized cans of Campbell's Chicken Noodle soup, expired 1/7/22;

-24 quart-sized cans of Home Taste Corned Beef Hash, expired 2/4/22, and;

-2 cases of Cheerios BOWLPAK dry cereal, each having 96 containers, expired 2/22.

In an interview at the time of these findings, Staff #1, #2, #14, #22, and #13 acknowledged that the supplies should have been thrown out when they expired and should not have been present in the facility.


During the initial facility tour 03/03/22 at 1445 with staff 1 Chief Executive Officer (CEO) and Staff 14 Environmental Control Director (EOC) began on the Meadows unit. The unit had multiple soft bendable pens on tables for patient use. The writing end of the pens was pointed metal, hard and sharp when touched with pressure.
Units Cedars, Willows, and Sunrise were toured, and all had the same pens openly available throughout the units for patient use.

During an interview 03/03/22 at 1450 staff 1, CEO stated "Those are psych safe pens." When asked to touch the metal pen end to her inner wrist skin Staff 1 confirmed the tip was sharp and could possibly break through skin. She stated she would have them removed.

Based on record review, interview, and policy review, the facility failed to uphold the rights of 3 out of 5 patients (Patient #9, #12, #13) who complained of sexual abuse.

Findings included:

Review of facility policy titled, "Sexually Acting Out", #10359909, last revised 12/2019, showed that Sexually Acting Out (SAO) is defined as a sexual act against someone without that person's consent. This included unwanted sexual contact defined as intentional touching either directly or through clothing, of the genitalia, breast, inner thigh, and buttocks. Also, SAO included noncontact such as making sexual comments.

The policy also showed that the facility would investigate SAO events immediately, as well as inform the parents and guardians of patients who were involved.

Record review of the facility's investigation into SAO complaints showed that three patients who submitted complaints on 2/24/22 (Patient #9, #12, #13) were not interviewed, and there was no documentation of these complaints being investigated. Further record review of these three patients' clinical records showed they were all present in the facility for several days after 2/24/22.

The patient's complaints of nonconsensual sexual contact were handwritten and submitted to the Patient Advocate (PA)-Staff #21. They showed the following:

Patient # 9 wrote that Patient #11 assaulted her by rubbing her hand up and down her leg;

Patient #12 wrote that she had been sexually touched by Patient #11, was forced to touch Patient #11's vagina, had her breasts felt by Patient #11, and was forced to kiss Patient #11 three times. Patient #12 added that it made her very uncomfortable. In addition, Patient #12 wrote that patient #11 was forcing Patient #16 to kiss her but Patient #16 pulled away. Patient #11 then slapped Patient #16;

Patient #13 wrote that Patient #11 assaulted her by rubbing her legs against hers.

In an interview on 3/10/22 at 1:25 pm, Patient Advocate (PA)-Staff #21 stated he was aware that five patients had submitted written grievances on 2/24/22. However, he stated he had not investigated any of the grievances or had made contact with the patients' parents and guardians.

In an interview on 3/10/22 at 4:30 pm, CEO-Staff #1 and Director of Quality (QD)-Staff #2 acknowledged that the grievances the three patients had made should have been addressed and investigated.

Based on observation record review and interview the facility failed to ensure methods were in place to prevent and/or control the transmission of infections in that:

(1) Multi drink (by the glass) drink dispensers were coated with thick dust and leaking into cabinet spaces below.

(2) The kitchen was not maintained in a manner to ensure cleanability and prevent contamination.

Findings included:

1. During the initial facility tour 03/03/22 at 1445 with staff 1 Chief Executive Officer (CEO) and staff 14 Environmental Control Director (EOC) began on the Meadows unit. The plumed, multi drink (by the glass) drink dispenser was observed to be coated with thick dust on the top. The cabinet door below the cabinet had visible dust on the edge of the closed door. Employee 14 the EOC was asked to unlock the cabinet directly under the drink station for observation. The back of the door was spotted with brown dust and dirt. The floor was a medium brown instead of light tan like the same floor tiles on the rest of the floor. The tiles under the cabinet had visible dirt, debris, and dried water stains. The back wall under the cabinet had the blackened irregular shaped stain that went out the wall approximately 5 inches high that resembled mold.

Units Cedars, Willows, and Sunrise were toured, and all had the same beverage machines. All the plumed, multi drink (by the glass) drink dispensers were coated with thick dust on the top. The cabinet doors below the cabinet had visible dust on the edge of the closed door. When the cabinet doors were opened all floors under the cabinets were discolored with dirt, several were felt and were wet, one had multiple white particles of an unidentified substance in the liquid catch tray below the dispenser spouts. one had 2 basins half full of water catching dripping from the dispenser. There was trash under 2 cabinets including a Styrofoam cup and a playing card that was adhered to the floor due to water. All but 3 cabinet areas had black irregular staining up the back wall. Two cabinets had loose tiles with water under the curled-up edges. One cabinet had multiple hard approximately 0.25-inch, black cylindrical bits on the floor with both ends tapered to a point, like rodent excrement.

2. During the initial facility tour 03/03/22 at 14 with staff 1 Chief Executive Officer (CEO) and staff 14 Environmental Control Director (EOC) The kitchen plumed, multi drink (by the glass) drink dispensers were observed to be coated with thick dust on the top and the sides. When wiped with the hand the dust floated to the ground resembling thick dryer lint. There was thick dust behind the machines and on the exposed connecting tubing. The corner of the countertop by the dispensers had a layer of dust.

3. During an observation of lunch service 3/10/22 at 1130 the kitchen was observed. The grill had a thick coating of brown and black and grease covering approximately 1/3 to ½ the of the grill service as well as the back guard and front lip of the grill.

a. The warming oven containing fish filets being served for lunch that day had copious black, brown and yellow caked-on dirt and debris and crumbs on the bottom and sides of the oven. There also were bits of aluminum foil scattered on the bottom of the oven.

b. The floors in the serving area had layers dirt, dust and crumbs under the serving carts and on the wheels of the carts.

c. The commercial toaster was caked with black shiny, greasy, crumbed residue on the top breads slot.

d. The microwave on the counter behind the serving steam tables had visible dried on spills inside on the walls, top and bottom and both sides of the door.

e. The walk-in refrigerator had a clear plastic container with celery that was brown on the ends in water that was cloudy and slimy. The container was dated 2/14, twenty-eight days before the observation day.

f. The walk-in refrigerator had 2 clear multi pound plastic bags of carrot sticks with "Best if used by" dates of "Feb 28 2022." The carrots were turning white in the bags.

g. The dry and New Leaf cereal dispensing station had dust and white particles on the top. Two of the four cereal spouts were empty and had white debris making the clear spouts opaque.

Review of Woodland Springs "2022 Infection Prevention and Control Plan
PURPOSE:

The purpose of the infection surveillance, prevention, and control program is to establish a comprehensive program to ensure that the organization has a functioning coordinated process in place to reduce the risk of endemic and academic healthcare acquired infections.

C. Surveillance: 3. Environment of care. a. The monthly rounding of all patient care units and ancillary departments and at least by annual rounding for non-patient care areas. Results reported to Infection Control Committee Specific Prioritized 2022 Goals: 3. To focus on proper disinfection of patient equipment.

1.) During interviews 03/03/22 beginning at 1445 and throughout the initial tour staff 1, CEO and staff 14, EOC both stated they did not know there was a leaking problem with the drink dispensers. Neither knew how the plastic catch basins were placed under the one dispenser however staff 14 stated only he and housekeeping had a key for the dispenser cabinets.

Both stated they had no idea what the multiple hard approximately 0.25-inch, black cylindrical bits on the floor with both ends tapered to a point, like rodent excrement was. Staff 1 stated "We need to call the extermination company." Staff 14 stated he thought it was rolled dust but had no explanation on how dust could become black, tightly rolled and hard under a cabinet.

2.) During an interview 03/11/22 at 1220 with staff 23, this cook stated the kitchen has been short staffed for months and it is difficult to prep 3 meals, serve, wash dishes, prepare lunches to go for outpatient therapy, order supplies and unload trucks twice weekly with 2 full time staff and 1 additional staff twice weekly. Staff 23 stated occasionally a housekeeper will come and help clean.
During an interview 03/11/22 at 1240 staff 14, EOC stated he had a housekeeper in to clean the kitchen but has been short staffed and is having difficulty finding housekeepers to hire.