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Based on record review, observation and interview, the facility failed to ensure the means of egress through the double door set in the crisis stabilization unit was readily accessible for clients without a clinical diagnosis requiring specialized security measures; failed to ensure 1 of over 3 hazardous area doors, such as storage rooms, were provided with properly working self-closing devices; and failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 3 of 4 quarters.

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe environment.

Based on document review and interview, the facility failed to maintain a list of all contracted services.

Findings include:

1. The facility lacked or failed to produce documentation of a list of contracted services.

2. On 05-20-2025 at 1350 hours, staff A7 (Director of Quality) confirmed that they did not have a list of contracted services and no documentation was provided by the end of survey.

Based on document review and interview, the facility failed to ensure personnel completed CPR (Cardiopulmonary Resuscitation) recertification for 3 of 7 [N3 (Mental Heath Technician), N5 (Mental Heath Technician), and N7 (Registered Nurse)] personnel files reviewed.

Findings include:

1. Policy titled, First Aid & CPR Policy # 912, Last Reviewed: 07/26/2021, indicated the following: Select staff members are required to be trained in CPR in accordance with his or her Learner Profile on Relias (staff documented training) and then on a bi-annual basis thereafter. These select staff are all inpatient unit staff members.

2. Review of N3, N5, and N7 personnel files and Relias indicated CPR training was dated greater than bi-annual.

3. Interview on 05/21/2025, with A2 (Inpatient Supervisor) confirmed N3, N5, and N7 lacked having an updated CPR certificate.

Based on document review, observation, and interview, facility nursing staff failed to label an opened multidose insulin vial with an opened date and expiration date, and failed to ensure the narcotics key was in the possession of a licensed nurse at all times.

Findings include:

1 Facility procedure titled: NovoLog Manufacturers Guideline, last revised 3/2023 indicated after a vial has been opened it is be thrown away after 28 days, even if the vial contains insulin.

2. Facility policy titled, "Medication Storage, Loss, Theft", no policy number, last revised 11/3/2023, indicated under Steps: 1. Medication will be stored in the locked medication cart or emergency drug kit (EDK) in a locked medication room with the medication nurse holding the key. Personnel licensed to administer medications will be allowed in the medication room, and others are permitted to enter under the direct supervision of licensed personnel, when necessary.

3. During observation tour on 5/20/25 at approximately 11:30 pm this writer observed in the medication room the controlled substance/narcotic key located in the lock of the controlled medication drawer. This writer observed in the medication refrigerator an opened vial of insulin without an indicated opened date on the vial. Without an opened date this writer was unable to determine the discard date of the opened vial.

4. In interview on 5/20/2025 at approximately 11:30 am with N2 (Registered Nurse) confirmed the narcotic/medication key should be with the medication nurse at all times but was not. N2 confirmed the multidose insulin vial found in the medication fridge was not marked with an opened date, cannot confirm when the insulin was last used, nor if there is a policy for labeling or discarding multidose medication vials.

5. In interview on 5/20/25 at approximately 4:30 pm with A2 (Inpatient Supervisor) confirmed the facility does not currently have policies for multidose patient medication at this time.

Based on document review and interview, the facility failed to provide an approved formulary.

Findings include:

1. Policy titled, Formulary Policy #: 703, Last Reviewed: 07/10/2023. Indicated to determine the nature and scope of pharmaceuticals prescribed, ordered, or dispensed by the facility and to ensure safe and appropriate procedures for the use of pharmaceuticals in treating the facilities patients. The inpatient unit shall use the same formulary utilizing a contract pharmacy.

2. The facility lacked documentation of a formulary or failed to produce documentation of an approved formulary.

3. On 05-21-2025 at 1500 hours, staff A7 (Director of Quality) confirmed that they did not have an approved medication formulary.

Based on observation and interview, the facility failed to ensure the means of egress through the double door set in the crisis stabilization unit was readily accessible for clients without a clinical diagnosis requiring specialized security measures. Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side unless otherwise permitted by LSC 19.2.2.2.4. Door-locking arrangements shall be permitted in accordance with 19.2.2.2.5.2.

Based on observation and interview, the facility failed to ensure 1 of over 3 hazardous area doors, such as storage rooms, were provided with properly working self-closing devices. This deficient practice could affect more than 5 residents, as well as staff and visitors in the near the nurse's office area.


Findings include:

Based on observations and interviews during a tour of the facility with the Safety and Security Coordinator (SSC) and Director of Quality Improvement (DOQ) on 05/19/25 at 3:30 p.m. the double doors separating the Full Crisis Unit from the Mobil Crisis Unit, marked from each side as a facility exit, was magnetically locked and could be opened with panic hardware from the Mobil Crisis side. However, the doors could only be opened from the Full Crisis side without the use of a badge or special key. The aforementioned doors were not connected to the hospital's fire alarm system and this part of the facility did not have a fire alarm system. The DOQ stated the arrangement with the doors was added during a recent remodel/refresh of this part of the facility.

This finding was acknowledged by the SSC and DOQ at the time of observation and again at the exit conference with the SSC and DOQ each present.

Based on the facility tour and interview with the Safety and Security Coordinator (SSC) and Facilities Maintenance Manager (FMM) on 05/19/25 at 3:45 p.m., an office/room the facility was using as the nurse's station was greater than 50 square feet and contained a number of combustible items, such as, paper, and over 8 large cardboard boxes. The corridor door to this office/room/nurse's station was not equipped with a self-closing device and did not self-close and latch into the door frame.

This finding was acknowledged by the SSC and FMM at the time of observation and again at the exit conference with the SSC and Director of Quality present.

1. Based on record review and interview, the facility failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 3 of 4 quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.5 requires that waterflow alarm devices shall be inspected quarterly to verify they are free of physical damage. NFPA 25, 5.3.3.1 requires the mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 5.3.3.2 requires vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually.
Findings include:

Based on review of the quarterly sprinkler system inspection records with the Safety and Security Coordinator (SSC) and Facilities Maintenance Manager (FMM) on 05/19/25 at 3:15 p.m., only 1 (dated 06/13/24) of the required 4 quarterly sprinkler inspections was available for review. During an interview at the time of record review, the FMM acknowledged there was no written documentation available to show the sprinkler system had been inspected three of the four quarters stating that they had only had one inspection per year since he began working at the facility a few years ago. During a tour of the Riser Room on 05/20/25 at 10:05 a.m., hang tags from the sprinkler company indicated that only the aforementioned inspection was conducted. Previous hangtags from several years earlier revealed that once upon a time four quarterly inspections were conducted on the sprinkler system. The FMM stated he would contact the facility's sprinkler provider and begin 4 quarterly inspections immediately.

2. Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler systems were provided with spare sprinklers, a spare sprinkler cabinet and a sprinkler wrench on the premises. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.4 states a supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have been operated or damaged in any way can be promptly replaced. The sprinklers shall correspond to the types and temperature ratings of the sprinklers on the property. The sprinklers shall be kept in a cabinet located where the temperature in which they are subjected will at no time exceed 100 degrees Fahrenheit. A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers.
Findings include:

Based on the facility tour and interview with the Safety and Security Coordinator (SSC) and Facilities Maintenance Manager (FMM) on 05/20/25 at 10:10 a.m., there was one spare sprinkler cabinet in the riser room that included in excess of 15 spare sprinklers; 7 or more of which were not in their own protected slot. They were stored loose in and on the cabinet and not secured in holders. Based on interview at the time of the observation, the FMM agreed the spare sprinkler cabinet had spare sprinklers not in protected slots.

This finding was acknowledged by the SSC and FMM at the time of observation and again at the exit conference with the SSC and Director of Quality present.